Laparoscopic pancreaticoduodenectomy and laparoscopic pancreaticoduodenectomy with robotic reconstruction: single-surgeon experience and technical notes

Abstract

Purpose: Despite the increasing number of robotic pancreaticoduodenectomies, laparoscopic pancreaticoduodenectomy (LPD) and LPD with robotic reconstruction (LPD-RR) are still valuable surgical options for minimally invasive pancreaticoduodenectomy (MIPD). This study introduces the surgical techniques, tips, and outcomes of our experience with LPD and LPD-RR.

Methods: Between March 2014 and July 2021, 122 and 48 patients underwent LPD and LPD-RR respectively, at CHA Bundang Medical Center in Korea. The operative settings, procedures, and trocar placements were identical in both approaches; however, different trocars were used. We introduced our techniques of retraction methods for Kocherization and uncinate process dissection, pancreatic reconstruction, pancreatic division, and protection using the round ligament. The perioperative surgical outcomes of LPD and LPD-RR were compared.

Results: Baseline demographics of patients in the LPD and LPD-RR groups were comparable, but the LPD group had older age (65.5 ± 11.6 years vs. 60.0 ± 14.1 years, p = 0.009) and lesser preoperative chemotherapy (15.6% vs. 35.4%, p = 0.008). The proportion of malignant disease was similar (LPD group, 86.1% vs. LPD-RR group, 83.3%; p = 0.759). Perioperative outcomes were also comparable, including operative time, estimated blood loss, clinically relevant postoperative pancreatic fistula (LPD group, 9.0% vs. LPD-RR group, 10.4%; p = 0.684), and major postoperative complication rates (LPD group, 14.8% vs. LPD-RR group, 6.2%; p = 0.082).

Conclusion: Both LPD and LPR-RR can be safely performed by experienced surgeons with acceptable surgical outcomes. Further investigations are required to evaluate the objective benefits of robotic surgical systems in MIPD and establish widely acceptable standardized MIPD techniques.

Keywords: Laparoscopy; Minimally invasive surgical procedures; Pancreaticoduodenectomy; Robotics.

Fig. 1

Basic operative setting. The patient is positioned in the supine and reversed Trendelenburg positions with slight right-side elevation. Three 12-mm and two 5-mm trocars are used in laparoscopic pancreaticoduodenectomy. In laparoscopic pancreaticoduodenectomy with a robotic reconstruction approach, port 5 is replaced with an 8-mm robotic trocar, and two robotic working arms are docked to port 3 (using the double-docking technique) and port 5. The operator and scopist stand on the left side of the patient, and the assistant surgeon stands on the right side. *Pancreatic neck resection line.

Fig. 2

Mobilization of the duodenum. (A) Surgical gauze is used to wrap the duodenum to protect it from injury using an assistant grasper during medial traction of the duodenum. (B) With medial retraction of the duodenum, the ligament of Treitz is completely opened, and dissection of the posterior aspect of the pancreatic head proceeds to the root of the superior mesenteric artery and the celiac trunk.

Fig. 3

Operative setting and intraoperative view during the uncinate process dissection. (A) After applying our self-traction method to the uncinate process dissection, the operator moves from the left side to the right of the patient. The laparoscopic camera is also moved from the umbilical trocar to the right side 12-mm trocar for better visualization of the uncinate process. (B) With this operative setting, an appropriate operative view for uncinate process dissection could be obtained (B). SMA, superior mesenteric artery; SMV, superior mesenteric vein; IPDA, inferior pancreaticoduodenal artery.

Fig. 4

Laparoscopic and robotic pancreatic reconstructions. Pancreatic reconstruction is made by a basic principle of end-to-side pancreaticojejunostomy with conventional interrupted sutures, duct-to-mucosa anastomosis, and internal short catheter insertion. Suturing views of the posterior side of the pancreatic duct in laparoscopic (A) and robotic (B) reconstructions, and the superior side of the pancreatic duct in laparoscopic (C) and robotic (D) approaches.

Fig. 5

Protection method using the round ligament. (A) The round ligament is widely harvested, including nearby fat tissues and falciform ligament. The harvested round ligament (B) is inserted into the superior space of the pancreaticojejunostomy (C) and pulled out underneath it (D). The wide round ligament automatically covered the stump of the gastroduodenal artery and the confluence of the superior mesenteric-portal vein.