TIPS AND TRICKS TO SIMPLIFY A ROBOT-ASSISTED PANCREATO-DUODENECTOMY

Aims: Robotic technology can facilitate challenging minimally invasive abdominal surgeries, such as pancreato-duodenectomy. We are presenting a case of an ampullary tumor treated with a full robotic Traverso-Longmire (T-L) procedure, reporting some tips and tricks to simplify the entire intervention, making it easier and faster. Methods: A 64-years old woman with a finding of an ampullary neoplasia, underwent a robot-assisted pancreato-duodenectomy with the use of the da Vinci Xi system. Patient was placed in lithotomic position and robotic trocars on the transverse umbilical line. Results: The T-L procedure was successfully completed in 385 minutes. A clip was applied to close the main bile duct after its section, avoiding a bile leakage staining the operative field. The Treitz liberation was performed by the right side, continuing the Kocher maneuver, to minimize the risk of malrotation of the intestinal loop during its retro mesenteric transposition in the reconstructive phase. The dissection of the pancreatic head from the portal vein, and of the retro portal lamina were entirely performed using the EndoWrist Vessel Sealer Extend device, avoiding any ligation or clips application. A personal modified end-to-side invaginated pancreatojejunostomy was carried out with 3/0 V-Loc double layer running suture. The duodeno-jejunostomy was also fashioned with a double layer of running barbed suture. No intra- or post-operative complications occurred and the patient was discharged on POD 7th. Conclusions: The da Vinci Xi gives some advantages in pancreatic surgery allowing to perform challenging procedures, such as pancreato-duodenectomy, with a minimally invasive technique. The Treitz liberation by the right side to minimize the risk of malrotation of the anastomotic loop, the use of the fully wristed Vessel Sealer Extend, which allows a fast dissection and safe sealing of vessels, the use of a personal end-to-side invagination technique of pancreato-jeujeunostomy with a double layer of running barbed suture and the fashioning of the duodeno-jejunostomy with a double layer of running barbed suture, can definitely enhance the surgical workflow.