ROBOT-ASSISTED TRANS-GASTRIC TREATMENT OF WALLED-OFF PANCREATIC NECROSIS WITH THE DA VINCI XI

Background: Walled-off pancreatic necrosis (WOPN) is a late complication of acute pancreatitis which represents a challenging critical problem with still high rate of mortality and morbidity. The management depends on the patient's symptoms and the location of the WOPN. Trans-gastric drainage and debridement of WOPN is a valid surgical treatment option for selected patients. Herein we report the case of a WOPN treated with a robot-assisted trans-gastric drainage and debridement using the da Vinci Xi with the new EndoWrist stapler. Materials and Methods: A 63-years old man with a previous episode of acute severe pancreatitis was referred to our center. We started with medical conservative treatment ( total parenteral nutrition), with progressive normalization of pancreatic enzymes. However, the patient developed a walled massive fluid collection, with an extensive pancreatic necrosis, causing obstruction of the gastrointestinal tract. The CT-scan, performed 6 weeks after the acute episode, confirmed the presence of a WOPN that compressed the stomach and the first duodenal portion. The patient was then operated with the use of the da Vinci Xi surgical system. Results: The procedure was successfully completed in 130 min. Firstly, guided by intraoperative US scan, an anterior ideal gastrotomy was performed. The intra-operative US scan was obtained with a dedicated robotic probe using the TilePro function. This technology consents the surgeon to view a 3D rendering of the operative field along with the US exam. Then, through the gastrotomy, the best location for drainage on the posterior gastric wall was again US-guided identified. The anastomosis between the posterior gastric wall and the WOPN wall was carried out with the new EndoWrist stapler with vascular cartridge. Debridement and washing of the cavity through the anastomosis were performed. The Xi platform flexibility was particularly useful in this phase, reducing external conflict between the robotic arms and allowing an easier access to the narrow cavity. Finally, the anterior gastrotomy was closed with three layers of 3-0 V-Lock running sutures and the cholecystectomy was performed. No intra-operative complications occurred . The postoperative course was uneventful and a post-operative CT-scan showed the collapse of the fluid collection. Conclusions: In selected cases of WOPN the da Vinci Surgical System can be safely used as a surgical treatment option, alternatively to endoscopic approach. The enhanced surgical dexterity allows an extensive debridement in the narrow cavity. The robotic stapler, with its range of 108° of articulation, can facilitate the suture and allows the operator to directly control all the steps of suturing. Furthermore, the stapler is able to detect the suitable thickness of the tissue between the branches and this function, together with the vascular cartridge, reduces the risk of anastomotic bleeding, which is one of the most frequent complications of this operation. Finally the TilePro multi-input display function can superimpose the US imaging on the console screen, eliminating several problems related to hand-eye coordination and interrupted surgical dissection.