Extended Lymphadenectomy during Robotic Pancreatico-duodenectomy: Case Reporting a Right Hepatic Artery Coming from SMA and a Median Arcuate Ligament Syndrome

Abstract

Purpose: The video shows the dissection time with an extended lymphadenectomy during a pancreatico-duodenectomy performed by robotic approach. Method: The patient is a 63-years-old woman diagnosed with a pancreatic head cancer. In the CT-Scan, a median arcuate ligament is observed causing a stenosis of the celiac trunk and a right hepatic artery coming from the superior mesenteric artery (SMA). After a multidisciplinary tumor committee, we decided to perform a pancreatico-duodenectomy (PD) with total meso-pancreas excision by robotic approach. Results: The surgery begins with an extreme Kocher maneuver that allows us to access the posterior face of the duodenopancreatic block. After this we proceed to dissect the origin of the SMA and the origin of the celiac trunk cutting the median arcuate ligament in order to release the celiac trunk. During the dissection of the SMA the right hepatic artery is dissected and preserved. We continue with lymphadenectomy of the hepatic artery and the bile duct section.The next step is the gastric section that allows us to access the anterior pancreatic face. The retropancreatic tunnelisation allows us to put a loop in order to achieve the pancreatic hanging maneuver and sectioning the pancreas safely. The meso-pancreas is totally resected. Conclusion: Robotic approach is safe, effective and reproductible. Through a standardised technique, it may overcome some of the technical difficulties of laparoscopic PD.