First report of robotic spleen-preserving distal pancreatectomy for children suffered from insulinoma

Abstract

Objective To report the first case of robotic-assisted splenic vascular preserving distal pancreatectomy for child patient in China, and to investigate the feasibility and safety of this surgical method in the treatment of children's benign pancreatic diseases. Methods A 9-year-old female patient (24 kg in weight and 1.20 m in height) diagnosed with insulinoma in the tail of pancreas was hospitalized in Jul. 2016 and was treated with robotic-assisted splenic vascular preserving distal pancreatectomy. The pneumoperitoneum was established with Veress needle through a minor incision in the inferior edge of umbilicus and the incision was closed whereafter. The robotic-assisted procedure was performed with four ports: a 10 mm optical port in the ventral midline 5 cm blow the umbilicus, an 8 mm port for the first robotic arm in the left anterior axillary line at the level of umbilicus, an 8 mm port for the second robotic arm in the right anterior axillary line 2 cm below the level of umbilicus, a 12 mm assistant port in the left midclavicular line 3 cm below the level of umbilicus. The gastrocolic ligament was divided by ultrasonic scalpel to expose the pancreas. The tumor was identified in the tail of pancreas using laparoscopic ultrasound, with a diameter of 2 cm. Then the splenocolic ligament was divided and splenic flexure was dissected downwards. The pancreas was separated from the retroperitoneal tissues with robotic hook cautery along the inferior border of pancreas towards the splenic hilum.After division of adhesion between the tail of pancreas and spleen, the splenic vein and artery were dissected off the posterior of pancreas and superior edge of pancreas, respectively. The branches of splenic vessels into the pancreas were progressively ligated or sutured to free the tail of pancreas completely. Subsequently, the distal pancreas was transected using laparoscopic linear stapler (Echelon 60, blue cartridge, Ethicon Endo-Surgery, Cincinnati, OH, United States) 1 cm from the right side of the tumor. The cut edge was continuously sutured using 4-0 Prolene. The resected specimen was transferred into the endo-bag and removed through the assistant port. A rubber drainage tube along the cut edge of pancreas was brought out through a stab incision on the right side of abdominal wall. Results The operative time was 155 minutes and the pneumoperitoneum time was 120 minutes. The estimated blood loss was 10 ml. The postoperative recovery was smoothly, without complications like pancreatic fistula, bleeding and infection, etc. The blood glucose was restored normal with a fasting insulin to glucose ratio less than 0.4. Unenhanced and contrast-enhanced MRI showed no sign of tumor residue. Conclusions Compared with traditional laparoscopic procedure, robotic-assisted surgery has advantages including three-dimensional vision and flexible manipulation, etc. The successful operation of this case initially ascertained the safety and feasibility of robotic-assisted spleen-preserving distal pancreatectomy in the treatment of insulinomas in children. Key words: Children; Robotic-assisted surgery; Distal pancreatectomy; Insulinoma