Robot-assisted Pancreatic Surgery

Abstract

The use of robots in minimally invasive surgery has become increasingly common in recent years. Robot-assisted pancreatoduodenectomy is more frequent than the laparoscopic procedure especially due to the greater flexibility of instruments and therefore better handling and better angulation. Furthermore, there are benefits from enhanced 3D visibility, software-based tremor control and reduction in the physical exertion of the surgeon. This review delivers a point-by-point approach to the setup of a robotic pancreatic programme and a detailed approach to robot-assisted pancreatoduodenectomy. In our standardised SOP approach, we use 5 trocars, 4 robotic trocars and one assist trocar. We prefer the position of the robot ports to be in a straight horizontal line with a distance of 20 cm away from the operational field. The operation is dissected in 11 standardised procedural steps, namely 1. Access to the pancreas and visualisation, 2. extended Kocher manoeuvre, 3. lower rim and mesenterico-portal axis, 4. upper rim and hepato-duodenal ligament, 5. dissection of the pancreatic neck, 6. mesenteric root and pars IV duodeni, 7. mesopancreas, 8. pancreatic anastomosis reconstruction, 9. bilio-enteric anastomosis, 10. dudenojejunal anastomosis, 11. drainage and closure. The set up of the pancreas program and the structured approach to complex pancreatic resections are elucidated. In summary, this review describes the approach to robotic pancreatic surgery in a high-volume pancreas centre at a structural and procedural level, in order to support establishment of such programs at other locations.