Robotic pancreaticoduodenectomy in a patient with a replaced right hepatic artery

Abstract

Presenter: Sharona Ross MD | AdventHealth Tampa Background: Ductal adenocarcinoma of the pancreas carries a poor prognosis. Resection with adjuvant therapy remains the sole chance for cure. A minimally invasive approach can improve perioperative outcomes by attenuating postoperative pain, reducing blood loss, and increasing the availability of curative intent to more patients. We present a case of robotic pancreaticoduodenectomy of ductal adenocarcinoma of the pancreatic head in a patient with a replaced right hepatic artery. We hope the stratagems demonstrated can assist other surgeons in providing minimally invasive resection for their patients. Methods: A 78 year old man presented with painless jaundice and weight loss. CT scan demonstrated a 4cm pancreatic head mass without metastasis. Endoscopic ultrasound and fine needle aspiration revealed a ductal adenocarcinoma without evidence of vascular invasion. He underwent robotic pancreaticoduodenectomy after initiation of an Enhanced-Recovery After Surgery (ERAS) protocol. Results: Operative duration was 6 hours. After Kocherization of the duodenum and division of the gastroduodenal artery, we divided the gastrocolic omentum and duodenum post pylorus. Next, the pancreatic neck was transacted. The dissection was carried from the jejunal mesentery to the SMV, SMA, and portal vein, carefully preserving the replaced right hepatic artery coming off the SMA. The gallbladder was dissected off the liver bed, the cystic artery ligated & divided, and the common hepatic duct divided as well. Once the specimen was removed and negative margins confirmed, we began the reconstruction. The choledochojejunostomy, pancreaticojejunostomy, and duodenojejunostomy anastomoses were completed with v-lock sutures. No blood transfusions were required. The final pathology showed a moderately differentiated pancreatic ductal adenocarcinoma, T3N1 with negative margins. The patient recovered uneventfully and was discharged home on postoperative day 4. Conclusion: The patient’s rapid and uneventful recovery resulted in adjuvant FOLFIRINOX initiation on post-operative day 27. Robotic resection, when utilized safely, provides adequate oncologic outcomes with good and quick postoperative recovery.