Robotic transduodenal ampullectomy

Abstract

Background: Our video describes the use of the da Vinci Surgical System Xi® (Intuitive Surgical, Sunnyvale, CA) to perform a transduodenal ampullectomy. The patient is a 61 y.o. female status post cholecystectomy with no history of pancreatitis who presented with chronic abdominal pain. Imaging revealed a dilated common bile duct and relative normal pancreatic duct. She underwent multiple ERCP's with biliary and pancreatic duct stent placement that resulted in the improvement of her abdominal pain. Her workup for malignancy was negative. Results: Diagnostic laparoscopy revealed no findings of overt pathology or malignancy. The round ligament was taken down using the monopolar scissors and left attached to the under surface of the liver. This was later used as a vascularized pedicle flap to cover the resection bed of the liver at the end of the procedure. A Nathanson retractor was used to retract the liver and expose the porta hepatis. The robotic vessel sealer was used to mobilize the gastrocolic ligament and gain access to the lesser sac following which the greater curvature of the stomach was mobilized. The pancreas, and duodenum were grossly normal with no signs of inflammation. Intra operative ultrasound was used to identify the critical vascular structures in the porta hepatis and the common bile duct. It did not show pancreatic duct dilation or stones in this patient. The bipolar vessel sealer was used to mobilize the hepatic flexure and kocherize the duodenum. A 10cm longitudinal duodenotomy was made using the mono polar scissors. The mono polar scissors were used to dissect the ampulla away from the medial wall of the duodenum. Once amputated this was sent for frozen section which was negative. The pancreatic and common bile duct were sutured circumferentially using eight 5-0 monocryl sutures. Seven Fr stents were placed in both ducts. The duodenotomy was closed in Lemberted fashion using three barbed sutures. The round ligament flap was then placed in close proximity to the closure to reinforce it. Conclusion: Intra operative findings were consistent with pancreatic duct stenosis as well as common bile duct stenosis at the ampulla. The patient did well post operatively and recovery was as expected.