Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.