Feasibility of “cold” triangle robotic pancreatoduodenectomy

Abstract

Background Triangle pancreatoduodenectomy adds to the conventional procedure the en bloc removal of the retroperitoneal lympho-neural tissue included in the triangular area bounded by the common hepatic artery (CHA), the superior mesenteric artery (SMA), and the superior mesenteric vein/portal vein. We herein aim to show the feasibility of “cold” triangle robotic pancreaticoduodenectomy (C-Tr-RPD) for pancreatic cancer (PDAC). Methods Cold dissection corresponds to sharp arterial divestment performed using only the tips of robotic scissors. After division of the gastroduodenal artery, triangle dissection begins by lateral-to-medial divestment of the CHA and anterior-to-posterior clearance of the right side of the celiac trunk. Next, after a wide Kocher maneuver, the origin of the SMA, and the celiac trunk are identified. After mobilization of the first jejunal loop and attached mesentery, the SMA is identified at the level of the first jejunal vein and is divested along the right margin working in a distal-to-proximal direction. Vein resection and reconstruction can be performed as required. C-Tr-RPD was considered feasible if triangle dissection was successfully completed without conversion to open surgery or need to use energy devices. Postoperative complications and pathology results are presented in detail. Results One hundred twenty-seven consecutive C-Tr-RPDs were successfully performed. There were three conversions to open surgery (2.3%), because of pneumoperitoneum intolerance (n = 2) and difficult digestive reconstruction. Thirty-four patients (26.7%) required associated vascular procedures. No pseudoaneurysm of the gastroduodenal artery was observed. Twenty-eight patients (22.0%) developed severe postoperative complications (≥ grade III). Overall 90-day mortality was 7.1%, declining to 2.3% after completion of the learning curve. The median number of examined lymph nodes was 42 (33–51). The rate of R1 resection (7 margins < 1 mm) was 44.1%. Conclusion C-Tr-RPD is feasible, carries a risk of surgical complications commensurate to the magnitude of the procedure, and improves staging of PDAC. Graphical abstract

Tips and tricks for robotic pancreatoduodenectomy with superior mesenteric/portal vein resection and reconstruction

“…In our experience complexity of RPD-VR was shown by a mean operative time approaching 10 h and a median estimated blood loss of approximately 900 ml. Despite we have not provided a matched comparison with contemporary RPD, these figures exceed those that we have published for standard RPD [16,17,20]. Operative time and blood loss are well established quality metrics in PD [56].…”

“…Vascular relationships between tumor and SMV/PV are also carefully noted, as previously described [ 19 ]. In addition, in preparation for triangle RPD [ 20 ] origin, course and branching pattern of right renal and adrenal arteries are also noted.…”

“…The patient is prepared as for a standard RPD [ 16 , 20 ]. Part of this standard preparation includes exposure of both groins and the left lateral region of neck, in preparation for procurement of vascular grafts (Fig.…”

“…Dissection proceeds following the technique recently reported for the “cold” triangle RPD [ 20 ]. The specimen is therefore mobilized from all retroperitoneal attachments, but the area of suspected vein involvement, by proceeding along the adventitial plane of large peripancreatic arteries (Figs.…”

Radiological classification of the Heidelberg triangle and its application in laparoscopic pancreaticoduodenectomy for malignancies

“…Although the TRIANGLE operation may have a survival benefit for patients with pancreatic cancer, its safety has not been adequately studied [ 25 – 27 ]. In this study, we classified the vascular structure of the Heidelberg triangle for the first time and examined the effects of different types on surgical and pathological indexes.…”