First description of extended and tailored fluorescence-guided lymphadenectomy during robotic distal pancreatosplenectomy: case report

Abstract

Background: Minimally invasive distal pancreatosplenectomies for the treatment of pancreatic duct adenocarcinoma (PDAC) of the pancreatic body have become a well stablished approach. To improve oncologic resection and lymph node (LN) dissection, technical alternatives have emerged on the last few years, such as the radical antegrade modular pancreatosplenectomy (RAMPS). While it is accepted that 12 LNs should be retrieved during distal pancreatosplenectomies, during RAMPS procedure the mean harvest is described to be 21 LNs (range, 11-30). With the objective of performing extended and tailored lymphadenectomies during robotic distal pancreatosplenectomies, we developed a novel technique for LN dissection with the use of real-time near-infrared robotic fluorescence and direct injection of indocyanine green in the pancreas as a contrast agent.Case Description: The patient presented pathologically confirmed PDAC on the body of the pancreas and was submitted to totally robotic distal pancreatosplenectomy. After exposing the pancreatic body and under intraoperative sonography guidance, 1 mL of indocyanine green was injected on the pancreas just proximal to the tumor. Using robotic fluorescence, we could clearly identify the lymphatic drainage of the pancreatic body, in order to perform fluorescence guided, extended and tailored lymphadenectomy.Operative time was 4 hours and 43 minutes. Forty-three LNs were retrieved. Surgical margin was free from neoplasia. Postoperative period was uneventful.Conclusions: Fluorescence guided extended lymphadenectomy with intrapancreatic injection of indocyanine green is a novel technique that may improve oncological results and staging during robotic distal pancreatosplenectomies for the treatment of PDAC of the pancreatic body.