Technical Reports

Robot-Assisted Laparoscopic Middle Pancreatectomy

Pier C. Giulianotti, MD,1 Fabio Sbrana, MD,1 Francesco M. Bianco, MD,1

Pietro Addeo, MD,1 and Giuseppe Caravaglios, MD2

Abstract

Background: Middle pancreatectomy has been accepted as a valid surgical alternative to more extensive stan-dard resections for the treatment of benign central pancreatic tumors. In this article, we describe a new mini-mally invasive approach to this procedure, using a robot-assisted laparoscopic technique.Materials and Methods: From May 2004 to October 2005, 3 patients (2 female and 1 male), with a mean age of52 years (range, 44–68), underwent robot-assisted laparoscopic middle pancreatectomies at the Department ofGeneral Surgery of Misericordia Hospital in Grosseto, Italy. Two of the patients had symptomatic serous cysta-denomas, and 1 patient had a mucinous cystadenoma, which was discovered incidentally. The da Vinci� SurgicalSystem (Intuitive Surgical, Sunnyvale, CA) was used to perform the main steps of the intervention. All patientsunderwent a pancreaticogastrostomy for pancreaticoenteric reconstruction to the distal stump.Results: The mean operative time was 320 minutes (range, 270–380). Mean blood loss was 233 mL (range, 100–400). There were no mortalities. One patient developed a postoperative pancreatic fistula, which was managedconservatively. The postoperative hospital stay was 9 days for 2 patients and 27 days for the third patient. Noendocrine or exocrine deficiencies were observed in the patients during a mean follow-up of 44 months (range,38–48).Conclusions: Robot-assisted laparoscopic middle pancreatectomy presents an interesting, less-invasive optionfor resection of benign tumors of the neck and proximal body of the pancreas. In benign disease, it allows for thepreservation of functional pancreatic parenchyma and, subsequently, reduced operative trauma.

Introduction

Tumors of the neck or proximal body of the pancreaspose a surgical challenge due to anatomic location. Ma-

lignant lesions are usually treated by an extended pancreaticresection, such as a pancreaticoduodenectomy (PD) or a distalpancreatectomy (DP). However, these types of resections,if performed for a benign or borderline pancreatic tumor,sacrifice a large amount of functional parenchymal tissue andincrease the risks of postoperative pancreatic deficiency.Examples include pancreatic exocrine insufficiency, whichcan occur in 60% of patients after undergoing PD, and post-operative diabetes, which can affect 10–40% of patients fol-lowing DP.1–3 In an effort to avoid these long-term functionalconsequences, limited resections, such as a middle pancrea-tectomy (MP), have been proposed for the removal of selectbenign and borderline lesions of the central pancreatic region.The preservation of functional parenchymal tissue achievedby this procedure decreases the risks of postoperative diabe-

tes and exocrine insufficiency and guarantees a good, long-term quality of life.4–6 Most recently, laparoscopy has becomean acceptable approach for the resection of benign pancreatictumors, resulting in decreased morbidity associated withopen surgery. Studies on laparoscopic MP, however, have notbeen as readily available.7–11 In this article, we describe a newapproach to minimally invasive MP, using a robot-assistedlaparoscopic technique.

Materials and Methods

A program for minimally invasive pancreatic surgerywas started at our center in 2001, when the da Vinci� SurgicalSystem became available (Intuitive Surgical, Sunnyvale,CA).12 All patients referred to our center with pancreatictumors were systematically evaluated for minimally invasiveresection. The presence of major cardiovascular comorbid-ities, respiratory insufficiency, American Society of Anesthe-siologists (ASA) status greater than III, a preoperative

1Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois.2Department of General Surgery, Misericordia Hospital, Grosseto, Italy.

JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUESVolume 20, Number 2, 2010ª Mary Ann Liebert, Inc.DOI: 10.1089=lap.2009.0296

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diagnosis of cancer, and suspicion of vascular involvementwere considered as general contraindications for a minimallyinvasive pancreatic resection.

A single surgeon with significant experience in both pan-creatic and minimally invasive robotic surgery performed allprocedures. Between May 2004 and October 2005, 28 patientsunderwent robotic pancreatic resections. Of these, 3 under-went a robotic middle pancreatectomy (RMP). All patientsunderwent a thorough preoperative evaluation, includingendoscopy, abdominal ultrasonography, computed tomo-graphy, and magnetic resonance imaging. Information re-garding possible risks of the surgical procedure was providedto all patients, and signed informed consent forms wereobtained. Postoperative pancreatic fistulas were defined, ac-cording to the International Study Group on PancreaticFistula (ISGPF), as ‘‘any measurable drainage from an oper-atively placed drain on or after postoperative day 3, withamylase levels greater than three times the upper limit ofnormal serum amylase levels.’’13 Octreotide (300mg=d) wasprophylactically administered subcutaneously (S.C.) untilpostoperative day 7. An upper gastrointestinal tract X-ray,using a water-soluble contrast dye, was performed 6 daysafter surgery in order to assess anastomotic leakage andgastric emptying.

Surgical technique

The da Vinci Surgical System was used to perform allprocedures. General endotracheal anesthesia was adminis-tered, and patients were placed in a supine position with legsapart and a 20-degree reverse Trendelenburg. The pneumo-peritoneum was achieved with the use of a Verres needle inthe left hypochondrium. A 12-mm trocar was placed in orderto position a 30-degree-scope robotic camera at the umbilicus.Three 8-mm robotic ports were inserted in the left-upperquadrant (right operating arm), right-upper quadrant (leftoperating arm), and right subcostal area (fourth robotic arm),as shown in Figure 1. An additional 12-mm port was placedon the left side of the umbilicus for use with the assistant’sinstruments.

The first part of the procedure was performed lapar-oscopically. The gastrocolic ligament was opened with anUltraCision� Harmonic Scalpel (Ethicon Endo-Surgery, Inc.,Cincinnati OH), and the left colonic flexure was mobilized toexpose the pancreatic body. An ultrasonic examination of thepancreas was performed, using a 7-MHz probe, to confirmthe location of the tumors and delineate their location withrespect to the main pancreatic duct. The da Vinci surgical armcart was then brought into a position directly cranial to thepatient and docked to the robotic trocars. The posterior gastricwall was lifted and retracted by the fourth robotic arm, usinggrasper forceps. The splenic artery on the superior borderof the pancreas was dissected and surrounded with a vesselloop, in the event that clamping was required. The insertion ofthe mesocolon was then dissected. Following the middle colicvein, the superior mesenteric vein was exposed at the inferioredge of the pancreatic neck.

Using the robotic grasper, a tunnel was created under thepancreatic neck by gentle dissection with tangential move-ments in relation to the vascular axis. Upon completion of thetunnel, tape was passed through in order to provide tractionon the pancreas, which was divided to the right side of the

lesions by using an endoscopic stapler (Endo-GIA,� 45 mm,blue load; Ethicon Endo-Surgery) (Fig. 2A and B). Interruptedstitches of polypropylene 4=0 were applied to the proximalstump to achieve good hemostasis and reduce the risk ofpostoperative pancreatic fistulas. The pancreatic body wasprogressively dissected from the splenic vessels. Each smallbranch of the splenic vein and artery, to and from the pan-creas, was tied and sectioned by using transfixed stitches ofnonresorbable 5-0=6-0 suture (Fig. 3).

Transection of the pancreas was carried out on the left sideof the lesions, using a robotic ultracision device. The distalpancreatic stump was checked for bleeding points, whichwere then controlled by using selective stitches of polypro-pylene 5=0. The specimens were placed in a sample collectionbag, removed through the enlarged assistant’s port, andprocessed for frozen sectioning. Using the monopolar hook, a3- to 4-cm incision was made in the seromuscular layer of theposterior gastric wall. The fourth arm was used to retract theposterior gastric wall in a stable position. The anterior wall ofthe distal pancreatic remnant was then anastomosed to theposterior wall of the gastric body, using a single layer ofmonofilament 4-0 running suture, from the pancreatic pa-renchyma to the gastric seromuscular layer. The gastric wallwas then opened by using the monopolar hook, and theposterior aspect of the pancreatic stump was sutured to theposterior gastric wall by using a single layer of monofilament4-0 running suture (Fig. 4). Interrupted 4=0 polypropylenestitches were placed to reinforce the pancreaticogastrostomyand to achieve hemostasis of the eventual bleeding point.Two drains were systematically placed close to the ends of theproximal pancreatic stump and pancreaticogastrostomy.

FIG. 1. Operative room set-up and positioning of portsfor middle pancreatectomy. 1: 12-mm trocar for endoscope;2: 8-mm trocar for right robotic arm; 3: 8-mm trocar for theleft robotic arm; 4: 8-mm trocar for the fourth robotic arm; 5:12-mm trocar for assistant instruments.

136 GIULIANOTTI ET AL.

These were usually left for 7 days in order to watch for pan-creatic leak and amylase content in the effluent. The pneu-moperitoneum was stopped and the da Vinci surgical cartremoved from the surgical field.

Results

The clinical characteristics of the patients (1 male and 2female) who underwent RMP are detailed in Table 1. Themean operative time for the 3 cases was 320 minutes (range,270–380). The mean blood loss was 233 mL (range, 100–400),and none of the patients required intra- or postoperative blood

transfusion. Intravenous (i.v.) analgesic administration wasstopped at postoperative day 2. No mortalities occurred. Onepatient developed a pancreatic fistula that was radiologicallydocumented and conservatively managed with parenteralfeeding, i.v. antibiotic administration, and continuous gastricaspiration until postoperative day 20. Oral feeding resumed atpostoperative day 7 in the 2 patients without complications.

The postoperative hospital stay was 9 days for the 2 un-complicated patients and 27 days for the patient who devel-oped a pancreatic fistula. Postoperative pathologic analysisrevealed 2 serous cystadenomas and 1 mucinous cystadeno-ma. The mean size of the tumors was 3.0 cm (range, 1.5–3.5).Resection margins were tumor free in all patients. At a meanfollow-up of 44 months (range, 38–48), none of the patientsshowed signs of exocrine or endocrine deficiency.

Discussion

Cystic pancreatic tumors are now being diagnosed withmore frequency due to an increased use of cross-sectionalimaging in diagnosing abdominal disorders. Resection is thetreatment of choice for symptomatic benign cystic lesions orwhen malignancy cannot be ruled out during a preoperativeevaluation. Middle pancreatectomy was first described byDagradi and Serio in 1984 as a valid alternative for the re-section of benign and borderline tumors of the isthmus andproximal body of the pancreas.4,5 There are three main ad-vantages of this surgical procedure, as compared to a stan-dard resection, for the removal of a benign central pancreatictumor: 1) avoidance of the loss of functional parenchyma,thereby reducing the risk of postoperative diabetes and exo-crine insufficiency; 2) preservation of the spleen and itsimmunologic properties; and 3) guarantee of a good, long-term quality of life.14,15

In 1994, Ganger and Pump and Cuschieri reported the firstapplication of laparoscopy for pancreatic surgery.16,17 Sincethat time, laparoscopy has been increasingly applied to pan-creatic surgery, although at a slower rate, compared to otherabdominal procedures. Distal pancreatectomy and enucle-ation represent the majority of the pancreatic resection pro-cedures currently performed in using laparoscopy. Theadvantages of using the laparoscopic approach for surgicalresections have been reported in retrospective comparativestudies and include decreased postoperative pain, reducedmorbidity, and increased speed of recovery.18,19 Laparoscopy

FIG. 2. (A) Intraoperative view of a middle pancreatec-tomy. (B) Transection of the pancreatic neck at the right sideof the lesion with an endoscopic stapler. SMV, superiormesenteric vein.

FIG. 3. Dissection of the pancreatic body from the splenicvessels. SV, splenic vein.

FIG. 4. Final view after reconstruction. PG, pancreatico-gastrostomy; SV, splenic vein; SA, splenic artery.

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has not, however, gained widespread acceptance in morecomplex pancreatic resections requiring a reconstructivephase, as in the case of pancreaticoduodenectomies or MPs.A major reason for this has been the technical limitationsof laparoscopic instruments. This, combined with oncologicconcerns, has limited the widespread application of laparos-copy for complex pancreatic resections.

At our institution, we have been performing minimallyinvasive, robot-assisted pancreatic resections since 2001. Toour knowledge, this is the first report describing the applica-tion of robotic surgery for middle pancreatectomy (Table 2).The feasibility of this approach is supported by successfulintra- and postoperative results. The operative time in thesecases was slightly longer, compared to reports for the lapa-roscopic surgical procedure without use of the robotic sys-tem.10 We believe this will decrease with increased experience.

Two phases of this surgical procedure were facilitated by therobotic system in particular, including dissection of the pan-creatic body from the splenic vessels and the pancreaticoen-teric reconstruction. These are normally carried out in narrowand deep operative fields. The magnified three-dimensional(3-D) view provided by the robotic system, combined withinstruments equipped with Endowrist� technology (IntuitiveSurgical), provided for improved recognition and control ofeach tiny branch as it was directed toward the pancreatic body.These vessels were also individually controlled by using se-lective sutures.

We prefer to use the pancreaticogastrostomy as a method ofpancreaticoenteric reconstruction. It is our view that even if aRoux-en-Y pancreaticojejunostomy is feasible with the samerobotic port setting and cart placement, a pancreaticogas-trostomy following MP might present more advantages. Theproximity of the distal pancreatic stump to the gastric poste-rior wall made this anastomosis technically easier. The ex-cellent blood supply, the thickness of the gastric wall, andemptying through the nasogastric tube suction also presented

advantages.20 Moreover, as compared to pancreaticojeju-nostomy, the absence of small-bowel mobilization and theinterruption in intestinal continuity can help to avoid anyincreased operative times and risks. Finally, this method ofreconstruction also allows for gastric acidity and preventspancreatic enzyme activation.

Some technical points should be highlighted, which canhelp to ensure that this kind of anastomoses is performedcorrectly. First, a sufficient dissection of pancreatic distalstump from the splenic vessels has to be achieved in orderto provide a relatively tension-free anastomosis. Second,as with open surgery, each bleeding point detected on the cutedge of the pancreatic stump, or during the constructionof this anastomosis, has to be tacked with selective stitches toavoid the occurrence of postoperative intragastric bleeding.20

Finally, careful attention should be paid to avoid the occur-rence of tearing in the pancreatic parenchyma, which can becaused by an inappropriate passage of the stitches or an ex-cessive traction on the suture. The improved vision and thepresence of instruments with Endowrist technology (IntuitiveSurgical) also help to ensure that the anastomosis is per-formed correctly. The magnified 3D vision of the roboticsystem helps to recognize each small bleeding point on the cutsurface, which can then be controlled by using selective stit-ches, and allows for the safe recognition of the main pancre-atic duct. The presence of Endowrist instruments allowsprecise suturing by using fine sutures in a deep, narrow space.Finally, the presence of a fourth arm, used as a retractor underthe direct control of the surgeon, improves the stability of theoperative field.

One patient developed a pancreatic fistula that was suc-cessfully managed with conservative treatment. As reportedin the majority of MP studies found in the literature, theprincipal drawback of this surgical procedure is the relativelyhigh incidence of postoperative pancreatic fistulas, occurringin 7–44% of cases. Neither the approach (open or laparo-

Table 1. Summary of Patient Clinical and Pathologic Data

Patient Age Sex PresentationTumorlocation

Size(cm) Pathology

Surgicalcomplications

Hospital stay(days)

Follow-uptime (months)

1 44 F Abdominal pain Body 3.5 SCN None 9 482 45 F Abdominal pain Neck 1.5 SCN None 9 473 68 M Incidental finding Body 2.5 MCN Pancreatic fistula 27 38

SCN, serous cystadenoma; MCN, mucinous cystadenoma.

Table 2. Published Reports and Studies on Minimally Invasive Middle Pancreatectomy

Report YearNo.

of cases

Type ofpancreaticoenteric

reconstructionOperative time

(minutes)Blood loss

(mL)Pancreatic

fistula

Baca and Bokan7 2003 1 PJ 140 50 0Ayav et al.8 2005 1 NA NA NA NAOrsenigo et al.9 2006 1 PJ 330 300 0Sa Cunha et al.10 2007 6 PG 225(*) 125(*) 2=6Rotellar F et al.11 2008 9 PJ 435(^) NA 2=9Giulianotti et al.(present series)

2009 3 PG# 320(^) 233(^) 1=3

PJ, Pancreaticojejunostomy; PG, pancreaticogastrostomy; #, robot assisted; (*) median; (^) mean; NA, not available.

138 GIULIANOTTI ET AL.

scopic) nor the type of reconstruction appears to modify theoccurrence of pancreatic fistulae.6,11,21,22 The presence of twopancreatic stumps and a soft pancreatic parenchyma can beconsidered to be primarily responsible for the development ofpancreatic fistulae. As observed in one of the patients in thissmall series, the occurrence of pancreatic fistulae can increasethe length of the postoperative hospital stay. In uncompli-cated patients, however, a relatively short hospital stay can beachieved.6,21,22 The postoperative stay, although shortercompared to the open procedure, may be considered rela-tively long for a minimally invasive procedure. This reflects apolicy of using gastric aspiration until postoperative day 6 toallow for a proper healing of the pancreaticogastrostomy andthe abdominal drainage until postoperative day 7 to detectany leak. Despite the prolonged stay, the advantages of thisapproach are evident, including the preservation of functionalpancreatic parenchyma for benign disease, reduced abdomi-nal damage, less postoperative pain, and early return to pre-vious activity.

Conclusions

We believe that robot-assisted middle pancreatectomy is afeasible, less-invasive option for the resection of benign orborderline tumors of the neck or proximal body of the pan-creas. The ability to perform a middle pancreatectomy byusing a minimally invasive technique provides comparablefunctional advantages as well as reduced operative trauma.As a result, robot-assisted middle pancreatectomy representsa valid alternative, in experienced hands, to open resection.Additional studies on the use of this technique are required tofurther validate this initial report.

Acknowledgment

The authors would like to thank Mr. Sanchit Bhatia for theillustrations used in this article.

Disclosure Statement

No competing financial interests exist.

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Address correspondence to:Pier C. Giulianotti, MD

Division of General, Minimally Invasive, and Robotic SurgeryDepartment of Surgery

University of Illinois at Chicago840 South Wood Street, Suite 435E

Chicago, IL 60612

E-mail: piercg@uic.edu

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