Robot-assisted Whipple procedure

Pier C. Giulianotti (Chicago – USA)

Summary:The pneumoperitoneum is induced with the Verres needle.
The abdominal exploration does not show carcinomatosis and liver metastases.
The inferior vena cava is exposed mobilizing the right colon and the duodenum. A lymph node sampling is taken at this level for frozen section (negative).
The gastro-colic ligament is entered and the superior mesenteric vein (SMV) is prepared to rule out neoplastic encasement. Cholecystectomy is carried out with the standard technique. The hepatic hilum is dissected. The main biliary duct is cut upstream of the cystic duct and the gastro-duodenal artery is ligated and cut. The stomach is transected with multiple fires of endoscopic linear stapler and the lymph node dissection extended to the common hepatic artery, the celiac trunk and the root of the splenic artery. The pancreas is transected with the harmonic scalpel and margin of the Wirsung duct sent for frozen sections (negative).
The first jejunal loop is separated with linear stapler and rotated on the right side of the SMV. The Henle trunk is ligated and sectioned. The pancreas head and uncinate process are then dissected free from the portal and SMV confluence. Thereafter, the superior mesenteric artery is skeletonized on its right side, allowing identification of the inferior pancreatico-duodenal arteries. The jejunal limb is positioned in the right upper quadrant, via a retro-colic route. The pancreaticojejunostomy is completed in a manner replicating the open procedure. The pancreas-to-jejunal anastomosis is fashioned using a two- layer duct-to-mucosa technique. The hepaticojejunostomy is fashioned as an end-to-side anastomosis and finally the gastro-jejunostomy is completed. The specimen is extracted through a suprapubic incision and two drains are routinely left in place.