Robotic distal pancreatectomy and splenectomy: rationale and technical considerations

Abstract

Minimally invasive distal pancreatectomy has had significant adoption in the United States over the past decade. Robotic distal pancreatectomy is a type of minimally invasive technique which affords greater dexterity and visualization compared to traditional laparoscopy. In addition to standard distal pancreatectomy procedures with or without splenectomy, the use of robotic surgical systems has been efficacious in performing more complex techniques such as radical antegrade modular pancreatosplenectomy (RAMPS) or spleen-preservation. There are important technical considerations to performing robotic distal pancreatectomy procedures which differ from other minimally invasive approaches. The purpose of this report is to describe the rationale and technical considerations for implementation of robotic distal pancreatectomy procedures in clinical practice.

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© Journal of Visualized Surgery. All rights reserved. J Vis Surg 2017;3:135jovs.amegroups.com
Introduction
Minimally invasive distal pancreatectomy has become
the most commonly performed technique for distal
pancreatectomy in the United States (1). A majority of
surgeons had utilized laparoscopic techniques for minimally
invasive distal pancreatectomy prior to the advent of
modern robotic surgical systems. In contrast to traditional
laparoscopy, robotic distal pancreatectomy has been shown
to be feasible in performing both standard and more
complex resections with greater technical demands (2-4).
To date, there is no standardized approach to minimally
invasive distal pancreatectomy to guide surgeons in
selecting the most appropriate technique for an individual
patient. Cost considerations and surgeon-specific
experience or competency level are oftentimes used as the
main determinants for performing a specic technique (1,5).
With increased availability and a potentially shorter
learning curve, robotic distal pancreatectomy may be a
useful modality in increasing the successful adoption and
application of minimally invasive distal pancreatectomy.
The purpose of this report is to describe the rationale and
technical approach for the implementation of robotic distal
pancreatectomy.
Rationale
Robotic surgical systems provide more instrument range of
motion and control compared to traditional laparoscopic
instruments. Hand movement in standard laparoscopy leads
to exponentially increased instrument movement which
makes dissection around sensitive structures challenging. In
contrast, robotic surgical systems allow manipulation of the
Review Article on Pancreatic Surgery
Robotic distal pancreatectomy and splenectomy: rationale and
technical considerations
Nelson A. Royall, R. Matthew Walsh
Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Contributions: (I) Conception and design: All authors; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV)
Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final
approval of manuscript: All authors.
Correspondence to: Dr. R. Matthew Walsh, MD, FACS. Professor and Chairman, Rich Family Chair of Digestive Diseases, Chairman. A100,
9500 Euclid Ave, Cleveland, OH 44195, USA. Email: walshm@ccf.org.
Abstract: Minimally invasive distal pancreatectomy has had significant adoption in the United States
over the past decade. Robotic distal pancreatectomy is a type of minimally invasive technique which affords
greater dexterity and visualization compared to traditional laparoscopy. In addition to standard distal
pancreatectomy procedures with or without splenectomy, the use of robotic surgical systems has been
efcacious in performing more complex techniques such as radical antegrade modular pancreatosplenectomy
(RAMPS) or spleen-preservation. There are important technical considerations to performing robotic
distal pancreatectomy procedures which differ from other minimally invasive approaches. The purpose of
this report is to describe the rationale and technical considerations for implementation of robotic distal
pancreatectomy procedures in clinical practice.
Keywords: Pancreatectomy; pancreatic diseases; robotic surgical procedures; robotics; minimally invasive surgical
procedures
Received: 22 April 2017; Accepted: 27 July 2017; Published: 30 September 2017.
doi: 10.21037/jovs.2017.08.01
View this article at: http://dx.doi.org/10.21037/jovs.2017.08.01

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hand to instrument movement ratio, which allows for safe
dissection of delicate structures which otherwise require
high psychomotor ability. In the situation of a standard
distal pancreatectomy, there is limited need to manipulate
the hand to instrument movement ratio and does not require
signicant instrument articulation. Standard port placement
and in-line laparoscopic instruments, such as a Maryland
dissector and right-angle dissector, are generally adequate
for dissection of the splenic vein and artery or other
structures in a standard distal pancreatectomy with total
splenectomy. In contrast, the use of articulating instruments
and manipulating the hand to instrument movement ratio
may change the ability to complete a minimally invasive
distal pancreatectomy without open conversion in those
patients with significant peripancreatic fibrosis, enlarged
tumors, or other challenging anatomy. Table 1 provides a
relative comparison of traditional laparoscopy and robotic
techniques for distal pancreatectomy procedures.
For patients with locally advanced pancreatic tumors or
those warranting a more thorough lymphadenectomy [i.e.,
radical antegrade modular pancreatosplenectomy (RAMPS)]
the use of the robotic system has particular appeal (6). In
locally advanced pancreatic body and tail tumors the use
of the robotic systems can aid the surgeon in performing
en bloc resections of the involved structures such as the
duodenum or adrenal gland. Additionally, the robotic
system is decidedly more straightforward for the surgeon to
perform hand-sewn anastomoses should they be necessary
in the case of a bowel anastomosis or oversewing of vessels.
The full wrist articulation mimicking the surgeon’s hand can
make performing these anastomoses more straightforward,
particularly in the case of a surgeon less comfortable with
advanced intracorporal suturing skills.
Further, robotic surgical systems are advantageous
in RAMPS procedures where the gastroduodenal and
infra-pancreatic lymph node basins must be resected to
Table 1 A relative comparison of applications of laparoscopy and robot-assisted minimally invasive distal pancreatectomy
Technique
Psychomotor level
Ergonomic
comfort
Open
conversion
Procedural
cost
Primary
surgeon
First
assistant
Standard distal pancreatectomy with total splenectomy
Laparoscopy ––––↓
Robotic ––––↑
Distal pancreatectomy with total splenectomy and enterectomy and/or adrenalectomy
Laparoscopy ↑↑↑ ↑↑↑ ↓ ↑↑↑ –
Robotic ↑––↑ ↑
Distal pancreatectomy with total splenectomy and celiac axis resection (modified Appleby procedure)
Laparoscopy ↑↑↑↑ ↑↑↑ ↓ ↑↑↑ ↓
Robotic ↑↑ ––↑ ↑
RAMPS
Laparoscopy ↑↑↑ ↑↑ ↓ ↑↑ –
Robotic ↑–––↑
Distal pancreatectomy with spleen-preservation (vessel-preservation technique)
Laparoscopy ↑↑↑ ↑↑ ↓ ↑↑ –
Robotic ↑––↑ ↑
Distal pancreatectomy with spleen-preservation (Warshaw technique)
Laparoscopy ↑↑↓↑–
Robotic ↑––↑ ↑
RAMPS, radical antegrade modular pancreatosplenectomy.

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complete the N1 dissection. Clearance of nodal tissue
along the right gastroepiploic vein, gastroduodenal artery,
and common hepatic artery is believed to be a critical
component for the survival advantage noted in RAMPS (6).
Although a pure laparoscopic approach may be feasible,
many pancreatic surgeons are unlikely to feel comfortable
with this dissection given the limited dexterity of current
laparoscopic instruments. In minimally invasive RAMPS,
careful dissection and mobilization of perivascular
lymphatic tissue is greatly facilitated using fully articulating
instruments which can also be adjusted to decrease the hand
to instrument movement (4).
A nal technical modication of the distal pancreatectomy
which can be facilitated using the robotic system is spleen-
preservation (2,3,7). In spleen preserving techniques where
pancreatic branches from the splenic vein and artery are
individually ligated and sutured (splenic vessel preservation),
robotic surgical systems increase the likelihood of successful
splenic preservation compared to traditional laparoscopy
(2,3). This effect can be explained by the impact of the
robotic instrument articulation providing greater needle
dexterity which is critical in ligating small venous or arterial
branches along the relatively thin-walled splenic vein.
Given the number of sutures required, surgeon comfort
also becomes a greater consideration during these types
of technically demanding procedures and the improved
ergonomics seen with robotic surgical systems can help
prevent surgeon discomfort and fatigue throughout the
procedure. In comparison, the Warshaw technique (non-
splenic vessel preserving) where the splenic vein and artery
are divided, the ability to carefully dissect the splenic
vein tributaries seen in the diffuse splenic vein anatomy is
challenging in pure laparoscopy. Robotic instrumentation
with articulation and modication of the hand to instrument
movement ratio appears to aid in minimizing blood loss
and completing the procedure with a minimally invasive
approach.
Considerations
Robotic surgical systems require institutional credentialing
prior to use (8). Furthermore, mentorship to develop
competency in robotic instrumentation is critical to avoid
life-threatening injuries which can be seen with any surgical
instrument (8). Although robotic surgical systems are
certainly more generalizable to the traditional surgeon
compared to laparoscopic techniques, training in safe
trochar and robot-specic instrument use must be obtained
prior to implementing the technology in clinical practice.
With respect to robotic distal pancreatectomy, trochar
placement is similar to those used in laparoscopic distal
pancreatectomy. Depending on the robotic surgical system
used and preferred instrumentation, the trochars are a
combination of either 5, 8, or 12 mm in diameter. The patient
should be deemed a safe candidate for pneumoperitoneum
and if intraperitoneal adhesions exist then trochar placement
may need to be staged with adhesiolysis performed until all
trochars can be placed under direct visualization.
Most minimally invasive distal pancreatectomy procedures
utilize endoscopic stapling devices to transect the pancreatic
parenchyma. Both robotic stapling devices, depending on
the surgical system used, and laparoscopic stapling devices
can be used. Parenchymal suturing at the transection margin
can be performed depending on surgeon preference and
does increase the degree of technical challenge encountered
compared to open techniques. If a RAMPS procedure is
performed, additional trochars are used to aid in performing
the hepatoduodenal ligament and infra-pancreatic lymph
node dissections. The assistant port in RAMPS procedures
is of greater importance to retract or hold structures during
the dissection. In the setting of a locally advanced tumor
requiring duodenal resection, table manipulation may be
needed during the procedure while mobilizing the ligament
of Treitz. Although commercially available operative tables
are available which coordinate table movement with the
robotic system, if not available the robotic system will need
to be undocked from the patient to manipulate the operative
table during this portion of the procedure.
Technique
The peritoneal cavity can be entered in a variety of methods
including traditional laparoscopic techniques or a robot-
assisted method. Utilizing the robotic camera with an
optical view trochar in the left aspect of the epigastrium is a
cost-effective method we utilize to avoid use of laparoscopic
equipment. Additional trochars are then placed in the right
anterior axillary line, right para-median, supraumbilical, left
para-median, and left anterior axillary line. The size of the
trochars depends on the robotic device utilized. Examples of
port placement are demonstrated for the Intuitive Da Vinci
Si and Xi systems for distal pancreatectomy in Figures 1,2.
The potential use of smaller trochars such as robotic 5 mm
trochars has the advantage of a potentially lower risk for
incisional hernia, although the instruments at this time are
more limited in the existing robotic systems and not ideal

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for robotic distal pancreatectomy.
After placement of the robotic trochars, the epigastric
trochar is removed and the camera repositioned to the
supraumbilical trochar site. A liver retractor such as the
Nathanson retractor is placed through the epigastric port
site. The robotic surgical system is then docked from either
above the head or obliquely depending on the surgical
system used. The rst assistant is positioned on the patient’s
left side and will utilize the left para-median trochar
for suctioning and potentially stapled transection of the
pancreas. The surgeon at this point moves to the robotic
console after ensuring correct placement of the desired
instruments. An example of an instrument orientation
would be an atraumatic grasping device in the right anterior
axillary and left anterior axillary trochars with an ultrasonic
dissector or bipolar dissector in the right para-median
trochar.
The operation proceeds similar to previous descriptions
of distal pancreatectomy depending on the extent of
lymphadenectomy or performance of splenic preservation.
Figure 3 demonstrates the standard technique for a robot-
assisted distal pancreatectomy with splenectomy. For a
standard distal pancreatomy with total splenectomy, the
gastrosplenic ligament and short gastric vessels are serially
divided using the dissecting device up to the level of the
left phrenoesophageal ligament. The stomach is grasped
and retracted lateral and caudal using the right anterior
axillary grasping device while the left anterior axillary
grasping device retracts the greater omentum caudal. The
right anterior axillary grasping device serially regrasps the
posterior aspect of the stomach and rotates the stomach
counter-clockwise to better expose the gastric fundus and
Figure 1 Sample port placement for robotic distal pancreatectomy
with an Intuitive Da Vanci Si system. Eight mm trochars are
utilized for instrument arms and the supra-umbilical trochar is
used for the camera and eventual specimen removal. The 12 mm
left para-median trochar is used for the assistant port in addition to
the site for a stapling device if used.
Figure 2 Sample port placement for robotic distal pancreatectomy
with an Intuitive Da Vanci Xi system. Eight mm trochars are
utilized for instrument arms and the supra-umbilical trochar is
used for the camera and eventual specimen removal. The 12 mm
left para-median trochar is used for the assistant port in addition to
the site for a stapling device if used.
Figure 3 Technique for robotic-assisted distal pancreatectomy and
splenectomy (9).
Available online: http://www.asvide.com/articles/1719
Video 1. Technique for robotic-assisted
distal pancreatectomy and splenectomy
Nelson A. Royall, R. Matthew Walsh*
Department of General Surgery, Digestive Disease
Institute, Cleveland Clinic Foundation, Cleveland,
Ohio, USA
▲

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cardia while dividing the gastrosplenic ligament. The
superomedial aspect of the splenodiaphragmatic ligament
can be divided at this point as well given the excellent
exposure. The liver retractor is re-positioned to retract the
stomach and liver anteriorly. Similarly a Penrose drain can
be placed to similarly retract the stomach anteriorly.
The gastrocolic ligament is divided in conjunction
with the gastrosplenic ligament up to the level of the
right gastroepiploic vein depending on the extent of
pancreatectomy and lymphadenectomy desired. If a distal
pancreatectomy at the level of the superior mesenteric vein
is necessary then the right gastroepiploic vein is followed
distally to the junction with the superior mesenteric vein
while retracting the stomach anteriorly with the left
anterior axillary grasping device. The peritoneum overlying
the superior mesenteric vein and caudal aspect of the
pancreatic neck or body is divided using an electrosurgical
device or dissector. The peritoneum along the caudal aspect
of the pancreatic body and tail is similarly divided to allow
for caudal retraction of the colon and transverse mesocolon
to prevent an iatrogenic mesocolic defect.
A retro-pancreatic tunnel is created using blunt dissection
with the right and left anterior axillary grasping at the
level of the superior mesenteric vein. The dissection ends
at the cephalad aspect of the pancreas beyond the level
of the splenic vein. The dissection proceeds anteriorly at
the cephalad aspect of the pancreas to isolate the splenic
artery. The splenic artery should be followed proximally
to the celiac trunk and all lymphatic tissue dissected from
the splenic artery and celiac trunk to be included with
the specimen. A laparoscopic or robotic ultrasound probe
should be routinely employed to evaluate the pancreatic
parenchyma, identify the pancreatic lesion, and main
pancreatic duct. The ultrasound exam is additionally used
to guide the level of pancreatic parenchyma transection
ensuring an adequate margin is achieved.
Except in the case of splenic vessel preservation, the
splenic artery is divided at the level of the celiac trunk or
distally to preserve the dorsal pancreatic artery. The splenic
artery can be divided using either surgical clips or a surgical
vascular stapler load. The splenic vein is then bluntly
dissected from the pancreatic parenchyma circumferentially
on the posterior aspect of the pancreatic body at the level
of the planned parenchymal transection. The splenic vein
is divided using either surgical clips or a surgical vascular
stapler load. The pancreatic parenchyma can be divided at
this step using a variety of transection techniques including
a surgical stapling device, electrosurgical dissector, ultrasonic
dissector, or sharp transection. If desired the pancreatic
transection stump and main pancreatic duct can be over
sewn using robotic needle drivers placed through the left
anterior axillary trochar.
The pancreatic body and tail are then elevated anteriorly
using the right anterior axillary trochar while the transverse
colon is retracted caudal. The splenocolic ligament is
divided using either a monopolar or a surgical dissecting
device to mobilize the splenic flexure of the colon. The
splenorenal ligament can be divided at this point with
adequate caudal retraction of the transverse colon. The
retro-pancreatic lymphatic tissue is then divided using
either an ultrasonic or bipolar dissector to complete
the retro-pancreatic lymphadenectomy. The remaining
splenodiaphragmatic and splenorenal ligaments are divided
as well to complete the resection.
There are two predominant methods for specimen
removal in minimally invasive distal pancreatectomy with
splenectomy. The specimen can be left intact or the distal
pancreas can be divided from the spleen and the specimens
removed separately. There has been no evidence suggesting
a benefit of maintain the specimen intact at the time of
removal assuming the lesion is not violated by performing
this maneuver. The most commonly utilized extraction site
for the specimen is the supra-umbilical trochar site which
requires replacement of the robotic camera to the right
para-median or left para-median trochar depending on the
surgical system utilized. Prior to removal of the specimens a
surgical drain can be placed through the left anterior axillary
trochar site with removal of the trochar. The specimens
are placed within a protective bag to avoid trochar site
seeding or contamination. The extraction trochar often
requires enlargement for specimen removal. Trochar fascial
defects can be closed using either a transfascial or anterior
approach.
Conclusions
Robotic distal pancreatectomy is a valuable technique
for performing minimally invasive distal pancreatectomy.
The increased dexterity afforded by the robotic surgical
systems can aid the surgeon, particularly during lymph node
dissections such as those in a RAMPS procedure or vascular
dissection such as spleen-preserving techniques. Further
investigations which will attempt to expand the body of
evidence on the role of robotic distal pancreatectomy may
be important to clarifying how to best implement the
technology.

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Acknowledgements
None.
Footnote
Conicts of Interest: The authors have no conicts of interest
to declare.
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Available online: http://www.asvide.com/articles/1719
doi: 10.21037/jovs.2017.08.01
Cite this article as: Royall NA, Walsh RM. Robotic distal
pancreatectomy and splenectomy: rationale and technical
considerations. J Vis Surg 2017;3:135.