Robotic Artery-First Approach During Pancreatoduodenectomy.

Background: Surgical resection with adjuvant or neoadjuvant chemotherapy is the only curative modality for treatment of patients with pancreatic and periampullary tumors. With the increasing use of minimally invasive techniques, laparoscopic and robotic pancreatoduodenectomy (PD) has become more common, but laparoscopic artery-first techniques have been described in few studies. The aim of this study is to describe our robotic artery-first technique.

Methods: Video clips were compiled from several robotic PDs to demonstrate the artery-first technique. This technique consists of early retroperitoneal dissection of the superior mesenteric artery from the pancreatic head.

Results: Overall, 73 patients underwent robotic PD at our center between March 2018 and August 2020. Of these, 24 patients underwent the robotic artery-first approach. Indication for its use included proximity of the tumor to the portal vein or SMV in six cases. In three cases, partial resection of the portomesenteric axis was necessary, and the artery-first approach allowed for safe venous resection and reconstruction. In three other cases, the tumor was in close contact with the vein, but it could be resected with free margins without venous resection. In the remaining 18 patients, the approach was systematically used regardless of tumor proximity to the portomesenteric axis.

Conclusions: This robotic artery-first approach is feasible and safe for PD. The approach could facilitate robotic PD, and its systematical use could provide some important advantages during the resection phase. The videos could also help oncological surgeons to perform this complex yet important maneuver.