Quality of superior mesenteric and hepatic artery dissection in robotic pancreatoduodenectomy for pancreatic cancer

Abstract

This video manuscript by Ikoma and colleagues demonstrates their approach to the superior mesenteric artery and hepatic artery periadventitial dissection. The quality of superior mesenteric artery and hepatic artery dissections should be maintained in robotic pancreatoduodenectomy when performed for pancreatic cancer, to provide the best possible oncological outcomes. With the recent advancement in robotic surgery platforms, a robotic approach has been increasingly applied to complex surgical oncology procedures, including pancreatoduodenectomy (PD). Periadventitial dissection along the superior mesenteric artery (SMA) and hepatic artery is considered important to achieve a negative margin and removal of key diagnostic lymph nodes, and defines the oncological quality of PD for pancreatic ductal adenocarcinoma (PDAC).1-4 At our institution, periadventitial SMA dissection is routinely performed in open and robotic PD performed for PDAC located at the head of the pancreas to improve the chances of complete (R0) resection, and we believe this step should not be compromised. In this video, we present our surgical approach to SMA and hepatic artery dissection in robotic PD. The first case presented had cT3N1 resectable PDAC at the pancreatic uncinate process, with tumor extension and lymphadenopathy at the posterior SMA. The dissection was completed at the periadventitial layer to achieve a negative margin and clearance of prominent lymph nodes. The second case had cT2N1 resectable PDAC at the pancreatic head with prominent lymphadenopathy at the anterior and posterior hepatic artery. The dissection included posterior hepatic artery lymph node dissection, which was connected to the SMA dissection. For both patients, an external retraction technique5 was used to retract the portal vein and superior mesenteric vein to the patient's left, to provide consistent and critical exposure of the SMA that allowed safe and high-quality oncological dissection. The additional key technique used in the presented videos is the double-bipolar method, originally introduced by Uyama and colleagues.6, 7 Use of two different bipolar settings allows bloodless and precise dissection along the SMA. In addition, using two forceps simultaneously provides additional safety in case bleeding is encountered. Appreciation of anatomical variations of the hepatic arteries and SMA branches for the individual patient is of paramount importance.8, 9 Preoperative computer tomography (CT) scans with arterial and portal venous phases should be thoroughly reviewed for anatomical variants to allow careful hepatic artery and SMA dissection (Figure 1). This preoperative planning is particularly important for a robotic approach because of lack of tactile feedback and difficulty in identifying such vascular variations. In summary, here we demonstrate our approach to SMA and hepatic artery periadventitial dissection. The quality of SMA and hepatic artery dissections should be maintained in robotic PD when performed for PDAC, to provide the best possible oncological outcomes. Supported in part by the U.S. National Institutes of Health/National Cancer Institute under Cancer Center Support Grant P30CA016672. NI received a research grant from Intuitive Surgical (2021). Appendix S1 Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.