We gain access to the peritoneum with a 5 mm OptiView port in the left upper quadrant under direct vision. This can also be accomplished with a Veress needle using the standard Veress insertion technique. The placement of this port is planned to allow for eventual upsizing to one of the 8 mm robot working ports (Fig. 20.2). The abdomen is insufflated to 15 mmHg of pressure, and an initial inspection of the abdominal cavity is performed to determine the presence of any metastatic disease or other pathology that would alter the operative approach. If the decision is made to proceed, a periumbilical 12 mm camera port is placed. We immediately also insert a figure-of-eight 0 Polysorb/Vicryl suture using a Carter-Thomason suture passer to allow for a rapid fascial closure at the end of the case. Additional 8 mm robotic and 5 mm/12 mm assistant ports are placed as demonstrated in Fig. 20.2. A right lateral 5 mm port is used as an entry site for the liver retractor to allow for the elevation of the left lateral segment of the liver and the stomach. The left lower quadrant 12 mm port site will eventually be slightly enlarged and serve as the specimen extraction site during the operation .

The patient is placed in a steep reverse Trendelenburg position and rotation to the left or right is utilized to optimize the visualization of the operative field. This is a key step in the operation because once the daVinci^® system is docked, no further adjustments in patient or bed positioning can be made without removing all of the instruments and completely undocking the robotic arms. With all ports in place, we insert a triangular liver retractor to elevate the left lateral segment of the liver and directly visualize the anterior surface of the stomach and the spleen. We expose the anterior surface of the pancreas by dividing the greater gastrocolic omentum immediately outside of the right gastroepiploic arcade. The line of division is continued taking the short gastric vessels all the way to the left crus of the gastroesophageal hiatus. We utilize the laparoscopic LigaSure™ instrument for the omental division. The operating surgeon is typically on the right side of the patient, while the first assistant provides countertraction and exposure from a position between the patient’s legs during this step. Division of the omentum provides exposure to the anterior surface of the pancreas toward the spleen.

Once the stomach is mobilized, it can be placed above the triangular liver retractor to keep it out of the operative field without sacrificing an active instrument. At this point, the daVinci^® system is brought into the field. Arms 1 and 3 are docked to the left of the camera; arm 2 is docked to the right. The 30° robotic camera is inserted into the 12 mm periumbilical port with a 30° downward orientation. Under direct vision, we typically place the robotic hook cautery instrument into arm 1, the fenestrated bipolar grasper into arm 2, and a second non-cautery grasper (Prograsp or Cadiere forceps) into arm 3. The assistant uses a suction irrigator device and a long 5 mm laparoscopic LigaSure™ device through the 5 and 12 mm assistant ports to keep the field clear and to assist with the hemostasis .

The first step of the dissection focuses on the isolation of the proximal splenic artery, which can typically be found above the superior border of the pancreas. For pancreatic cancer s, we divide the pancreas at the neck to ensure an excellent lymphadenectomy along the left gastric pedicle and celiac trunk. For pNETs or other non-PDA diseases, we divide the pancreas 1–2 cm to the right of the lesion. A splenectomy is performed en-bloc for all PDA cases. Careful blunt dissection and judicious use of hook cautery supplemented with the 5 mm LigaSure™ and the fenestrated bipolar device are used to circumferentially dissect the splenic artery. A vessel loop is used to provide gentle traction on the vessel (Fig. 20.3). Occasionally, a robotic Maryland forceps instrument is also used for assistance during this dissection. Once isolated, the splenic artery is divided with the 45 mm gold vascular load for the EndoGIA stapler.

The specific point of division on the pancreas will depend on the patient pathology. We often utilize an intraoperative ultrasound probe for the daVinci^® system to confirm our planned point of division. The dissection of the pancreatic body begins at the inferior border of the pancreas. Specific attention is given to the location of the superior mesenteric vein (SMV), which forms the most proximal extent of the dissection. Additional vascular structures needing identification during this step are the inferior mesenteric vein (IMV) at its insertion to the splenic vein or SMV. We carry the dissection posterior to the pancreas along the avascular plane that separates it from the rest of the retroperitoneum. Along this course, we identify the splenic vein, if it has not been isolated yet. Once the superior edge of the pancreas is reached, we pass a moistened umbilical tape around the gland to provide gentle traction (Fig. 20.4). A 60 mm purple or gold (depending on thickness) EndoGIA stapler load is used for division of the gland. Alternatively, if the gland is too thick, we will transect it with electrocautery scissors and close the stump with a running 3-0 V-Loc suture with 5-0 pds suture closure of the pancreatic duct if found.

With the pancreas and the splenic artery divided, the only structure left to isolate is the splenic vein. At this point, the vein is typically easily visible and is again circumferentially dissected (either at its junction with the superior mesenteric vein [SMV] or to the left of the spleno-portal confluence) and then encircled with the help of a vessel loop (Fig. 20.5). Division of the splenic vein is performed with a 45 mm gold EndoGIA stapler load (Fig. 20.6). At the end of this maneuver, all of the major vascular tributaries to the spleen have been controlled, and we turn our attention to the final retroperitoneal dissection and splenic mobilization.

The extent of the retroperitoneal dissection depends on the pathology being treated. If we are performing a distal pancreatectosplenectomy for a pancreatic adenocarcinoma, we also resect the superficial retroperitoneum anterior to the adrenal gland, renal vessels, and Gerota’s fascia en bloc with the pancreas. If the etiology is a benign or a malignancy other than a true pancreatic adenocarcinoma, the dissection can be simply carried along the retropancreatic avascular plane (just posterior to the splenic vein) toward the spleen. The tissue dissection is typically performed with gentle elevation of the pancreas toward the anterior abdominal wall using arm 3 grasper. The hook cautery, the 5 mm LigaSure™, and the fenestrated bipolar are all involved in hemostasis with the assistant using the suction irrigator to keep the field clear of fluid, blood, and smoke. Carrying the retroperitoneal dissection laterally eventually brings the surgeon to the posterior, superior, and inferior attachments of the spleen. These are divided with hook cautery or the 5 mm LigaSure™ to finish the mobilization of the entire specimen (Fig. 20.7).