The operation starts with the patient bed in neutral position, and a 5 mm optical trocar is placed to the left of the midline through the rectus sheath 2–3 cm above the level of the umbilicus. Upon entry into the abdomen the peritoneum is explored for evidence of metastatic disease. Barring any contraindications to resection additional laparoscopic/robotic ports are placed as shown in Fig. 22.2. Approximately 10 cm (roughly one hand-breadth) is required between robotic ports to minimize collisions between the robotic arms. The right lateral trocar is placed with the patient in reverse Trendelenburg and the right side rotated upwards to allow it to be positioned as far laterally as possible. The initial entry 5 mm trocar is changed to an 8 mm trocar for robotic instruments.

The initial dissection and exploration are performed laparoscopically. Any adhesions between the liver and stomach are divided to allow placement of the liver retractor. The lesser sac is entered through the gastrocolic ligament below the level of the gastroepiploic arcade and opened widely. The right colon is mobilized completely to the cecum. Next, a marking stitch is placed in the jejunum 80 cm distal to the ligament of Treitz (LOT). Proximal to the marking stitch the jejunum is tacked to the greater curve of the stomach with another stitch. This maneuver facilitates identification and orientation of the jejunal loop for creation of the gastrojejunostomy (GJ).

The robot is docked and robotic instruments are inserted: monopolar cautery hook dissector in arm 1, fenestrated bipolar cautery grasper in arm 2, and Prograsp™ forceps in arm 3. A 30°, down-angled stereoscopic laparoscope is used. The bedside assistant, standing between the legs of the patient, operates the vessel sealer and suction–irrigator or laparoscopic graspers through the right lower quadrant 5 mm trocar and the left lower quadrant 12 mm trocar. The bedside assistant is responsible for clearing the surgical field of blood/fluids, providing dynamic retraction, dividing blood vessels and achieving hemostasis with the vessel sealer, operating staplers, exchanging robotic instruments, passing sutures, and extracting the specimens. Bedside assistant requires sound surgical instinct, a thorough knowledge of surgical anatomy and the steps of the operation, as well as maneuvers to stem blood loss or manage emergencies. It is not an appropriate role for most surgical scrub technicians, physician assistant, or junior surgical residents.

Once the robot arms are positioned, hook cautery is used to dissect the duodenum and the head of the pancreas off of the retroperitoneum until the left renal vein is visible and the LOT is reached. The proximal jejunum is delivered into the dissection field whereupon a point 10 cm distal to the LOT can be chosen to create a mesenteric window and divide the bowel with a stapler (2.5 mm staple height). The vessel sealer is used to divide the mesentery. This linearizes the distal duodenum and facilitates the lateral SMV dissection later.

The lesser omentum is opened in the pars flaccida taking care not to divide a replaced/accessory left hepatic artery (HA), if present. A stapler with 3.5 mm staples is used to divide the stomach 2–3 cm proximal to the pylorus. The antrum is retracted to expose the underlying neck of the pancreas. The hepatic artery lymph node (level VIIIa) is identified and the peritoneum is opened along its inferior border. The entire lymph node is excised exposing the [common] HA beneath it. Once the HA is identified, it is traced distally to the takeoff of the gastroduodenal artery (GDA) which is skeletonized. The HA [proper] is also traced further distally where the right gastric artery may be found and divided with a vessel sealer. The importance of using Doppler flow ultrasound to confirm flow in the HA while occluding the GDA cannot be understated. It is also the author’s practice to rotate the specimen medially (to the left) and dissect the lateral border of the hepatoduodenal ligament to confirm the presence or absence of an accessory/replaced right HA before the GDA has been ligated. Once these steps have confirmed the arterial anatomy, a stapler with 2.5 mm staples can be used to transect the GDA . The bedside assistant applies a 10 mm vascular clip to the GDA stump.

With the GDA transected the portal vein (PV) is easily identified immediately deep to the previous dissection. The hook cautery is used to dissect in the peri-adventitial plane of the vein, and soft tissue at the superior neck of the pancreas is divided. This is a convenient time to create the superior aspect of the superior mesenteric vein (SMV) tunnel as well. Next, the lateral border of the PV is dissected, freeing it from the bile duct anterio-laterally. This dissection may be difficult in patients with bile duct tumors; care must be taken not to injure the PV where it may be adherent to the common bile duct (CBD). At this point the lymph node posterior to the PV and CBD (level XI) may be dissected and retracted caudally to be taken with the specimen. Again, identification and protection of a replaced right HA are necessary and may be aided by placing vessel loop around it. If no CBD stent has been placed the bile duct is divided with a stapler with 2.5 mm staples. If a stent is present the bile duct may be transected with a stapler above the stent or with cautery. Cholecystectomy can then be performed in a standard fashion.

Next, with the third arm retracting the specimen cephalad the inferior neck of the pancreas is exposed. The peritoneum at the inferior border of the pancreas is opened until the SMV is identified, allowing creation of the pancreatic neck tunnel. This is accomplished by using a grasper to gently lift the pancreas while the hook cautery bluntly develops the avascular plane anterior to the SMV using gentle downward movements progressively more proximal on the vein wall (Fig. 22.3). Several maneuvers assist in making the tunnel dissection safer and easier: create a wide window in the peritoneum at the inferior border of the pancreas—this will open the dissection to allow greater access to the tunnel and effectively make the tunnel shorter. Also, use the vessel sealer or bipolar cautery to divide the soft tissue at the inferior neck of the pancreas medial to tunnel. There are typically several small vessels here which bleed profusely if divided with monopolar cautery. Finally, pan outwards with the camera to identify the PV at the superior neck of the gland, as this will establish the trajectory of the SMV and help to avoid creating a tunnel that does not connect to the superior dissection. The superior and inferior tunnels are joined and the bedside assistant places a laparoscopic grasper through the tunnel so an umbilical tape may be passed through .

Retracting the specimen laterally, the robotic scissors are used with the tips opened 3–5 mm to bluntly ‘roll’ the vein off of the pancreas. The bedside assistant applies gentle retraction on the vein medially allowing progressive dissection towards the uncinate process. Inferiorly, this dissection will expose the middle colic and gastroepiploic veins as they drain into the SMV. Next, the entire specimen is rotated medially and the lateral wall of the SMV is identified and skeletonized. This maneuver is important to avoid mistaking the first jejunal vein for the SMV which can set the stage for ligating the true SMV under the assumption that it is an expendable mesocolic tributary. Once the SMV is positively identified the specimen is rotated laterally again and the middle colic and gastroepiploic veins may be ligated.

The uncinate process is typically the most challenging portion of the dissection. The bedside assistant plays an active role in retracting the SMV/PV medially and maintaining a bloodless field, while the third robotic arm retracts the specimen laterally ‘up and out’ (analogous to the surgeons left hand during open PD). The console surgeon applies liberal use of bipolar cautery both for obtaining hemostasis and to ‘pre-coagulate’ visible uncinate vessels prior to dividing them. Fortunately, the visualization of the SMA is unparalleled in comparison to the traditional open technique where these steps are performed with a combination of ‘feel’ and blind dissection. This enhanced visualization allows the dissection to follow a plane immediately adjacent to the artery, which enables maximize the retroperitoneal surgical margin. While most bleeding can be avoided with careful use of cautery, there is usually some level of ‘oozing’ that may persist until the specimen is completely freed. As a result, overzealous attempts to achieve a bloodless field may unnecessarily prolong this step and paradoxically result in more blood loss.