Robot-assisted spleen preserving distal pancreatectomy for NET

Graziano Pernazza, Stefano Mattacchione, Paolo Mazzocchi, Carlo E Vitelli. AO San Giovanni Addolorata Hospital

INTRODUCTION

Minimally invasive approach to pancreatic resection grew during last decade and pancreatic operations are frequently performed laparoscopically.

Major pancreatic resections remain extremely challenging, long time consuming and skill requiring.

Robotics still offer an additional option to achieve meticoulus dissection and delicate manipulation of tissues, reducing the risk of bleeding and conversion.

All these aspects afford peri-operative benefits such as shorter hospital stay, fewer complications and more patient satisfaction.

METHODS AND PROCEDURE

41 y.o female was submitted to clinical evaluation and to abdominal ultrasound (USS) for an aspecific symptomatology with diffuse abdominal pains.

The USS incidentally revealed a nodular mass in the proximal part of the pancreatic tail.

Onco-markers serum test and a complete screening for neuroendocrine pancreatic tumor (NET) was performed. Both MDCT and DWI-MRI scan were performed.

A 2.5 cm max diameter nodule, confined to the body-tail pancreatic parenchyma without Wirsung stenosis was confirmed. No vascular structures were involved and no lymph nodes were grossly pathologic.

An echo-endoscopy guided FNAB confirmed the radiologic findings and cytology was suggestive for NET.

Patient was submitted to robot-assisted spleen preserving distal pancreatic resection.

RESULTS

The procedure was completed in 195 min. The dissection was carried out with a full-robotic technique. Each branch of the splenic vein was isolated, ligated and sectioned. Blood losses were negligible. The body of the pancreas was interrupted by a linear stapler.

A minimal bleeding from the splenic vein was controlled robotically, closing the small tear by a single 5-0 prolene stitch.

Postoperative course was uneventful. Drainage was removed on 1st PO day. Histological examination confirmed NET pT2 pN0 R0 G1. Patient was discharged in 3rd postoperative day in excellent conditions.

DISCUSSION

Pancreatic surgery is one of the most complex fields of surgery. The role of MIS has been widely discussed and a convergent opinion is still far, but the application of minimally invasive techniques is progressively growing and robotic surgery is leading the process. Technological improvements and specific training programs allows to define pancreatic surgery safe and feasible with similar results than in open surgery, with better short-term outcomes.

In our experience of proximal pancreatic surgery, robotic platform was crucial in overcoming limitations of conventional laparoscopy in performing fine dissections and microsutures.

In this operation robotic assistance was essential to perform a correct dissection of the tail of the pancreas, with minimal bleeding. In case of major bleeding robotic assistance allows to avoid open conversion.