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Robotic Assisted Sleeve Duodenectomy for D4 Duodenal Adenocarcinoma

Spencer M Mossack, MS1, Joseph Kim, MD2, Aaron R Sasson, MD1, Georgios V Georgakis, MD, PhD1. 1Stony Brook University, 2University of Kentucky

We are presenting a robotic assisted sleeve duodenectomy for a D 4 duodenal adenocarcinoma

Patient is a 72 year old male who presented with recurrent GI bleed with anemia.

He was on Eliquis for paroxysmal atrial fibrillation. Prior work up was unable to identify the source of bleeding. Push enteroscopy showed a large, friable proximal jejunal ulcerated mass. Pathology was consistent with moderately differentiated invasive adenocarcinoma. CT scan excluded the presence of metastatic disease.

During surgery, a suspicious lesion on segment 2 of the liver was excised and sent for frozen section. It came back negative. With arm 3 we pulled the stomach anteriorly and we entered the lesser sac through the gastrocolic ligament.  The avascular plane was dissected to identify the posterior stomach. This plane was followed to the right upper quadrant and further towards the hepatic flexure.

The patient had a prior cholecystectomy and he had adhesions in this area. We performed a Cattel Braasch maneuver medializing the right colon as much as possible. Next, we performed a Kocher maneuver, focusing on the distal second and third part of the duodenum. Once the duodenum was freed from its retroperitoneal attachments, we were able to take down the ligament of Treitz from the right side. The proximal jejunum was pulled in the right upper quadrant and was divided with an laparoscopic stapler. The proximal jejunum mesentery was then divided with a vessel sealing energy device towards the pancreas. Care was taken to protect the small bowel mesentery and especially the superior mesenteric artery and vein. The last fibers of the ligament of Treitz were taken with an energy sealing device and the third part of the duodenum was separated from the pancreas.

The freed third part of the duodenum was divided from the second part with an laparoscopic stapler. Care was taken to stay away from the pancreatic ampulla. An isoperistaltic duodenojejunostomy was created using a 60 mm laparoscopic stapler. The common enterotomy was closed with a 2 layer running 3-0 Monocryl V Lock suture starting from the inferior part of the opening.  This is very important because the inferior part of the common enterotomy is very difficult to visualize if the suture starts from the superior part of the enterotomy. Finally, viability and good perfusion of the anastomosis was verified with Indocyanine Green and fluorescent imaging in situ.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 95932

Program Number: V168

Presentation Session: Video Loop Day 1

Presentation Type: VideoLoop

191

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