The Role of the Robotic Assisted Laparoscopic Technique in the Uncinate Process Dissection Debate

Federico Gheza, MD, Stefano D’ugo, MD, Mario Masrur, MD, Paolo Raimondi, MD, David Calatayud, MD PhD, Francesco Bianco, MD, Subhashini Ayloo, MD FACS, Piercristoforo Giulianotti, MD FACS. UIC – Chicago

INTRODUCTION:
Partial pancreaticoduodenectomy (PD) with or without pylorus preservation remain the gold standard in pancreatic head tumors treatment. The laparoscopic pancreaticoduodenectomy is still the prerogative of a few centers worldwide, mainly for the technical difficulties. Uncinate process dissection represents one of the most challenging steps of the PD and in open surgery the discussion about the “uncinate first” or “superior mesenteric artery first” approches is animating the surgical debate. Ten years after the introduction of the robotic technology in minimally invasive PD, we herein describe the role of this approach in the uncinate process dissection.
METHODS:
This single surgeon series includes 95 robotic assisted PD, collected from March 2001 to September 2011, 63 of which for malignant tumors. The trocar positioning, with the camera placed 4 cm on the right side of the umbilicus, is tailored to allow a perfect lateral-to-medial vision during uncinate process dissection and combined with the 30 degrees camera permits to approach the mesenteric vessels almost from behind. Our standardized uncinate process dissection proceeds like in the classical open technique: it is performed after the transection of the pancreatic neck and the first jejunal loop, as the last foundamental step of pancreatic head dissection. The technical difference with the robotic assistance is that the surgeon’s point of view could range for 180 degrees on the right side of the vessels. This means that we can choose the direction of the dissection along the Leriche’s plane approaching all the vessels from a better angle, without losing the traction on the freed head of the pancreas, applied using the fourth arm. This action reproduces the open maneuver of pulling out the uncinate process from its nest, which is the main advantage of this approach.
RESULTS:
Following this pathway the uncinate process dissection was accomplished in all the patients, without major vascular injuries or need of conversion. The first technical improvement came with the introduction of the fourth arm: coming from the right side it is in the perfect direction to apply traction during the mesenteric vessels dissection. Our second major progress was the camera port positioning in the right side: theoretically the laparoscopic technique could provide the same point of view, but without the flexibility of robotic instruments moving the camera on the right could make the other phases of the PD extremely demanding.
CONCLUSIONS:
Combining the classical open “uncinate as the last” approach and the whole robotic dissection armamentarium with a right-to-left and posterior vision, we can change the surgeon’s capacity to dissect also the retroperitoneal peripancreatic tissue, trying to reach a higher number of R0 resection. Future experiences are needed to evaluate the possible prognostic impact of the different approaches and their oncological relevance, but probably the robotic technique has to be included in this debate and no longer considered only in terms of safety and feasibility.