Counter-Clockwise Approach for Robotic Pylorus-Preserving Pancreatoduodenectomy.

PURPOSE: This multi-media article aims to describe a counter-clockwise approach for pancreatoduodenectomy (CCA-PD) in robotic surgery.

METHODS: A CCA-PD was used as a strategy for robotic surgery to treat a 69-year-old woman without comorbidities who presented a ductal adenocarcinoma of the head of the pancreas (2.7 cm) in contact with the portal vein (less than 180°), preoperatively treated with FOLFIRINOX. The procedure was entirely done in the abdominal right upper quadrant (RUQ) following the main steps of CCA-PD resection: section of the first portion of the duodenum; biliary duct transection; Kocherization of the duodenum and retropancreatic lymphadenectomy; section of the jejunum; portal vein dissection; transection of the pancreas and uncinate detachment. The reconstruction also followed the counter-clockwise direction with a single jejunal loop with end-to-side anastomoses: pancreato-jejunal; choledoco-jejunal; duodenojejunal.

RESULTS: The total operation time was 435 min, and the estimated blood loss was 200 mL. The postoperative course was uneventful without complications, with hospital discharge on the fifth postoperative day. The final pathology was ductal adenocarcinoma (G2), ypT2ypN2 (07/31), with negative surgical margins.

DISCUSSION: The entire surgery happens in a unique surgical field, the RUQ, which saves time by avoiding unnecessary mobilization of the bowel and favors a layer-by-layer dissection with enough space for both dissections and sutures on each step of the procedure and improving bleeding control if necessary.