Chapter 91: Resection of the Tail of the Pancreas and Spleen, Robotic

INDICATIONS

Robot-assisted resection of the body and tail of the pancreas may be used for localized pancreatic adenocarcinoma, pancreatic neuroendocrine tumors such as insulinomas, pancreatic cystic neoplasms, and pseudopapillary tumors. The approach is not recommended for chronic calcific pancreatitis. For adenocarcinoma of the body and tail of the pancreas, splenectomy should be performed. Splenic preservation may be considered in the absence of a malignant neoplasm.

PREOPERATIVE PREPARATION

Preparation is related to the preoperative diagnosis. If splenectomy is to be performed, vaccinations for pneumococcus, Haemophilus influenza, and meningococcus should be administered prior to surgery. For patients with insulinoma, suggested by fasting hypoglycemia of less than 50 mg/dL, supplementary glucose administered by mouth or intravenously for the 24 hours prior to surgery and intravenously during surgery is required. When a gastrinoma is suspected, the fluid and electrolyte balance should be corrected, particularly if there have been large losses of gastric secretions or losses from enteritis. Every effort should be made to localize one or more neuroendocrine tumors by computed tomography, magnetic resonance imaging, endoscopic ultrasound, or ⁶⁸Ga-DOTATATE positron emission tomography prior to surgery. It is less common to need to use somatostatin scintigraphy or selective arteriography and selective arterial stimulation with either secretin (for gastrinoma) or calcium (for insulinoma) given the sensitivity of current imaging modalities.

ANESTHESIA

General anesthesia with endotracheal intubation is used.

POSITION

Patients are positioned supine with a split-leg position to facilitate the assistant standing at bedside (FIGURE 1A).

OPERATIVE PREPARATION

Clippers are used to remove hair from the level of the nipples to the pubis. This skin is prepped in routine manner. Sterile drapes are applied. A preoperative antibiotic is administered prior to incision. Then a time-out is performed.

INCISION AND EXPOSURE

After ensuring placement of a nasogastric tube for decompression of the stomach, a Veress needle is placed in the left upper quadrant at Palmer’s point (see Chapter 14). Placement is confirmed with the saline drip test. The abdomen is insufflated with 15 mm Hg of carbon dioxide gas. Robotic ports are placed approximately at the level of the umbilicus depending on patient habitus and size (FIGURE 1B, C).

The first robotic port is placed using an optical trocar or other technique. The additional three 8-mm ports are placed evenly spaced across the abdomen. An assistant 12-mm port in placed in the left lower quadrant that will be used as the extraction site. Use caution not to injure the inferior epigastric artery when placing this port. An additional 5-mm port can be placed in the right lower quadrant if an additional assistant port is needed. A Nathanson liver retractor is placed in the epigastrium to facilitate exposure. The ...