Robotic Resection and Reconstruction of the Superior Mesenteric Vein Without Graft During Pancreatoduodenectomy (with Video).

BACKGROUND: Pancreatoduodenectomy is the procedure of choice for tumors in the head of the pancreas. Invasion of major vessels is a relative contraindication for minimally invasive approach. We present a video of a robotic resection and reconstruction of the superior mesenteric vein (SMV) without the use of a graft during pancreatoduodenectomy. METHODS: A 56-year-old female with ductal adenocarcinoma is referred for treatment. CT scan and endoscopic ultrasound showed a 3-cm tumor in the pancreatic head with contact with SMV. The multidisciplinary team decided for upfront surgery. Robotic superior mesenteric artery first approach was used to release the head of the pancreas, so the whole surgical specimen is only attached by the tumor invasion of the SM. After the partial resection of the SMV, its extension precluded lateral suture and a transverse anastomosis was necessary to minimize the risk of narrowing of the SMV. After completion of the venous anastomosis, reconstruction of the alimentary tract was done as usual. RESULTS: Operative time was 430 min. Time of clamping was 30 min and the time for the SMV suture is 23 min. Estimated blood loss was 370 mL. Pathology confirmed a T3N1 ductal adenocarcinoma with free margins. The patient was discharged on the 7th postoperative day. CONCLUSIONS: Robotic resection and reconstruction of the SMV is safe and feasible without graft during pancreatoduodenectomy in patients with invasion but not encasing of the portal vein or SMV. The proposed technique should be used in cases where the invasion requires extended resection that precludes simple lateral suture.