LAUSR

Background Robotic pancreaticoduodenectomy (RPD) is performed for resectable periampullary lesions with comparable outcomes to the open approach. 1 Surgical therapy for borderline-resectable (BR) pancreatic tumors is technically challenging and poses a significant risk of bleeding and positive margins. 2 As experience with RPD grows at high-volume centers, case selection can be carefully expanded to include complex vascular resections. 3 We demonstrate a RPD performed for BR pancreatic adenocarcinoma with portal vein (PV) involvement and presence of anomalous hepatic arterial anatomy. Methods A 75-year-old female presented with abdominal pain and obstructive jaundice. She was previously healthy and had a relatively normal body mass index (25.7 kg/m 2 ). Endoscopic ultrasound and computed tomography imaging identified a pancreatic head mass measuring 2.3 cm with evidence of concomitant abutment of the PV (90–180 degree) and abutment of a replaced right hepatic artery (rRHA) originating from the superior mesenteric artery (SMA). Following four cycles of neoadjuvant gemcitabine/nab-paclitaxel, restaging imaging demonstrated partial radiographic response, represented by a lesser degree of PV abutment and resolution of rRHA abutment. RPD was performed with side-bite resection of the PV and preservation of rRHA. The video demonstrates the key steps followed in a robotic pancreaticoduodenectomy performed for a technically challenging pancreatic head cancer and highlights robotic control of bleeding from the PV and SMA obviating the need for conversion. Histopathology revealed a residual moderately differentiated ductal adenocarcinoma with 4-of-40 positive lymph nodes and negative surgical margins. The tumor was staged as ypT1cN2 (AJCC 8 th edition). The patient had an uneventful postoperative course and was discharged on hospital day 8. Conclusion In high-volume centers, the robotic approach can be safely used in selected cases of technically challenging BR pancreatic head cancers.