Robotic Central Pancreatectomy: Patient Selection and Surgical Approach

Central pancreatectomy (CP) is one of the parenchyma-sparing approaches proposed for low-grade tumors¹. CP has a lower incidence of diabetes compared with distal pancreatectomy², but may harbor risks of positive distal pancreatic margin, inadequate lymph node (LN) removal, and pancreatic fistula from the pancreaticojejunal anastomosis. Given the reported oncologic safety³, we selectively perform CP for small pancreatic neuroendocrine tumors (pNETs) that are localized to the pancreatic neck. A robotic surgical approach with augmented skills can perform a CP procedure in a minimally invasive fashion⁴; however, a standard surgical procedure for robotic CP has not yet been established. A key safety consideration when performing CP is to avoid injury to the dorsal pancreatic arteries, which supply blood to the pancreatic neck⁵. We report on a robotic CP in a 59-year-old male with a 2.2 cm nonfunctional, clinically node-negative pNET localized to the pancreatic neck. The pancreatic tail showed a large volume. After discussing the risks and benefits, the patient underwent a robotic CP. Following tumor localization at the pancreatic neck via ultrasound, we transected the proximal neck using a stapler. We then continued dissection of the hepatic and splenic arteries, and the dorsal pancreatic artery, originating from the splenic artery, was securely clipped. After transection of the pancreatic body, the Roux limb was elevated through the left mesocolic window to complete the pancreaticojejunostomy. Recovery was favorable, without incidence of diabetes. The pathological findings were a well-differentiated neuroendocrine tumor, without LN involvement.In summary, robotic CP with regional LN dissection can be safely performed for small pNETs, without lymphadenopathy.