Robotic distal pancreatectomy with a left posterior approach

Standard procedures for performing robotic distal pancreatectomy for pancreatic cancer have not yet been established. The left posterior laparoscopic approach to left-sided cancers has been described in the direction dorsal and caudal to the pancreas 2). We describe a left posterior approach for robotic distal pancreatectomy.

Six abdominal ports were placed via trocars, including two for the assistant surgeon, and the laparoscope was inserted through the left lower abdomen (Fig. 1a). Then, the retroperitoneum of the inferior border of the pancreas was dissected, and the retroperitoneum dissected along the surface of the left renal vein and left adrenal gland. After lifting the pancreas ventrally, the left diaphragmatic crus and the anterior aspect of the superior mesenteric artery were widely exposed (Video S1, Fig. 1b). After exposing the confluence of the splenic vein (SPV), the origin of the splenic artery (SPA) was secured by dissecting the nerves around it (Fig. 1c). Because an adequate surgical field for handling the SPA could not be secured, we temporarily clamped the SPA and then proceeded to divide the SPV. Retroperitoneal tissues and lymph nodes were then dissected in an en bloc manner from the dorsal aspect (Video S2). The laparoscope was switched to the umbilical port, and the pancreas was transected using a linear stapler inserted through the left lower abdominal port (Video S3, Fig. 1b).

Although division of the splenic artery is generally performed using an anterior approach from above the pancreas, an "artery-first" left posterior approach can achieve both goals in the same operative field.