Step-by-Step Hepatic Artery and Celiac Axis Dissection According to the Inoue Classification During Robotic...

Area of Science:

• Minimally Invasive Surgery
• Surgical Oncology
• Robotic Surgery

Background:

• The Inoue classification defines three levels of celiac axis (CA) and hepatic artery (HA) dissection during open pancreaticoduodenectomy (PD).
• Robotic PD adoption necessitates standardized techniques to achieve the oncological standards of open surgery.
• A clear robotic approach for all Inoue classification levels of CA-HA dissection is currently lacking.

Purpose of the Study:

• To present a stepwise robotic technique for celiac axis (CA) and hepatic artery (HA) dissection.
• To demonstrate the feasibility of achieving Inoue classification levels 1, 2, and 3 using a robotic approach.
• To provide a standardized robotic method for CA-HA dissection in pancreaticoduodenectomy (PD).

Main Methods:

• A standardized robotic technique for graded CA-HA dissection (levels 1-3) is presented via surgical video.
• Key principles include arterial control with vessel loops, selective instrument use (monopolar scissors, Maryland bipolar forceps), and energy devices away from major arteries.
• A four-hand robotic strategy involving two experienced surgeons optimizes exposure and safety.

Main Results:

• Robotic PD successfully achieved all three levels of CA-HA dissection per the Inoue classification.
• The robotic platform provided magnified visualization and precise dissection along vascular and perineural planes.
• Advanced dissections, including perineural clearance, were performed without intraoperative arterial injury or complications.

Conclusions:

• A graded robotic dissection of the CA and HA, following the Inoue classification, is safely reproducible in PD.
• This technique supports the standardization of oncological principles in robotic pancreatic surgery.
• Robotic PD can achieve the same oncological safety as open surgery for perivascular dissection.