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

In 2018, Inoue et al.¹ introduced a systematic classification of the extent of dissection along the celiac axis (CA) and hepatic artery (HA) during open pancreaticoduodenectomy (PD). Three levels of perivascular dissection were defined according to surgical indication: level 1, limited organ resection without oncological dissection for benign or low-grade malignant lesions; level 2, formal lymphadenectomy with preservation of the perivascular nerve plexus for borderline or low-grade malignancies; and level 3, radical dissection, including perineural clearance for pancreatic cancer. As robotic PD is increasingly adopted, it should reproduce the same oncological standards established in open surgery.^2-4 However, a standardized robotic technique capable of achieving all levels of the Inoue classification has not yet been clearly described. This video article aims to present a stepwise robotic approach to CA-HA dissection consistent with these principles.

We present a comprehensive surgical video demonstrating a standardized robotic technique to achieve graded dissection of the CA and HA from level 1 to level 3. A supplementary video specifically illustrates advanced CA-HA dissection in the setting of vascular involvement requiring resection and reconstruction. Independently of the dissection level, three constant technical principles are systematically applied: (1) arterial control through vessel loop encirclement of the HA to avoid undue manipulation; (2) a selective and stepwise use of robotic instruments according to the depth of dissection, with monopolar curved scissors used to develop the superficial planes and Maryland bipolar forceps employed for precise periadventitial skeletonization of the arterial structures, thereby minimizing mechanical and thermal injury to the arterial wall. Energy sealing devices such as the vessel sealer (Intuitive Surgical, Sunnyvale, CA, USA) are used selectively and only away from major arteries, mainly for lymphatic or venous division and for final hemostasis once lymph nodes have been mobilized from the arterial wall. Alternatively, cold dissection with scissors can be used for precise arterial divestment, as previously described by Kauffman et al.⁵; (3) a structured four-hand robotic strategy involving two experienced hepato-pancreato-biliary surgeons to optimize exposure and vascular safety, with one surgeon operating at the console and a second surgeon assisting at the bedside to provide dynamic retraction, suction, and vascular control.

All three levels of CA-HA dissection according to the Inoue classification were successfully achieved robotically. The robotic platform enabled stable magnified visualization and precise skeletonization along vascular and perineural planes. Advanced dissections, including circumferential perineural clearance, were feasible without intraoperative arterial injury or uncontrolled vascular complications, even during level 3 dissections or when vascular resection and reconstruction were required.

A graded clearance of the CA and HA according to the Inoue classification can be safely reproduced during robotic PD, supporting standardization of oncological principles across different levels of perivascular dissection.