Robotic RAMPS with 360° celiac axis skeletonization: a standardized vascular approach (technical note with video)

Radical antegrade modular pancreatosplenectomy (RAMPS) is an established technique for left-sided pancreatic cancer, increasingly performed using a robotic approach. However, vascular dissection at the level of the celiac axis and superior mesenteric artery (SMA) remains technically demanding, and standardized strategies are still lacking. We describe a robotic anterior RAMPS using early SMA exposure through a ligament of Treitz approach followed by systematic celiac axis dissection and circumferential (360°) arterial skeletonization. The technique is illustrated in a 65-year-old patient with pancreatic body adenocarcinoma. After early identification of key vascular landmarks through a ligament of Treitz approach, the celiac trunk and its branches are progressively exposed and dissected using a meticulous layer-by-layer technique. Pancreatic transection and division of the splenic vessels allow optimal access to the arterial axis, enabling complete skeletonization of the celiac trunk and SMA and en bloc lymphadenectomy. Operative time was 240 min with minimal blood loss. The postoperative course was uneventful, with discharge on postoperative day 10; histopathology showed a well-differentiated (G1) pancreatic adenocarcinoma (pT3N0M0), R0 resection, and no lymph node metastases (0/15). This standardized vascular approach may improve reproducibility and safety of robotic RAMPS, facilitating precise arterial dissection and adequate oncological clearance.