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Jiao et al. Art Int Surg 2023;3:98-110 https://dx.doi.org/10.20517/ais.2023.03 Page 100

2. Patient positioning and port placement

3. Robotic instrumentation

4. Robotic pancreatoduodenectomy

(1) Resection

a. Hilar dissection/division of the gastroduodenal artery (GDA)

b. Transection of the stomach/ duodenum

c. Kocherization and mobilization of the duodenojejunal (DJ) flexure

d. Pancreatic tunneling and resection of the pancreatic neck

e. Transection of the common hepatic duct and cholecystectomy

f. Dissection from the superior mesenteric vein (SMV)/portal vein (PV)

g. Specimen extraction

(2) Reconstruction

a. Pancreatic anastomosis

b. Biliary anastomosis

c. Gastric and jejunal anastomosis

(3) Haemostasis and drains

Patient selection
We are a tertiary referral hospital for cancer patients in London, UK. All our patients undergo extensive
staging with CECT, MRI, PET/CT, and EUS for pancreatic cancer and are discussed at the weekly
multidisciplinary meeting before resection. Patients with vascular involvement of the superior mesenteric
vein and artery are treated with neoadjuvant chemotherapy/chemoradiotherapy followed by restaging. We
exclude patients requiring vascular resection for RPD and those who have had multiple laparotomies
previously. This is to reduce the conversion rate and risks of intraoperative bleeding. After a
multidisciplinary team discussion, patients are assessed by the anesthetic team, dietician, and
physiotherapist before the surgery. Patients with jaundice (bilirubin > 250 umo/L) are usually treated with
ERCP biliary stenting with SEMS to relieve jaundice before surgery. Biopsies are taken endoscopically and
repeated if inconclusive. The surgery is usually performed 4 weeks after the last cycle of systemic
neoadjuvant chemotherapy.