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Page 101 Jiao et al. Art Int Surg 2023;3:98-110 https://dx.doi.org/10.20517/ais.2023.03

Patient positioning and port insertion [Figures 1 and 2]:
The supine position with 15 degrees reverse Trendelenburg is used for RPD, and the table is lowered for
better ergonomics for the assistant surgeon. Arms are tucked at the sides of the trunk. The surgical assistant
sits or stands between the legs. Pneumoperitoneum is induced with a sub umbilical vertical Hasson
technique (Kii Balloon Blunt Tip system 12 × 100 mm, Applied Medical, Netherlands), through which the
resected tissue is extracted by enlarging the incision to 4-5 cm in length [Figure 3]. Standard port placement
is used with the Si and X system docked from the head of the patient and the Xi system from the side of the
patient. The camera port is inserted at 2-4 cm above and lateral to the umbilicus in the right mid-clavicular
line, as camera arm or arm 2 should ideally be 20 cm away from the head of the pancreas. Arm 1 is
positioned lateral to arm 2 on the right side of the patient, and arms 3 and 4 lateral to arm 2 on 3,
respectively, on the left side of the patient. For the X and Xi system, all ports are in the same horizontal line,
at least 6 cm apart [Figure 1A]; for the Si system, the ports should be placed in a ‘u’ shaped and 6 cm apart
[Figure 1B]. Further to the above 4 (8 mm bladeless obturator, Da Vinci Xi, Intuitive Surgical, USA) robotic
ports, we use a 12 mm port (Kii Fios first entry,12 × 100 mm, Applied Medical, Netherlands) with a
minimum of 3 cm below and between arm 1 and arm 2 on the right side of the patient as the assistant’s left
hand working port. The assistant ports are used for suction, insertion of sutures, swabs, laparoscopic
grasper, and staplers. The camera is inserted through arm 2 and targeted at the head of the pancreas. When
the robotic EndoWristed stapler is used, a 12 mm port will need to be used for arm 3.

Robotic instrumentation
The standard robotic instrument used after the camera insertion in arm 2 is bipolar fenestrated forceps in
arm 1, hook diathermy in arm 3 and Cadiere or Prograsp forceps in arm 4. Arm 3 is where most instrument
changes take place, swapping the hook diathermy for the vessel sealer (Vessel Sealer Extend, Da Vinci Xi,
Intuitive Surgical, USA), needle holder/suture cutter, hem-o-lok (Weck Hem-o-Lok L, Hem-0-Lok ML,
Teleflex Medical, USA) and scissors, as required.

Resection
We modified our RPD based on our extensive experience with OPD over 25 years and LPD over 15 years
and standardized it to be consistent with surgical techniques and instrumentation for improved training and
clinical outcomes by reducing variations with the following key points for resection following our initial 25
RPD:

(1) Following diagnostic laparoscopy to exclude peritoneal and/or liver metastasis, we start with hilar
dissection. However, we avoid cholecystectomy and bile duct transection at the start of the resection to
avoid spillage of bile, which requires frequent suction, increasing operative time.

(2) We perform a partial hepatic flexure mobilization in our approach after taking down the hepatocolic
ligament over Gerota’s fascia by opening the angle between D3 and the colonic mesentery to expose the
route of the small bowel mesentery and the origin of the SMV.

(3) The GDA is transfixed with 3/0 prolene suture and clipped with medium-large robotic Hem-o-loks
before transection.

(4) The pancreatic crural tissue behind the SMV and lateral to the superior mesenteric artery (SMA) is
divided with laparoscopic staplers (Echelon Flex Powered plus articulating endoscopic linear cutter 60 mm,
Ethicon, USA) for better hemostasis and prevention of bleeding postoperatively from SMA branches to the
pancreas.