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Page 105 Jiao et al. Art Int Surg 2023;3:98-110 https://dx.doi.org/10.20517/ais.2023.03

umbilical port is swapped with a 15 mm cannula (Versa One Optical trocar with fixation cannula, Covidien
USA) port for insertion of a 15 mm endo bag (Endo Catch II Auto suture, Specimen retrieval pouch,15 mm
Covidien, USA) to retrieve the specimen. However, there are several specimen retrieval bags available with a
capacity of over a liter (1,200-1,500 mL) that can fit in a 12 mm port without the need to swap for a 15 mm
diameter port. The port is removed with the specimen by extending the incision to allow for safe removal.
Pneumoperitoneum is released. After extraction of the specimen, the sub umbilical port site incision is
closed with loop 0/0 PDS and skin with 2/0 Monocryl subcuticular stitch and covered with a wound
dressing before proceeding to reconstruction.

Reconstruction
After the reintroduction of the pneumoperitoneum, the reconstruction proceeds with four robotic arms and
one existing assistant port in the right iliac fossa. Once again, we have standardized the techniques for
pancreatic, biliary, and gastric anastomosis to be consistent with very little variation. The key points are as
follows:

1. Pancreatic anastomosis

a.Visible pancreatic duct-Blumgart technique

b. Non-visible pancreatic duct-pancreaticogastrostomy

2. Biliary anastomosis

a. Duct ≥ 8 mm - end to side with continuous running suture, laparoscopic 3/0 V-Loc or 3/0 FILBLOC

b. Duct < 8 mm - end to side with interrupted 4/0 PDS suture

3. Gastric and jejunal anastomosis

a. Side to side gastrojejunostomy with endo GIA 45 mm

b. Side to side jejunojejunostomy 30cm below GJ with endo GIA 45 mm

Pancreatic anastomosis
Sixty-one different types of pancreatic anastomoses have been described in the literature, which can be
divided into three groups: end-to-end pancreatojejunostomy, end-to-side pancreatojejunostomy, and end-
to-side pancreaticogastrostomy. However, we have simplified and standardized this to use one technique for
the reconstruction of the pancreas based on the visibility of the pancreatic duct to reduce variations and
postoperative leaks. Before the anastomosis, the pancreatic remnant is mobilized for up to at least 2cm from
the splenic vein, and hemostasis is secured at the cut surface.

(1) Visible pancreatic duct
If the duct is visible, a modified Blumgart technique is used to form an end-to-side pancreatojejunostomy as
described for OPD . First, we take a transverse mattress (U stitch) cephalad to the pancreatic duct between
[14]
the pancreatic remnant and posterior jejunum with a 3/0 PDS suture, the first Blumgart stitch. The needle is
kept on the thread at this point. Next, the duct to mucosa pancreatic-jejunal (end to side) anastomosis is
completed using 4/0 or 5/0 PDS sutures. Due to the magnification and dexterity of robotic instruments, this