Robot transduodenal ampullectomy

Abstract

Purpose: Favorable results of minimally invasive hepatobiliary resections have been reported for malignant and benign tumor entities. While hepatobiliary resections are still performed mostly open up to now, the robotic approach is considered as an attractive alternative. Methods/Results: Here we present an 85-year-old female with an ampullary (ampulla vateri) mass (2x2cm) and consecutive biliary obstruction. Biopsy was negative for malignancy. The patient presented with a past surgical history of Billroth II with Roux-en-Y reconstruction for peptic ulcers disease. Past medical history is significant for CAD and DM2. As the mass was not accessible for endoscopic resection, surgical options (Whipple open or robotic, transduodenal ampullectomy open or robotic) were discussed with the patient. A robotic transduodenal resection was planned.The patient was placed in the supine position and 4 daVinci Surgical Systems™ trocars were inserted as well as an assistant port. After diagnostic laparoscopy and adhesiolysis, the gallbladder was suspended to the abdominal wall to expose the situs. Thereafter the duodenum and pancreatic head were mobilised from the retroperitoneum by a Kocher manoeuvre. Intraoperative ultrasound was used to clarify the location of the ampulla vateri and other relevant structures. Firefly Fluorescence Imaging - after praeoperative application of indocyanine green (Verdye®) - revealed the course of the bile duct. Duodenotomy was performed longitudinally and the ampulla vateri was exposed. Submucosal injection (lift off technique) facilitating sharp local excision of the ampulla was performed. Identification of the pancreatic and bile ducts was ensured during resection. Frozen section was sent to exclude malignacy and to ensure complete excision. Ductal reinsertion was achieved by circular single sutures (duct-to-mucosa). Single layer closure of the duodenal wall completed reconstruction. Gallbladder was removed. Pathology confirmed the diagnosis of an adenoma. Patient was discharged on POD 4. Conclusion: Robotic transduodenal ampullectomy is feasible, safe, efficient and demonstrates an attractive alternative to the conventional open approaches. Patients benefit from a fast recovery, early discharge and early possible further treatment needed.