Technique for Robotic Pancreaticojejunostomy

Background: Minimally invasive, robotic techniques for hepatobiliary procedures offer the potential for accelerated recovery and reduced opioid usage. Robotic pancreaticoduodenectomy is a technically challenging procedure with a complex reconstruction. In this regard, standardization of the pancreaticojejunostomy technique is critical for safe adoption of robotic technology in pancreatic surgery. Study Design: We demonstrate the primary steps and associated principles to perform a robotic pancreaticojejunostomy using a modified Blumgart/Nagakawa technique. Results: Key steps to this procedure include: 1) exposure and positioning of the pancreatic remnant and jejunal limb; 2) transpancreatic suture placement using augmented sutures with bulldog clamps for organization; 3) duct-to-mucosa anastomosis with well-defined order of suture placement and knot-tying for optimal exposure, tissue handling, and technical ease; 4) completion of the anterior row of transpancreatic sutures using Lapra-TY clips for gentle, but firm tissue apposition; and 5) placement of omental flap and surgical drains in proximity to the reconstruction. Conclusion: We described our technique for performing a robotic pancreaticojejunostomy, which compensates for the technical limitations of the robotic approach. These adjustments in combination with the magnified surgical vision and augmented skill associated with the robotic platform allow for safe and reliable performance of the pancreaticojejunostomy technique.