Robotic distal pancreas-sparing duodenectomy (duodenal sleeve resection) with transmesenteric approach: robotic approach for tumors in the third and fourth parts of the duodenum

Background Minimally invasive resection of the retroperitoneal duodenum is complicated because of its anatomical location, and the proximity of the ampulla of Vater and vascular structures. Benign or indolent pathology can add complexity to operative decision-making for these already challenging surgeries, and operations associated with lower morbidity may be considered. This study describes a novel robotic transmesenteric approach to duodenal sleeve resection for non-malignant lesions.Methods A retrospective review was performed on a prospectively maintained institutional database between 2011 and 2021. The Da Vinci XI or SI platform (Intuitive Surgical, Sunnyvale, CA) was used in all cases.Results Critical steps in robotic sleeve duodenectomy include the following: (1) techniques for avoiding damage to the ampulla; (2) Kocherization and reverse Kocherization; and (3) A transmesenteric approach for further mobilization of the duodenum. Nineteen patients were referred by experienced gastrointestinal endoscopists after endoscopic management was deemed unsuitable or their resections were incomplete. The histological diagnoses were either symptomatic benign or indolent duodenal pathology. All 19 patients underwent robotic duodenal sleeve resection during the study period. Lesions were located in the third to fourth parts of the duodenum. The median operative time was 216 min (IQR: 199-225), and the estimated intraoperative blood loss was 50 ml (IQR: 50.0-93.7). The 90 day readmission rate was 15.7% (3/19), and no 90-day mortality was observed.Conclusion This small case series of a transmesenteric approach for robotic sleeve duodenectomy demonstrates its feasibility and safety in this potentially challenging operation.