Pylorus-preserving pancreaticoduodenectomy, according to Longmire-Traverso, robotically assisted

The patient is positioned in supine position on the large vacuum cushion. The left arm can be positioned separately. The use of the cushion eliminates the need for any additional supports.

Initially, for the Artery First Approach, the patient is positioned in maximum head-down and right lateral position. From step 5 (opening of the bursa), the patient is then positioned slightly head-up and slightly in right lateral position.

Important: The positioning is of particular importance due to the docking of the patient to the robot's manipulator. Unless a coupled table (so-called Table-Motion function) is available, the arms must be undocked before each table movement. There is also a risk of injury if the patient slips.

Note: Vacuum cushions can have leaks. Check again before sterile draping.

The surgeon ideally sits at the console with the ability to look at the patient and the table assistant. The surgical robot (Patient Card) is approached to the patient from the cranial side in the X-System. In the Xi, the Patient Card can be variably approached to the patient, for example, directly from the right. The table assistant stands or sits on the left side of the operating table. Anesthesia is located at the head of the patient, and the scrub nurse is positioned to the right of the patient's legs with the table over the legs.

Creation of a pneumoperitoneum of 15 mmHg using a Veress needle at Palmer's Point in the left upper abdomen. Due to the varying abdominal wall compliance, it is advisable to determine the optimal position of the trocars on the inflated abdomen with pneumoperitoneum.

Note: Alternatively, the creation of the pneumoperitoneum can also be performed using the Optiview technique.

The three 8mm robotic trocars (Trocar 1-3) and the 12 mm robotic trocar (Trocar 4) are positioned on a line slightly curved cranially at the sides (smiley) 15 cm below the anticipated lower edge of the pancreas (usually below the navel). The trocars are inserted symmetrically with a distance of 8 cm between each other. In the left lower abdomen, a 12 mm assist trocar is placed 3 cm caudal to the aforementioned trocar line between Trocar 3 and 4. The patient is initially positioned maximally in a head-down and right lateral position. The patient cart is slightly offset to the right over the patient's head. The arms are connected (docked) with the four robotic trocars. Subsequently, the instruments are introduced under visual control and parked under the ventral abdominal wall.

Important: The trocars must be positioned with the wide black ring at the level of the muscular abdominal wall (so-called remote control) to avoid injury during movement.

Note: Ideally, the robotic trocars are inspected with the camera via the assist trocar when introducing the robotic instruments. This allows the position of all robotic trocars to be easily checked again before the start of the operation.