Stapled Wedge Resection of the Portal Vein/Superior Mesenteric Vein During Robotic Pancreaticoduodenectomy: Feasibility and Short-term Outcomes.

Abstract

Robotic pancreaticoduodenectomy (RPD) has been increasingly used in the management of pancreatic ductal adenocarcinoma (PDAC).^1,2 However, portal vein (PV) or superior mesenteric vein (SMV) involvement remains a technical challenge.^3-6 In particular, stapled wedge vein resection during RPD has not been well described. We present the case of a 65-year-old male with PDAC initially suspected to have liver metastasis. He underwent 11 cycles of gemcitabine and nab-paclitaxel, followed by diagnostic laparoscopy with liver biopsy, which revealed no malignancy. Then, surgical resection was recommended. Intraoperatively, after careful dissection of the SMV, a 5-mm segment of tumor adherence was identified on the right wall of the SMV. A stapled wedge resection was then performed. The SMV lumen appeared mildly narrowed after stapling, but no stenosis was evident and venous flow was satisfactory by inspection. This maneuver allowed medial retraction of the PV-SMV, facilitating exposure of the superior mesenteric artery and completion of resection-without vascular clamping. The operation time was 6 h, with minimal blood loss. The patient was discharged on postoperative day 5 without complications, including venous-related events. Final pathology confirmed portal vein invasion, but an R0 resection was achieved. Among five patients who underwent PV/SMV wedge resection at our institution, no postoperative venous thrombosis or stenosis occurred. Stapled wedge resection of the PV/SMV is feasible and safe during RPD for selected patients with minimal venous adherence. Further case accumulation and long-term evaluation are required to determine the appropriate indications, particularly with respect to safety and oncologic outcomes.