A Five-Year Survivor without Recurrence Following Robotic Anterior Radical Antegrade Modular Pancreatosplenectomy for a Well-Selected Left-Sided Pancreatic Cancer
A 72 year-old man (hight-172 cm, weight-78 kg, body mass index-26.37) with a three-month history of weight loss of 5 kg was admitted to the Department of Surgery in Severance Hospital, Seoul, Korea. On preoperative axial imaging, he had a suspicious mass-like lesion confined to the pancreas, which was suggestive of pancreatic cancer (). The tumor seemed not to invade retroperitoneal space and it was apart from celiac axis. The patient's CA 19-9 was elevated to 60 IU/mL. After careful consideration, a decision to perform minimally invasive pancreatectomy was made based on the concept of anterior RAMPS, and a robotic surgical system was subsequently used.\nThe complete procedure is described in a multimedia article published previously., In brief, surgery was performed with the patient placed in the supine position. After division of both the gastrocolic and gastrosplenic ligaments, the whole pancreas was exposed. Following the main outline of the original RAMPS, a complete window could be made via the avascular plane between the pancreatic neck and superior mesenteric vein-portal vein-splenic vein (SMV-PV-SV) confluence. This facilitated dissection of the lymph nodes around the common hepatic artery. Division of the pancreas was performed by endo-GIA at the pancreatic neck portion. The left gastric vein with soft tissue around celiac trunk and common hepatic artery were dissected (). The splenic artery and vein were controlled at the origin of the celiac trunk and t the junction of the SV and SMV, respectively. The robotic surgical system is thought to be helpful for these dissectional processes. The superior mesenteric artery and left renal vessels were not aggressively dissected. The distal part of the pancreas was dissected with soft tissue around the celiac trun and the fascia layer covering the adrenal gland and perinephric soft tissue in a right-to-left fashion. An endo-pouch was introduced and surgical specimen was retrieved through a small vertical abdominal wound. The total operation time was eight hours and the intraoperative blood loss was 700 mL.\nThe patient recovered without any complications. He returned to an oral diet on the first day and was discharged on the tenth day after operation. Pathologic examination revealed a pancreatic ductal adenocarcinoma with extension into the peripancreatic soft tissue (pT3). Regional lymph node metastasis was not identified (pN0, 0/2). Both the pancreatic resection margin and the tangential posterior margin were free of carcinoma (). No evidence of perineural and lymphovascular invasion was noted. The patient received only postoperative adjuvant radiotherapy around the tumor bed (total 55.67 Gy/19 fractions, daily 2.93 Gy) (). His CA 19-9 remained within normal limits after surgery (), and the patient survived for more than five years without cancer recurrence.