Left-Sided Uncinate-First Approach as a Technical Adjunct in Robotic Pancreatoduodenectomy: Video-Based Technical Insights in Challenging Anatomy.

backgroundUncinate process dissection and superior mesenteric artery (SMA) control represent critical steps in robotic pancreatoduodenectomy (RPD). However, the conventional right-sided uncinate-first approach may be technically demanding in patients with unfavorable anatomy, such as visceral obesity or bulky tumors.

methodsThis multimedia article presents a video-based demonstration of a left-sided uncinate-first approach in robotic pancreatoduodenectomy. Two illustrative operative scenarios are used to demonstrate technical nuances of SMA exposure and uncinate process dissection in challenging anatomic conditions.

resultsThe right-sided approach for a morbidly obese patient demonstrated limited SMA exposure due to increased operative depth and visceral adiposity, requiring substantial traction to identify the correct dissection plane. Conversely, the left-sided approach enabled early vascular control through creation of a mesenteric window, providing direct access to the SMA and facilitating a controlled medial-to-lateral uncinate dissection along a relatively avascular plane. This approach reduced traction on the superior mesenteric vein (SMV) and improved visualization of the posterior dissection plane. In all cases, R0 resection was achieved.

conclusionsThe left-sided approach represents a feasible technical adjunct in robotic pancreatoduodenectomy. It may enhance SMA exposure and facilitate safer uncinate dissection in selected patients with challenging anatomy, particularly in obesity or bulky tumors. This strategy should be considered within the armamentarium of advanced robotic hepatopancreatobiliary surgery.