A left-posterior approach to the superior mesenteric artery during robot-assisted pancreaticoduodenectomy

Background A complete dissection around the superior mesenteric artery (SMA) with artery-first concept is crucial during pancreaticoduodenectomy for periampullary cancers. The left-posterior (LP) approach to the SMA may be effective during robot-assisted pancreaticoduodenectomy (RPD), but data on its technical feasibility and clinical outcomes are limited. Methods We retrospectively reviewed 83 RPD patients utilizing the LP approach, dividing them into early (n = 42) and late (n = 41) groups to assess procedural maturity. The LP approach was initiated at the first phase of resection to achieve circumferential SMA dissection from the left and posterior aspect and early vascular control through ligation of the inferior pancreaticoduodenal artery (IPDA). Postoperative short-term outcomes were compared between the two groups. Results The late group demonstrated significantly shorter operative times (518 vs. 626 min; p < .01) and higher rates of IPDA ligation (90% vs. 71%; p = .03). The median blood loss in the late group was 50 mL (65 mL in the early group; p = .39). Lymph node retrieval number was 17 in both (p = .81), and R0 resection was achieved in all late group cases (96% in the early group; p = .35). Conclusions With experience from approximately 80 cases, the LP approach for RPD has enabled precise SMA dissection and early vascular control. A stable and super-magnified caudal view provided by robotic surgery is particularly advantageous for this approach.