Minimally invasive distal pancreatectomy (MIDP) is considered a safe and effective surgical approach for treating benign and borderline malignant pancreatic tumors. Moreover, recent data have shown the oncologic safety and feasibility of MIDP for patients with pancreatic cancer compared to open distal pancreatectomy [1].

Based on these results, surgeons have attempted to perform single-port (SP) or single-incision laparoscopic distal pancreatectomies (LDP) [2]. Although these procedures demonstrated the technical feasibility of SP LDP, this method remains controversial. Some studies have shown that SP LDP requires a longer operation time and has a learning curve [3].

However, spleen preservation is difficult during SP LDP. As a result, the indication for SP LDP has been confined to pancreatic tail masses abutting the spleen or splenic vessels that require splenectomy. To overcome this drawback and expand the indication, robotic single-site plus one-port distal pancreatectomy (RSS + 1 DP) was introduced, and its feasible outcomes in the early experience period were observed to be favorable [4,5].

However, the previous robotic platform specialized in multiport systems, and the RSS + 1 DP could only partially exploit the technical advantages of the robotic platform [6]. Due to these limitations, it is not generally accepted in the hepatobiliary and pancreatic (HBP) field.

Recently, a newly released da Vinci SP system (Intuitive Surgical, Inc.) was introduced to overcome the aforementioned limitations of the SP MIDP. Using this system, SP robotic distal pancreatectomy plus one-port was performed. Some surgeons have published their initial experiences and have reported favorable early outcomes [7,8]. In some cases, a spleen-preserving distal pancreatectomy was performed.

According to the trend, herein, we report our experience with robotic SP plus one-port splenic vessel-conserving spleen-preserving distal pancreatectomy (RSP + 1 SVc-SpDP) using the da Vinci SP system.

A 38-year-old male patient was incidentally found with a mass in the body of the pancreas (Fig. 1A). After endoscopic ultrasound-guided biopsy, the pancreatic mass was pathologically confirmed to be a neuroendocrine tumor. On May 12, 2023, RSP + 1 SVc-SpDP was performed using the da Vinci SP system.

Figure 1. (A) Preoperative computed tomography showing enhanced pancreas body mass (arrow). (B) Position of the assistant and ports placement. (C) Operative view after docking and insertion of the additional trocar. (D) Operative view after division of the pancreas. (E) Gross specimen containing pancreatic mass (arrow) that was revealed as a neuroendocrine tumor. SP, single port.

After general anesthesia, the patient was laid in a supine position with a 30° left-up tilting and reverse-Trendelenburg position. There was no table position change during the surgery. The robotic SP was replaced at a transumbilical site, and an additional 12-mm port was placed on the left side of the robotic SP (Fig. 1B). Usual robotic instruments such as hook, bipolar, scissor, forceps, and clip were used. The general surgical procedure was based on a splenic vessel-preserving distal pancreatectomy (Kimura technique).

The gastrocolic ligament was divided, and the pancreatic surface was approached. The stomach was hung using nylon and the operative view was obtained. The splenic artery and vein were identified by dissecting the inferior and superior borders of the pancreas. After isolation of these vessels, the pancreas was separated from the vessels. Through the additional 12-mm port, an intraoperative sonographic probe was inserted and the tumor location was identified. The pancreas was divided using endoscopic gastro-intestinal anastomosis (endo-GIA), and the remaining pancreas was carefully dissected from the splenic artery and vein (Fig. 1C). During dissection, the perforating vessels in the pancreas were ligated using endoscopic metal clips and then cut. After detachment, the specimen was delivered through the umbilicus, and a drain was inserted through the 12-mm port site (Supplementary Video 1).

The operative time was 350 minutes, and the estimated blood loss was 100 mL. The final pathology of the pancreatic tumor was a grade 1 neuroendocrine tumor (according to the 2019 World Health Organization classification) (Fig. 1D). The patient was discharged on postoperative day 8 without any complications.

Unlike conventional MIDP, vessel-conserving SP distal pancreatectomy has technical demands, which is a hurdle to the popularization of this procedure in the HBP field [2]. However, these hurdles have been reduced with advances in surgical techniques and the development of novel instruments. Based on our experience with single-site robotic distal pancreatectomy, this platform has several strengths and weaknesses compared with previous single-site platforms.

An outstanding aspect of the da Vinci SP system is its flexible joint compared to previous systems (da Vinci Xi or Si system). The da Vinci single-site system is a semi-rigid design and has the limitations of angulation and a meticulous approach [9]. However, the SP system increases the degree of freedom and enables surgeons to perform important procedures more freely [10]. These advantages are maximized in borderline malignant pancreas body and tail tumors candidate spleen-preserving distal pancreatectomy. Meticulous dissection using the SP system might enable the preservation of the spleen with vessels more efficiently during the pancreatectomy, especially at the splenic hilar area.

However, this procedure still has several limitations. Firstly, specific instruments for this system, such as staplers, suction, and small metal clips, are not commonly available. Considering the procedure of vessel-preserving distal pancreatectomy, pancreatic division and vascular dissection are crucial steps related to surgical outcomes. From this perspective, the lack of instruments is a critical drawback when performing RSP + 1 SVc-SpDP in the SP system [7].

Consequently, an additional port was required. In this case, division of the pancreas was performed using endo-GIA, and ligation of a small branch of the vessels was performed using endoscopic clips. Occasionally, the bleeding was cleared using endosuction. Therefore, some critical parts of the surgery are performed through an additional port, which means that the surgical ability of the first assistant near the patient is also as important as that of the operator. In other words, several crucial steps are routinely performed by the operator during surgery and should be performed by the first assistant.

In RSP + 1 SVc-SpDP, surgical comprehension of the first assistant is as important as case selection; this could be another hurdle to the popularization of this technique. However, in the selected cases, better postoperative outcomes, including spleen preservation, might be expected to focus on the delicate procedures. To do that, a stable operative field is necessary by traction of the stomach and colon. For example, more splenocolic ligament dissection is recommended compared to conventional distal pancreatectomy. With more experience and the addition of novel instruments, this technique can be generalized, and its indications can be expanded.

In conclusion, the initial experience of RSP + 1 SVc-SpDP using the da Vinci SP system showed the possibility of an alternative operation for splenic vessel-conserving spleen-preserving distal pancreatectomy. Further experience is mandatory.

Ethics statement

The study was approved by the Institutional Review Board of Yonsei University Health System (No. 4-2024-0501) and individual consent for this retrospective analysis was waived.

Authors’ contributions

Conceptualization, Investigation, Resources, Visualization: SHK

Data curation: NRK

Project administration: SHK, NRK

Supervision: CMK

Writing–original draft: SHK

Writing–review & editing: All authors

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Acknowledgment

Medical Illustration & Design (MID), a member of the Medical Research Support Services of Yonsei University College of Medicine, provided excellent support with medical illustrations.

Data availability

The data presented in this study are available upon reasonable request to the corresponding author.

Supplementary materials

Supplementary materials can be found via https://doi.org/10.7602/jmis.2024.27.3.177.