Pancreatectomy for pancreatic metastasis (PM) yields acceptable survival outcomes in selected patients with renal cell carcinoma (RCC) [1,2]. Given the unclear role of regional lymphadenectomy, the surgical technique is focused on a clear resection margin with organ preservation.

This study describes a technique for robotic subtotal left pancreatectomy with preservation of the common bile duct (CBD) and spleen in a patient with multifocal RCC-PM. The presenting case is a 71-year-old female with RCC who underwent a right nephrectomy 20 years ago. She had a pancreatic tail mass on an abdominal ultrasound. Computed tomography and endoscopic ultrasound demonstrated four masses in the tail (3 cm), body (1 cm), neck (1.5 cm), and head of the pancreas (HOP) (1.5 cm). HOP lesion located near the CBD and main pancreatic duct (MPD).

Operative planning

Our hospital policy for pancreatectomy prefers conventional distal pancreatectomy (DP) with splenectomy or pancreaticoduodenectomy (PD) for the tumor that requires regional lymphadenectomy for nodal staging, including pancreatic ductal adenocarcinoma, large pancreatic neuroendocrine tumor (PNET), and cystic tumors with worrisome features. The organ-sparing pancreatectomies (spleen-preserved DP, enucleation, and central pancreatectomy) are a good option for tumors that do not require regional lymphadenectomy including small PNET, cystic tumors without worrisome features, and PM. Total pancreatectomy is considered only in case of a large malignant tumor or multifocal tumors that involve essential structures of both the right and left compartments of pancreas (HOP, CBD or MPD; body/tail pancreas, splenic vessels or MPD).

In this case, we planned to perform robotic removal of all PMs with two possible options (subtotal left vs. total pancreatectomy). Subtotal left pancreatectomy was preferred due to better postoperative endocrine function.

Operative technique

Under ultrasound guidance, the resection started in the HOP lateral to the tumor with preservation of CBD and uncinate process. The pancreatic transection was performed with monopolar curved scissors and bleeding control with Maryland bipolar forceps. MPD was clipped and then applied the polypropylene loop for safe closure. After the complete removal of the tumor at HOP, the operation continued with splenic vessels-preserved DP. The surgical technique is demonstrated in the Supplementary Video.

The operative time was 360 minutes with minimal blood loss. The pathology revealed four metastatic RCCs with negative margins. The patient experienced only postoperative pancreatic biochemical leakage and could be discharged on postoperative day 4. Insulin was used for diabetes control initially. One month after surgery, the fasting insulin level was satisfactory. The patient required only medication for long-term diabetes management without insulin.

PM is a rare medical problem. PM accounts for 2% to 11% [3,4,5] of pancreatic tumors. However, RCC is the most common primary cancer that metastasizes to the pancreas [5,6]. Still, RCC rarely metastasizes to the pancreas and represents only <5% of all metastatic RCC [7]. Pancreatectomy is the treatment of choice for RCC-PM with acceptable outcomes [1,2,6,8]. Lymphadenectomy in the context of RCC-PM remains a controversial issue [2,9]. In this context, organ-sparing pancreatectomy deserves consideration.

Generally, the numbers and location of PM are important factors in deciding the operative plan. The tumor at body to tail of pancreas deserves the spleen-preserved DP or enucleation as a preferred option due to the organ-sparing concept. However, conventional DP with splenectomy is considered if the technique is not safe to preserve the spleen and splenic vessels. The tumor at HOP, a small subcapsular lesion might be considered enucleation as a first choice if the transection line is away from MPD and CBD otherwise most cases need PD as a suitable option. The multifocal PMs involve the head, body, or tail of the pancreas, the extended PD or extended DP should be considered as a first option to preserve endocrine function as much as possible. However, if not total pancreatectomy is the last option.

In this case, one tumor at HOP is located near MPD and CBD. Therefore, the possible operative plans included either subtotal left pancreatectomy with spleen preservation or total pancreatectomy. To enhance recovery, a minimally invasive pancreatectomy was preferred. In comparison with the laparoscopic approach, the robotic approach is associated with a higher success rate of spleen-preserved DP [10]. In addition, the endo-wrist and three-dimensional magnified laparoscopy of the robot system make the pancreatic parenchymal transection at HOP under ultrasound guidance precise, avoiding CBD injury, and safe closure MPD. In this article, we demonstrated the organ-sparing technique of robotic subtotal left pancreatectomy which conserved distal CBD and pancreatic parenchyma at HOP, and uncinate process. Compared with total pancreatectomy, this operation should be associated with a lower rate of long-term complications related to brittle diabetes and hepaticojejunostomy stricture. In conclusion, robotic complex pancreatectomy is feasible and safe in selected cases. The robot-assisted technique is helpful in increasing the success rate of the organ-sparing pancreatectomy.

Ethical statements

Exemption of further review of this study was approved by Institutional Review Board. Written informed consent was obtained from the patient for the publication of this report.

Authors’ contributions

Conceptualization: WD

Investigation: All authors

Visualization: CA, WD

Writing–original draft: CA

Writing–review & editing: WD, PM, CT

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Data availability

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

Supplementary materials

Supplementary materials can be found via https://doi.org/10.7602/jmis.2024.27.2.125.