Robotic pancreatoduodenectomy for a solid pseudopapillary tumor in a ten-year-old child

BACKGROUND: Pancreatoduodenectomy (Whipple resection) in children is feasible though rarely indicated. In several pediatric malignancies of the pancreas, however, it may be the only curative strategy [1]. With the emergence of robotic pancreatoduodenectomy as at least a clinically equivalent alternative to open surgery [2], it remains to be determined whether the pediatric population may potentially benefit from this minimally invasive procedure. Here we present, for the first time, a video of setup and surgical technique of robotic pancreatoduodenectomy in a child.

METHODS: A 10-year-old girl presented with complaints of fullness and abdominal pain in the upper quadrants. Investigations including a diffusion-weighted, pancreatic MR scan suggested the diagnosis of solid pseudopapillary tumor (Frantz's tumor). The patient was considered for robotic pancreatoduodenectomy.

RESULTS: After anesthesia, the patient was placed supine on a split-leg table. Trocar placement was adjusted to accommodate the child's length and body weight, according to pre-operatively calculated positions that would allow for maximum working space and minimize inadvertent collision between the robotic arms. The da Vinci Si surgical robot was positioned in-line towards the surgical target and all four robotic arms were docked, while two additional laparoscopic ports were placed for tableside assistance. After standard pancreatoduodenectomy, a conventional loop reconstruction was performed including an end-to-side pancreaticojejunostomy with duct-to-mucosa technique and stapled side-to-side gastrojejunostomy. We suggest that in this patient group, pylorus preserving pancreatoduodenectomy with end-to-side duodenojejunostomy may be a suitable alternative. Postoperative recovery was complicated by delayed gastric emptying but otherwise unremarkable. Hospital length of stay was 12 days. Final pathology demonstrated a solid pseudopapillary tumor with negative surgical margins.

CONCLUSION: This case illustrates the feasibility of robotic pancreatoduodenectomy in children. Essential elements of this procedure are a well-running robotic pancreatic surgery program as well as careful preoperative port placement planning.