Robotic modified Appleby: Case report, technical aspects and video()

INTRODUCTION AND IMPORTANCE: Pancreatic body and tail adenocarcinoma is a tumor of silent evolution, showing up as advanced disease at diagnosis in the majority cases. CASE PRESENTATION: A 60-year-old man, presenting a solid expansive lesion (3.1 × 2.8 cm) in the body of the pancreas, by imaging exams. There was 50% involvement of the celiac trunk at the level of the it's bifurcation and suspected peripancreatic lymph nodes. Clinical staging was cT4N1M0. After neoadjuvant chemotherapy (NQT), there was a small reduction of the tumor to 3.0 × 2.6 cm, an important decreasing of the celiac trunk involvement (25%), and also a reduction in the levels of C19–9 from 650 U/mL to 358 U/mL. Further on, the patient underwent a Robotic Modified Appleby procedure, without intra and postoperative complications. CLINICAL DISCUSSION: Locally advanced pancreatic tumors should be referred to NQT, and those with good response might benefit to radical surgery. The modified Appleby technique - distal pancreatectomy with splenectomy and celiac trunk resection – is the procedure of choice when there is involvement of celiac trunk, but concern must be given to the liver vascularization. The use of robotic system on pancreatic surgery is emerging, but still, there is lower data regarding its safety in major pancreatic procedures. CONCLUSION: The use of neoadjuvant therapy is recommended to assess the in vivo response, improve oncological results and increase negative margins. Pre-operative imaging is mandatory for surgical planning. The robotic modified Appleby procedure is feasible and safe, with reduced of intraoperative blood loss and transfusion rate, corroborating the literature.