A 62- year-old female patient was admitted to the department of surgery in Yonsei University Health System, in Seoul, Korea because of the residual bile duct tumor after endoscopic ampullectomy for ampullary adenoma with high grade dysplasia. She had been in good health without any previous medical history. The ampullary mass was incidentally found during her routine medical check-up. Endoscopic ampullectomy was attempted in a local hospital, but the tumor was not completely removed. Pathologic examination reported it as tubulo-villous adenoma with high grade dysplasia. Endoscopic retrograde cholangiopancreatography was done after admission. It showed polypoid mass protruded out of the orifice of common bile duct (CBD) (Fig. 1A). On cholangiogram, filling defect was noted at distal CBD area (Fig. 1B). Abdominal computed tomography scan revealed suspicious mass of about 0.9 cm in size in the ampulla of vater portion without evidence of significant lymph node enlargement. Routine chemistry and tumor marker levels (CA 19-9 [carbohydrate antigen 19-9], CEA [carcinoembryonic antigen]) were all within normal limits. She seemed to required PD and minimal invasive technique was regarded as appropriate. Finally, we decided to perform da Vinci robot-assisted laparoscopic PD for her.

After the da Vinci system and the patient was prepared, a 12-mm subumbilical camera port was placed through a vertical mini-laparotomy and pneumoperitoneum was achieved by CO₂ insufflation. Under the laparoscopy- providing vision, three additional 8-mm robotic instrument ports and two conventional laparoscopic ports were placed: port 1 on the right mid portion, port 2 on the mid portion of left side abdomen, port 3 on the left upper portion under the left subcostal area, and additional 5-mm and 12-mm accessory laparoscopic ports (ports 4 and 5) were placed for suction, surgical clipping and Endo-GIA by the table-side assisting surgeon (Fig. 2A). All three working robotic arms were used. The patient was placed in supine position with the head and the right side slightly elevated. The da Vinci surgical cart was rolled into the table over the patient. The robotic camera arm and other three instrument arms were then connected to their respective ports. At this point, the surgeon sat at the surgical console located about 3 m from the operating table. The assistant surgeon was positioned on the patient's right side for temporary use of laparoscopic instruments through ports 4 and 5. The robotic procedure was nearly the same as conventional PD. Preservation of pylorus and division of right gastric artery are our policy for PD. We began by dividing of the gastrocolic ligament. Duodenum was mobilized to the extent where the inferior vena cava and the left renal vein could be seen. Right gastroepiploric vessels were carefully dissected and individually ligated. After trimming the duodenal first portion, Endo-GIA was introduced through port 5 and divided duodenum at the point of about 2 cm distal to pylorus. Division of the right gastric artery facilitates the traction effect of the stomach to the left upper quadrant to ensure surgical field. Lower border of the pancreatic neck portion was carefully dissected to separate the portal vein and the pancreatic neck area. Good surgical field and endo -wrist could lead to safe and accurate dissection in this process. After making complete window between the pancreas and the portal vein, the pancreas was divided by Harmonic scalpel. Upper part of the pancreatic head was then sharply dissected to identify the common hepatic artery and the gastroduodenal artery. The gastroduodenal artery was safely ligated by intracorporeal tie, suture tie, and 5-mm endoclip. About 20 cm sized proximal jejunum from Treiz ligament was divided with another Endo-GIA, and mesenteric vessels were ligated by Harmonic scalpel. Then the proximal jejunum was placed to the right through retromesenteric root. With the duodenum retracted toward the patient's right side, uncinate portion of the pancreas beneath the portal vein was carefully divided by Harmonic scalpel. The robot system was thought to be benefitial in this part. Three-dimensional surgical field, stable portal vein retraction by another robotic arm without tremor helped the surgeon fully focus on sharp dissection of the uncinate process from retroperitoneal reflection (Fig. 2B). Several branches to the portal vein from the head of the pancreas were carefully divided and ligated by intracorporeal tie or endo-clip. After dividing the pancreatic uncinate process, the CBD was dissected from the portal vein and hepatic arteries upto the level of the common hepatic duct (CHD) just above the cystic duct. The cystic artery was then ligated and resected, and cholecystectomy was performed. 10-mm endo-clip was applied to the CHD. Lastly, CHD was divided. About 7-8 cm sized upper mid-line skin incision was made to remove the specimen and reconstruction. Roux-en-Y hepaticojejunostomy, pancreaticojejunostomy, and duodenojejunostomy could be perfomed through mini-laparotomy incision. Two closed suction drains were placed around the surgical field. Robot working time was about 8 hours, and blood loss was about 800 mL without blood transfusion.

She started to an oral diet on postoperative day 3. Grade B pancreatic leak was noted during the postoperative period, but was successfully managed by conservative management alone. She was discharged 1 month after surgery. The body weight was not reduced during her hospital stay. The permanent pathologic report showed that the patient had a tubular adenoma with focal high grade epithelial dysplasia involving the duodenum. The cosmetic effect of postoperative wound was better than that of conventional open PD (Fig. 2A).