Introduction: Pancreatic ductal adenocarcinoma continues to be one of the most challenging pathologies for surgical oncologists with many patients presenting with unresectable disease. Historically, locally advanced tumors with involvement of the celiac axis or portal vein were considered unresectable. However, recent case series have shown that portal vein resection and reconstruction during pancreatic resection can be performed safely with acceptable outcomes. Furthermore, other series have shown encouraging outcomes for patients undergoing distal pancreatectomy with en-bloc celiac axis resection (modified Appleby procedure) for locally advanced tumors. These operations are technically challenging but can be performed with minimally invasive techniques in experienced centers. The goal of this video is to present a case of robotic assisted modified Appleby procedure with concomitant portal vein resection and reconstruction.

Methods: The patient in this video is a 54 year-old man with locally advanced pancreatic adenocarcinoma in the body of the pancreas with encasement of the celiac axis and portal vein. He underwent neoadjuvant chemotherapy and radiation with good response, and he was offered surgical resection. This video provides excellent visualization of the key portions of the dissection and reconstruction. Relevant anatomy is highlighted at various points in the video for teaching purposes.

Results: The resection and reconstruction were performed entirely with a robotic-assisted approach. Final pathology showed negative resection margins with 0/10 lymph nodes positive for metastatic carcinoma.

Conclusions: This video demonstrates the feasibility of minimally invasive complex pancreatic surgery with major vascular resection and reconstruction.