# Robotic posterior radical antegrade modular pancreatosplenectomy for left-sided pancreatic cancer using the ligament of Treitz first approach: A case report and technical note

## TL;DR

This case report describes a robotic surgical technique for left-sided pancreatic cancer using a novel ligament of Treitz first approach.

## Contribution

The paper introduces a robotic posterior RAMPS technique using the ligament of Treitz first approach for left-sided pancreatic cancer.

## Key findings

- The ligament of Treitz first approach was successfully used in robotic posterior RAMPS.
- The procedure had an operative time of 303 minutes and estimated blood loss of 150 mL.
- The approach allows for retroperitoneal dissection and lymphadenectomy around key arteries.

## Abstract

Radical antegrade modular pancreatosplenectomy (RAMPS) is the standardized open surgical technique for treating left-sided pancreatic cancer. However, studies reporting the surgical approaches for robotic RAMPS are limited. Here, we present a robotic posterior RAMPS using the ligament of Treitz first approach.

A 46-year-old male patient with initially unresectable pancreatic body cancer underwent robotic posterior RAMPS as a conversion surgery after 1-year of chemotherapy with modified FOLFIRINOX.

Following evaluation of resectability, the ligament of Treitz first approach was applied. The transverse colon was lifted cranially, and the left renal vein was exposed after dissection around the ligament of Treitz. The left adrenal vein was divided, and the left adrenal gland was resected with special caution to avoid injury to the left renal artery. Retroperitoneal dissection was performed with lymphadenectomy around the superior mesenteric and celiac arteries using the ligament of Treitz first approach. After repositioning the transverse colon, the gastrocolic and gastrosplenic ligaments were dissected. Following the division of the pancreas and splenic vessels, the retroperitoneal dissection line was connected with those of the ligament of Treitz first approach. The operative time was 303 min, and the estimated blood loss was 150 mL.

The ligament of Treitz first approach may be an option for robotic RAMPS for left-sided pancreatic cancer. Surgeons should select the best approach for performing robotic RAMPS.

•Radical antegrade modular pancreatosplenectomy (RAMPS) is the standardized technique for left-sided pancreatic cancer.•Few studies have reported the surgical approaches for robotic RAMPS.•This video demonstrated a robotic posterior RAMPS using the ligament of Treitz first approach.•The ligament of Treitz first approach may be an option for robotic RAMPS for left-sided pancreatic cancer.

Radical antegrade modular pancreatosplenectomy (RAMPS) is the standardized technique for left-sided pancreatic cancer.

Few studies have reported the surgical approaches for robotic RAMPS.

This video demonstrated a robotic posterior RAMPS using the ligament of Treitz first approach.

The ligament of Treitz first approach may be an option for robotic RAMPS for left-sided pancreatic cancer.