Robotic Approach to Oncologic Pancreatoduodenectomy in a Case with an Aberrant Hepatic Artery Originating from the Superior Mesenteric Artery.

Background: Robotic pancreatoduodenectomy (RPD) has been increasingly performed, but maintaining oncological operative standards and safety remains challenging. An aberrant hepatic artery originating from the superior mesenteric artery (SMA), most commonly seen as a replaced right hepatic artery (rRHA), is present in approximately 16% of patients with pancreatoduodenal malignancies. The presence of the rRHA is a known risk factor for technically challenging RPD, and injury to this artery increases the risk of postoperative complications. Therefore, thorough preoperative review of CT images is essential. We demonstrate our approach to RPD with particular attention to oncologic proximal SMA dissection in a patient with an rRHA.

Methods: A 77-year-old White woman with cT3N1M0 distal bile duct cancer and an rRHA originating from the SMA underwent RPD. Preoperative CT images showed lymphadenopathy in the posterior hepatic artery station and the presence of the rRHA, necessitating careful intraoperative dissection. The procedure began with identifying and encircling the distal portion of the rRHA. Following pancreatic division, the superior mesenteric vein was retracted to expose the SMA. The rRHA was identified, and a precise periadventitial dissection of the SMA was performed, completing en bloc resection.

Results: The patient was discharged 8 days after surgery. Pathology revealed a 3.7-cm poorly differentiated adenocarcinoma (pT3N2) with 5 of 34 lymph nodes positive. All margins were negative.

Conclusions: Patients undergoing RPD often have an aberrant hepatic artery from the SMA. Preserving this artery while performing adequate en-bloc lymph node dissection is important for optimal outcomes.