Minimally invasive resection of duodenal tumors

Duodenal tumors represent fewer than 1% of all gastrointestinal neoplasms and are seldom truly benign. Current treatment options include open surgical resection and endoscopic techniques at opposite ends of the risk: benefit spectrum in regard to morbidity and oncological efficacy. Laparotomy has considerable associated morbidity and is in wider practice than laparoscopic resection due to the technical demands of duodenal reconstruction. Endoscopic strategies have proven useful for treating small, superficial lesions but carry a significant risk of bleeding, perforation and incomplete lesion retrieval for larger tumors. Robotic-assisted surgery may bridge the gap between these limitations of open and endoscopic resection: expedited recovery after minimally-invasive resection while minimizing morbidity associated with optimal tumor clearance. This overview of robotic-assisted resection of duodenal tumors presents operative techniques tailored to the anatomical location of the lesion, likely ampullary involvement, and the challenge of effective reconstruction. Techniques include transduodenal resection, transduodenal ampullectomy, segmental duodenal (sleeve) resection, and near-circumferential duodenectomy with Roux-en-Y duodenojejunostomy. At our institution, sixteen patients have undergone robot-assisted transduodenal resections between June 2013 and November 2017. Surgical indications included tubulovillous adenomas [13], neuroendocrine tumors [2] and leiomyomas [1]. The tumors were located in the ampulla [7], duodenum [8] and the minor papilla [1] with a median tumor diameter of 2.85 cm (1.5–5.0 cm). Operative time ranged from 214 to 393 mins with an estimated average blood loss of 50mL. There were no conversions to open surgery or intra-operative blood transfusions. There were no re-operations on index hospitalization, pancreatic fistulas, disease recurrences, or death.