Robot-Assisted Distal Pancreatectomy for Pancreatic Cancer with Type IIIa Portal Annular Pancreas Using a Novel Strategy of Ventral Pancreas Preservation: A Case Report.

INTRODUCTION: Portal annular pancreas (PAP) is a rare congenital anatomical variation, first reported in 1987, characterized by an uncinate process encircling the portal vein and fusing with the pancreatic body. While often asymptomatic, the presence of PAP poses a significant technical challenge during pancreatectomy because of its altered anatomy and the elevated risk of postoperative pancreatic fistula (POPF). Consensus is lacking on the optimal pancreatic transection method (1- or 2-cut margin approach) to minimize this complication. We report the first documented case of robot-assisted distal pancreatectomy (DP) for pancreatic cancer in a patient with PAP, highlighting a novel surgical strategy for pancreatic division.

CASE PRESENTATION: A 75-year-old woman with pancreatic cancer was preoperatively diagnosed with PAP type IIIa (suprasplenic confluence). Following neoadjuvant chemotherapy, the patient underwent robot-assisted DP. A novel technique was executed using the robot's stable, high-definition 3D vision and precise instrument control to dissect the ventral pancreas away from the dorsal pancreas, meticulously preserving the latter at the PAP fusion plane. The surgery achieved an R0 resection. Postoperatively, the patient's course was favorable, with no clinically significant POPF. She was discharged on POD 11 and remained recurrence-free at 18 months.

CONCLUSIONS: This case demonstrates the feasibility of a novel POPF-reducing transection strategy for challenging cases of PAP. Enabled by the robot's stable 3D vision and precise control, this approach offers a new and viable surgical option for DP in patients with PAP type IIIa.