Robotic Enbloc Pancreaticoduodenectomy with Right Hemicolectomy and Non-Anatomical Segment VI Liver Resection for Malignant Colo Duodenal Fistula

Abstract

Malignant Colo-duodenal fistula is a very rare entity in locally advanced colon cancer. Duodenal involvement close to ampulla requires combined pancreaticoduodenectomy (Whipple's procedure) with right hemicolectomy. R0 resection improves long-term survival in these patients. Minimally invasive approach helps in early postop recovery and return to adjuvant chemotherapy. We are reporting the first case of robotic en-bloc pancreatoduodenectomy with right hemicolectomy and non-anatomical liver resection for a case of malignant coloduodenal fistula from a locally advanced hepatic flexure adenocarcinoma. 70-year-old male admitted with vomiting, abdominal pain and weight loss of 2 months duration. CT and MRI abdomen and pelvis revealed hepatic flexure growth with colo duodenal fistula and endoscopy biopsy confirmed as mucinous adenocarcinoma. Whole-body PETCT showed uptake in the primary tumour without any distant metastases. Due to high risk of sepsis in neoadjuvant chemotherapy, MDT recommended surgery. After preoperative nutritional optimization with TPN, patient underwent combined pancreaticoduodenectomy with right hemicolectomy and non-anatomical segment 6 liver resection followed by reconstruction using Da Vinci Xi system. We used 4x8mm robotic ports and 2x12mm assistant ports. The specimen was taken out through umbilical port extension. The console and total operative time were 330 and 360 minutes. The patient had minimal blood loss without any intra-op blood transfusion. Patient was discharged on day 11. The postoperative histopathology reported as moderately differentiated mucinous adenocarcinoma (pT4bN1aMXPNI0V0R0) and he was started on oral capecitabine. The multi-visceral resections can be performed safely using robotic approach in experienced centres.