Tailored Approach for Portal Vein Involvement with a Replaced Right Hepatic Artery during Robotic Pancreatoduodenectomy

In robotic pancreatoduodenectomy (RPD) for tumors with portal vein (PV) involvement and a replaced right hepatic artery (rRHA), precise dissection from the posterior aspect of the pancreatic head is not always straightforward. Therefore, an anterior and inferior approach may be more appropriate in the robotic setting. The rRHA should be identified at both its proximal and distal ends (at its origin from the superior mesenteric artery [SMA] and along the right side of the bile duct within the hepatoduodenal ligament, respectively) and dissected from both sides to the greatest extent feasible. 1 The key principle is to obtain proximal and distal control of the rRHA before approaching the most adherent portion of the tumor. Unlike standard RPD, the presence of an rRHA requires early identification and vascular control from both its proximal and distal sides before PV/superior mesenteric vein (SMV) dissection because the artery may limit posterior exposure and is at risk during dissection of the tumor from the portomesenteric vein.