Background : In modern-day pancreatic cancer surgery, ‘Arterial divestment’ is gaining popularity to attain R0 resection. Arterial divestment is of two types;1) Sub-advential divestment described by Yi Miao in 2016 or 2) Peri-arterial divestment, popularized by the ‘Heidelberg’ group in 2021. We present the technique of ‘Robotic PPPD with peri-arterial hepatic artery divestment with stapling of Type IIIa Portal annular pancreas with a high hepaticojejunostomy (HJ) for a mid-CBD cholangiocarcinoma.

Methods : We present a case of a 69-year-old gentleman, diabetic who presented with jaundice. CECT abdomen revealed a mass at mid-CBD level with right hepatic artery abutment and a type IIIa portal annular pancreas. On initial evaluation, bilirubin was 6.5 mg/dl and serum CA19-9 was 170 U/ml.

Results : We performed an upfront robotic PPPD with the daVinci Xi system using six ports (4 robotic and 2 assistant ports). Resection along with peri-arterial HA divestment was performed with endo GIA stapler division of annular pancreas. Pancreatico-jejunostomy and a high HJ were performed robotically. A small left hypochondrial incision was taken for specimen extraction and for performing duodeno-jejunostomy. The procedure was performed in 720 minutes with a blood loss of 1200 ml. Post operatively patient developed Grade-B Chyle leak and was discharged of post-operative day 20. Final HPE was Moderately differentiated adenocarcinoma (pT3, pN0) with free resection margins.

Conclusions : Periarterial divestment is feasible while performing a robotic pancreaticoduodenectomy for providing a radical clearance with negative margin, in high volume centre like Tata Memorial Hospital, Mumbai having a dedicated Robotic surgery programme for HPB surgery.