This case demonstrates a robotic subtotal distal pancreatectomy with splenectomy and regional lymphadenectomyfor a resectable pancreatic carcinoma centered in the pancreatic body in a medically complex patient.

The patient presented with a 3.5 cm pancreatic body mass diagnosed by endoscopic ultrasound–guided biopsy as pancreatic ductal adenocarcinoma with CA 19-9 of 124 U/mL in the setting of normal bilirubin. Cross-sectional imaging demonstrated no evidence of distant metastatic disease and no involvement of the superior mesenteric artery, celiac axis, common hepatic artery, or PV/SMV confluence, consistent with anatomically resectable disease.

The patient’s clinical course was complicated by end-stage renal disease requiring hemodialysis, poorly controlled diabetes, and limited functional status (ECOG 2–3). Medical oncology evaluation concluded that the patient was not an appropriate candidate for systemic therapy, making a surgery-first strategy the most appropriate curative-intent approach.

Robotic staging laparoscopy confirmed no peritoneal metastatic disease. Intraoperative ultrasound localized a ~4 cm tumor within the pancreatic body. The operation included celiac axis dissection to define hepatic, left gastric, and splenic arterial anatomy, creation of a retropancreatic tunnel at the PV/SMV confluence, and pancreatic transection proximal to the tumor with negative proximal margin on frozen section. The splenic artery was divided at its origin from the celiac axis, and the splenic vein was divided distal to the IMV confluence, allowing completion of an en bloc distal pancreatectomy, splenectomy, and regional lymphadenectomy.

Final pathology demonstrated a 4.2 cm medullary carcinoma of the pancreas with negative margins, metastatic carcinoma in 5 of 27 regional lymph nodes, and intact mismatch repair protein expression (pMMR), corresponding to pT3 pN2 disease (AJCC 8th edition). A background low-grade branch-duct IPMN of gastric phenotype was also identified.

The patient recovered well postoperatively and was discharged home on postoperative day seven.

This operative video highlights robotic techniques for complex pancreatic body tumors, including ultrasound-guided tumor localization, celiac axis dissection, retropancreatic tunneling at the PV/SMV confluence, and oncologic lymphadenectomy, demonstrating the application of minimally invasive surgery within disciplined oncologic principles for pancreatic cancer.