Intraoperative celiac axis flow measurement and dynamic surgical strategies in robotic distal pancreatectomy

Locally advanced pancreatic ductal adenocarcinoma (LA-PDAC) involving the body and neck of the pancreas often necessitates complex resections in selected cases, such as the Appleby procedure, also known as distal pancreatectomy with en bloc celiac axis resection (DP-CAR). A 75-year-old female with LA-PDAC, confirmed by endoscopic ultrasound-guided biopsy and treated with neoadjuvant chemotherapy, was initially planned for a robotic DP-CAR. During surgery, transit-time flow measurement (TTFM) showed an inverted and threefold increase in the gastroduodenal artery flow after clamping of the common hepatic artery (CHA), ensuring adequate liver perfusion and avoiding unnecessary preoperative CHA embolization to enhance collateral arterial circulation to the liver. Intraoperative findings revealed only fibrosis without evidence of tumor infiltration around the celiac axis, as confirmed by intraoperative frozen sections. This led to a shift from the planned DP-CAR procedure to an anterior radical antegrade modular pancreatosplenectomy (RAMPS). Final histopathological examinations revealed chronic pancreatitis and complete tumor regression (tumor regression grade 0, ypT0N0). This case underscores the role of robotic platforms and intraoperative tools like TTFM in real-time decision making, enabling tailored surgical strategies for complex pancreatic resections, ensuring oncological adequacy, and optimizing patient outcomes.