Robotic-Assisted Lateral Pancreaticojejunostomy for Chronic Calcific Pancreatitis: A Case Report and Review of Surgical Options

Set H a 35-year-old female, mother of 2 children and having weakness in left side of hand and leg since childhood, presented with at atleast  3-year history of persistent upper abdominal pain radiating to the back. The pain had become progressively severe and debilitating, significantly affecting her quality of life. She was asuffering from chronic idiopathic ( unknown reason) calcific pancreatitis. Over the past three years, the patient had endured repeated episodes of severe abdominal pain accompanied by intractable vomiting. These episodes necessitated frequent hospitalizations every 2 to 3 months at various healthcare facilities, where she received parenteral medications, intravenous fluids, and strong analgesics for symptom control.

As a daily-wage worker from an economically challenged background, these recurrent admissions created immense hardship. Taking time off work was not a viable option, yet the intensity of her symptoms left her with no choice. The continuous need for painkillers further compounded her difficulties, leading to dependency concerns and interference with her everyday functioning. After being evaluated at multiple hospitals and advised surgery, she remained reluctant to undergo traditional open surgery due to the anticipated large incision, prolonged recovery, and associated risks. Seeking a less invasive solution, she approached our center for evaluation of feasibility for minimally invasive surgery.

Understanding the Pancreas and Chronic Pancreatitis

The pancreas is a vital digestive and endocrine organ located in the upper abdomen, nestled behind the stomach and adjacent to the duodenum (the first part of the small intestine). It serves two primary functions: exocrine and endocrine. The exocrine pancreas produces digestive enzymes (such as amylase, lipase, and proteases) and bicarbonate-rich fluid. These secretions neutralize the highly acidic chyme entering the small intestine from the stomach and facilitate the breakdown of proteins, fats, and carbohydrates for absorption. Endocrine functions of pancreas include insulin and glucagon production- for sugar control in blood.

In chronic pancreatitis, there is prolonged inflammation which leads to irreversible structural damage to the pancreatic tissue. This includes fibrosis (scarring), ductal strictures, calcification, and stone formation. The most common etiologies worldwide include:

•  Alcohol consumption – responsible for a large majority of cases in many populations.

•  Gallstone disease (biliary lithiasis) – where stones can obstruct the pancreatic duct.

•  Idiopathic – no clear cause identified.

•  Other factors: autoimmune diseases, genetic mutations (e.g., CFTR, SPINK1), hypercalcemia, severe hypertriglyceridemia, smoking, and certain medications.

The pathophysiology involves premature activation of digestive enzymes within the pancreas (autodigestion), leading to repeated injury. Over time, protein plugs and calcium deposits form stones within the dilated pancreatic duct. This increases intraductal pressure, causing ischemia, further inflammation, and intense pain often described as boring or penetrating to the back. Patients like Mrs H experience recurrent acute exacerbations on a background of chronic pain, steatorrhea, malabsorption, weight loss, nutritional deficiencies  & Diabetes Mellitus if the disease progresses unchecked.

Diagnosis typically involves a combination of clinical history, laboratory tests (serum amylase/lipase, HbA1c, fecal elastase), and imaging modalities such as ultrasound, CT abdomen, MRI/MRCP, and sometimes endoscopic ultrasound (EUS).

Challenges in Management and Evolution of Surgical Techniques

Initial management of chronic pancreatitis always is conservative and focuses on pain control, enzyme supplementation, nutritional support, and lifestyle modification (alcohol and smoking cessation). However, when medical therapy fails and patients develop intractable pain, ductal obstruction with stones, or complications, surgical intervention becomes necessary.

Traditional Open Surgery: For decades, open Frey’s pancreaticojejunostomy (has been the gold standard for patients with dilated pancreatic ducts and stones. This involves a large midline incision (typically 8–10 inches or 20–25 cm), thorough exploration, opening the pancreatic duct along its length and head coring, stone removal, and anastomosis with a Roux-en-Y jejunal loop. While effective in decompressing the duct and relieving pain in 70–80% of appropriately selected patients, it carries drawbacks including wound complications, significant postoperative pain, longer hospital stays (7–14 days), delayed recovery, and higher risk of adhesions and ventral hernia for future surgeries. Operative time often ranges from 3 to 5 hours.

Laparoscopic Approach: With the advent of minimally invasive surgery, attempts were made to perform this procedure laparoscopically. However, laparoscopy has proven technically demanding in chronic pancreatitis due to the need for precise ductal opening and anastomosis deep in the retroperitoneum, limited instrument dexterity, two-dimensional vision, and transmission of physiological tremors often result in uncontrolled bleeding, prolonged operative times, and high conversion rates to open surgery. Consequently, pure laparoscopic pancreaticojejunostomy remains uncommon and is performed for about 5 -10 procedures across the world.

Robotic-Assisted Surgery: Robotic platforms have revolutionized complex abdominal surgeries by addressing many limitations of conventional laparoscopy. The da Vinci robotic system provides:

•  Three-dimensional high-definition magnified vision (up to 10–15 times).

•  Tremor filtration and enhanced dexterity with 7 degrees of freedom.

•  Superior ergonomics for the surgeon.

•  Improved precision in delicate dissection and suturing.

Worldwide, robotic-assisted pancreatic procedures for chronic pancreatitis constitute only about 100-200 cases, reflecting the advanced infrastructure and expertise required. Our center has accumulated substantial experience, having performed atleast 4 such robotic pancreatic surgeries over the last two years with encouraging outcomes.

The Patient’s Robotic Procedure

After detailed counseling and preoperative optimization, HSmt H underwent robotic-assisted Frey’s pancreaticojejunostomy. Using five small ports (typically 8 mm), the robotic arms were docked. The pancreas was carefully exposed, and the main pancreatic duct was identified and laid open longitudinally from the head toward the tail along with head coring. Multiple stones were extracted from the ductal system, relieving the high pressure. A Roux loop of jejunum was fashioned and anastomosed in a side-to-side fashion to the opened pancreatic duct using fine, absorbable sutures. Hemostasis was meticulously ensured, and drains were placed.

The entire procedure was completed with the precision advantages of robotics, minimizing blood loss and tissue trauma.

Postoperative Course and Recovery

In the immediate postoperative period, the patient experienced delayed gastric emptying, a known temporary complication after pancreatic surgery. She was managed conservatively with nasogastric decompression, prokinetics, and nutritional support. One or two contrast-enhanced CT scans of the abdomen were performed to confirm the integrity of the anastomosis and rule out collections, leaks, or other complications requiring re-intervention. Fortunately, no major issues arose.

She was gradually started on oral liquids and advanced to a soft diet. Pain was well controlled with multimodal analgesia. She was discharged in stable condition on a liquid-to-soft diet with pancreatic enzyme supplementation and instructions for follow-up. At the three-month follow-up, Hamza Rani reported significant improvement. She is now pain-free, has resumed her daily activities and work, and no longer requires hospital visits or heavy painkillers. This transformation has markedly enhanced her quality of life and economic independence.

Advantages of Robotic Surgery in This Context

Robotic assistance offers several specific benefits for chronic pancreatitis patients:

• Smaller incisions (5–8 mm ports) leading to minimal postoperative pain

•  Reduced wound infection and hernia risk.

•  Faster recovery and shorter hospital stays.

•  Magnified 3D visualization allows safer handling of inflamed, fibrotic tissues and precise stone clearance.

•  Lower conversion rate to open surgery compared to laparoscopy.

•  Potentially better long-term pain relief due to thorough ductal decompression.

While robotic surgery involves higher initial costs and requires specialized training, the overall patient benefits — especially for working individuals like Hamza Rani — often justify its use in experienced centers.

Conclusion

This case highlights the successful application of robotic technology in a complex pancreatic condition traditionally managed by open surgery. Set H’s journey from debilitating chronic pain and repeated hospitalizations to a productive life underscores the potential of minimally invasive robotic approaches. As robotic systems become more accessible and surgeon experience grows, more patients with chronic pancreatitis may benefit from these advanced techniques, reducing morbidity while achieving excellent functional outcomes.

Chronic pancreatitis remains a challenging disease, but timely intervention — whether medical or surgical — can dramatically alter its course. Increased public awareness regarding risk factors (especially alcohol and gallstones) and the availability of advanced surgical options is essential for improving patient outcomes