title: The First Case Report of Robotic Multivisceral Resection for Synchronous Liver Metastasis from Pancreatic Neuroendocrine Tumor: A Case Report and Literature Review.
abstract: BACKGROUND
  Surgery for liver metastases in pancreatic neuroendocrine tumor (PNET) improves overall survival rate. We present the first case report for robotic multivisceral resection of distal pancreas, spleen, and left liver for metastatic PNET.
  
  
  METHODS
  We present a case of 52-year-old female diagnosed with PNET in the pancreatic neck metastatic to the liver, responding to somatostatin and bland embolization, who underwent surgical debulking using da Vinci robotic platform. Intraoperative Doppler ultrasound was used to define the vascular distribution and tumor extension. The parenchymal liver transection was performed with vessel sealer. The distal pancreas and the spleen were approached medial to lateral and resected in an en-bloc fashion. The left liver inflow, outflow, and splenic artery and vein were transected with vascular stapler device.
  
  
  RESULTS
  Da Vinci robot-assisted multivisceral resection has been performed with good postoperative outcome. Operative time was 369 minutes and the estimated blood loss was 100 mL. The patient had a short hospital stay with quick recovery and good outcome at 5 months follow-up after the surgery.
  
  
  CONCLUSIONS
  Liver metastases in PNETs are considered an adverse factor. Aggressive surgical management is a mainstay. The laparoscopic approach to pancreatic or hepatic surgery is difficult in inexperienced hands with steep learning curve. The recent robotic system seems to overcome many limitations. This is the first case of robotic multivisceral resection for synchronous liver metastasis from PNET. Concurrent primary tumor resection with hepatectomy offers potential curative intention.
authors.affiliation: 1 Department of General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana.
authors.forename: Marius L
authors.initials: ML
authors.lastname: Calin
authors.affiliation: 1 Department of General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana.
authors.forename: Aziz
authors.initials: A
authors.lastname: Sadiq
authors.affiliation: 1 Department of General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana.
authors.forename: Gabriel
authors.initials: G
authors.lastname: Arevalo
authors.affiliation: 1 Department of General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana.
authors.forename: Rocio
authors.initials: R
authors.lastname: Fuentes
authors.affiliation: 2 Department of Interventional Radiology, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana.
authors.forename: Vincent L
authors.initials: VL
authors.lastname: Flanders
authors.affiliation: 3 Department of Oncology, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana.
authors.forename: Niraj
authors.initials: N
authors.lastname: Gupta
authors.affiliation: 4 Department of Surgery, Tokyo Metropolitan Matsuzawa Hospital , Tokyo, Japan .
authors.forename: Baongoc
authors.initials: B
authors.lastname: Nasri
authors.affiliation: 1 Department of General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana.
authors.forename: Kirpal
authors.initials: K
authors.lastname: Singh
mesh_terms: D016063:Blood Loss, Surgical; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008113:Liver Neoplasms / Q000556:secondary / Q000601:surgery*; D008875:Middle Aged; D018358:Neuroendocrine Tumors / Q000556:secondary / Q000601:surgery*; D061646:Operative Time; D010190:Pancreatic Neoplasms / Q000473:pathology* / Q000601:surgery*; D065287:Robotic Surgical Procedures / Q000379:methods*; D013156:Splenectomy / Q000379:methods
keywords: Bochdalek; diaphragmatic; parahiatal hernia; phrenic artery