Enhancing the Workflow of Full Robotic Pancreatoduodenectomy: A Counterclockwise Step-by-Step Approach to Resection and Reconstruction.

BACKGROUND: Robotic technology has enabled the execution of complex surgical procedures through a fully minimally invasive approach. Among these procedures, robotic pancreatoduodenectomy (R-PD) remains particularly challenging due to its duration and the numerous steps involved. The authors present a standardized approach designed as a reproducible framework potentially applicable to the majority of standard R-PD techniques aimed at enhancing operative workflow. METHODS: The technique is based on a stepwise model for the resection phase, performed in a counterclockwise sequence that provides a logical and reproducible pathway through the complex anatomy of the pancreatic head. The reconstruction phase follows a second counterclockwise-inspired sequence, relying on standardized anastomotic techniques designed to improve reproducibility and operative flow. RESULTS: Between May 2018 and November 2025, 150 consecutive R-PDs were performed in our General Surgery Unit. The mean console time was 279.44 ± 55.85 min. All the procedures were completed using a fully robotic approach, without conversion to open surgery. The median hospital stay was 12 days (range, 9-23 days). Major complications (Clavien-Dindo ≥3) occurred for 20 patients (13.3 %). Clinically relevant postoperative pancreatic fistula developed in 10 patients (6.7 %), whereas clinically relevant delayed gastric emptying was reported in 35 patients (23.3 %). The 30- and 90-day mortality rates were 1.3 % (2/150 patients) and 3.3 % (5/150 patients), respectively. CONCLUSIONS: The structured, counterclockwise-inspired surgical sequence described combined with standardized reconstruction techniques may represent an effective strategy for performing most standard R-PDs. This approach has the potential to streamline workflow and enhance surgical outcomes.