case_images: PMC10910038_01
case_images: CT and MR results before radical surgery. (A,C,E) CT scan of the abdomen and pelvis with intravenous contrast agent showing an ill-defined 2.9 cm  x 2.8 cm mass with delayed enhancement of the uncinate process with proximal dilatation. (G,H) MR imaging showing a 2.6 cm x 3.6 cm x 2.1 cm mass originating from the common bile duct (CBD), presenting an equal signal on T1WI and an equal-high signal on T2WI. The common bile duct (CBD) was plugged up completely by the mass, resulting in the dilatation of the proximal biliary system. The dilatation of the common bile duct (CBD) reached 2.2 cm in diameter, and the pancreatic duct also presented a slight dilation of 0.1 cm. (B,D,F) CT scan for reevaluation showing the enlarged mass.
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case_images: F1
case_images: Computed tomography (CT) scan of the abdomen and pelvis with an intravenous contrast agent revealed an ill-defined 2.9 cm x 2.8 cm mass with delay enhancement in the uncinate process and common bile duct (CBD) and dilation in the biliary system (Figures 1A,C,E). Magnetic resonance (MR) imaging showed a 2.6 cm x 3.6 cm x 2.1 cm mass assumed to originate in the CBD, presenting an equal signal on T1WI and an equal-high signal on T2WI, which caused a thorough cutoff of the CBD (Figures 1G,H). While waiting 1 week for the pathological result, we performed another CT scan, which showed that the mass had enlarged to 4.4 cm x 4.3 cm (Figures 1B,D,F) while alpha-amylase had risen to 549 U/L.
case_images: Pathological results confirmed the diagnosis of rhabdomyosarcoma. In hematoxylin-eosin staining, the lesion was located under the epithelium and formed a neoplastic layer parallel to the epithelium with small round atypic cells with obvious heteromorphism (A), and positive markers such as desmin (B), myoD1 (C), and myogenin (D) staining confirmed the diagnosis of embryonal RMS originated in the ampulla.
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case_images: F2
case_images: Pancreatic Surgery. Pathological examination with desmin, myogenin, and myoD1 staining confirmed the diagnosis of embryonal RMS originating from the ampulla (Figure 2).
case_images: Robotic dissection in pylorus-preserving pancreatoduodenectomy (PPPD). (A) Port set up during surgery. (B) A neoplasm resembled a cluster of grapes inside the common bile duct (CBD). (C) The duodenum was transected at 2 cm distal to the pylorus. (D) The skeletonized SMV/SMA and dissected retroperitoneum with peripancreatic soft tissue and the nerve plexuses removed. (E) After the specimen was taken out, a stump of the common hepatic duct, pancreas, and duodenum. (F) A 3F ureteral stent tube was inserted into the MPD as an internal stent and fixed to the MPD with 4-0 Prolene.
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case_images: F3
case_images: A five-port approach is shown in Figure 3A with the da Vinci Xi Surgical System. Next, we performed a choledochotomy where a neoplasm that resembled a cluster of grapes was revealed (Figure 3B). The duodenum was then transected distal to the pylorus (Figure 3C). Simultaneously, we performed lymph node dissection of the coeliac trunk, hepatoduodenal ligament, SMV, the right side of the superior mesenteric artery, and the lymphatic tissue behind the pancreatic head; the specimens were sent for pathological examination (Figure 3D). A child reconstruction was performed sequentially: an end-to-end pancreaticojejunostomy, followed by an end-to-side hepaticojejunostomy and duodenojejunostomy (Figure 3E). A 3F ureteral stent tube was inserted into the MPD as an internal stent and fixed with 4-0 Prolene (Figure 3F).
case_images: Robotic child reconstruction and specimens. (A) End-to-end pancreatojejunostomy. (B) End-to-side single layer barbed suture hepaticojejunostomy. (C) The distal and free portion of omentum was fixed with 5-0 Prolene suture around the pancreatojejunostomy anastomosis as a mattress. (D) End-to-side single-layer barbed suture duodenojejunostomy. (E) Specimens removed with the Endo Bag.
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case_images: F4
case_images: Finally, both ends of the sutures in the anterior and posterior walls were tightened and tied for complete coverage by the jejunal end (Figure 4A). The hepaticojejunostomy anastomosis was performed in a single layer with a barbed suture, posterior and anterior, respectively (Figure 4B). The distal and free portion of the omentum was fixed with a 5-0 Prolene suture around the pancreatojejunostomy anastomosis as a mattress (Figure 4C). The duodenojejunostomy was performed in a single layer with a barbed suture, posterior and anterior, separately (Figure 4D). After being taken out with the Endo Bag, the specimens were dissected; these revealed a neoplasm that originated in the ampulla (Figure 4E).