Background : Locally advanced carcinoma body of pancreas carries dismal prognosis due to failure of local control of disease. Of late, neoadjuvant chemotherapy are showing better responses. Radical surgery with modified Celiac axis resection remains main modality for this group patients and with Radical Anterograde modular Pancreatosplenectomy (RAMPS) aids better tangential margin, lymph node staging and disease control.

Methods : We present a middle-aged women diagnosed with locally advanced carcinoma body of pancreas with celiac axis involvement. She was initially treated with neoadjuvant chemotherapy and response assessment imaging showed partial response with reduction in size of tumor and no change of vascular involvement. Tumor markers were decreased. She was planned surgery and preoperative imaging showed following vascular anomaly – retro-aortic left renal vein, double left renal artery, left gastric artery arising from aorta and replaced left hepatic artery.

Results : Intraoperatively, adequacy of blood flow through proper hepatic artery from superior mesenteric artery confirmed with ICG-fluorescence. She underwent Robotic assisted RAMPS and modified Celiac axis resection preserving replaced left hepatic artery from gastric artery. Operative time and blood loss was 600 minutes and 200 ml respectively. Postoperative uneventful. HPE reported residual disease, margin negative and no lymph node involvement. Patient asymptomatic at 3 months follow-up and stable tumor marker.

Conclusions : Multimodal treatment with neoadjuvant chemotherapy to understand the biology of the tumor and radical surgery with arterial resection permits better disease control and overall survival. Robotic platform with the magnification and freedom of movements helps precise anatomical dissection.