Laparoscopic Pancreatectomy

Updated: Mar 21, 2016
  • Author: Eddy C Hsueh, MD; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
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Overview

Background

Laparoscopic operations for pancreatic disease were first attempted in the 1960s. [1] Laparoscopic pancreatic enucleations and resections have been performed for both benign and malignant disease, with good immediate results. [1]

The first laparoscopic pancreaticoduodenectomy was performed by Gagner and Pomp in 1992 to treat chronic pancreatitis. [2] Subsequent small studies and case series have shown that laparoscopic pancreaticoduodenectomy has morbidity and mortality rates that are comparable to those of the open operation. [3, 4, 5]

Several centers have published their results with laparoscopic distal pancreatectomy and have found that, compared with an open approach, the operative time is increased, blood loss decreased, and length of hospital admission shortened. [6, 7, 8, 9, 10] . A 2016 meta-analysis compared robotic-assisted distal pancreatectomy with laparoscopic distal pancreatectomy and found the former to be associated with a lower volume of blood loss, a higher spleen-preservation rate, and a shorter hospital stay. [11]

With the publication of the Clinical Outcomes of Surgical Therapy (COST) trial, many centers are attempting increasingly complex laparoscopic operations in an attempt to decrease length of stay and associated complications with open abdominal operations. [12]

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Indications

Indications for laparoscopic pancreatectomy are the same for open procedures. However, the choice of proceeding with laparoscopic approach relies heavily on surgeon's judgment and experience:

  • Malignant or benign exocrine tumors
  • Malignant or benign endocrine tumors
  • Symptomatic serous cystadenoma
  • Mucinous tumors
  • Intraductal papillary mucinous tumor (IPMT)
  • Cystic pancreatic neoplasms
  • Solid pseudopapillary tumor of the pancreas [13]
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Contraindications

Contraindications to laparoscopic pancreatectomy are the same as for open procedures and include metastatic malignant tumors and tumors that are unresectable owing to local invasion or encasement of the perihilar portal vein, celiac axis, hepatic artery, or superior mesenteric artery.

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Technical Considerations

Procedural planning

Preoperative nutritional optimization should be performed, if possible.

Preoperative imaging, including CT scanning, positron emission tomography (PET)/CT scanning, endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS), magnetic resonance cholangiopancreatography (MRCP), and angiography, can be helpful to determine the resectability of pancreatic lesions, as well as to stage malignant lesions.

A diligent search for metastatic lesions that would obviate the benefit of resection should also be undertaken in patients with potentially malignant lesions. Any involvement of vascular structures should be ascertained preoperatively, as involvement of the superior mesenteric artery (SMA) with pancreatic adenocarcinoma makes a lesion unresectable owing to invasion of the periarterial neural plexus.

See Pancreatic Adenocarcinoma Imaging: What You Need to Know, a Critical Images slideshow, to help identify which imaging studies are used to identify and evaluate this disease.

Laparoscopic pancreatic resections can take anywhere from 78 to 848 minutes, depending on the surgeon and the type of resection. [1, 14, 15, 16]

Complication prevention

Bioabsorbable staple-line reinforcement, octreotide infusion, fibrin glue, and ultrasonic scalpel dissection have been studied as potential methods to lower the rate of pancreatic leaks but have had mixed results in clinical trials. [17, 18, 19, 20]

There is no significant difference in the incidence of delayed gastric emptying whether the pylorus is spared or not, but the administration of erythromycin has been found to reduce the occurrence of delayed gastric emptying. [21, 22]

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Outcomes

Laparoscopic pancreatectomy for benign disease has been shown to yield long-term results that are equivalent to those of open procedures, with shorter hospital stays and quicker return to full activity. [14, 23, 24, 25, 26, 27, 28]

Whereas the short-term benefits of minimally invasive surgery have also been observed in patients with malignant lesions, the long-term oncologic outcomes have not been studied rigorously. [1, 29]  Stauffer et al reported that laparoscopic distal pancreatectomy was associated with more resected lymph nodes than open distal pancreatectomy was (25.9 vs 12.7) and that the 1-, 3-, and 5-year survival rates were comparable between the laparoscopc procedure (69%, 41%, and 41%, respectively) and the open procedure (78%, 44%, and 32%, respectively). [30]

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