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, 2]
The first laparoscopic pancreaticoduodenectomy was performed by Gagner and Pomp in 1992 to treat chronic pancreatitis. [3] Subsequent small studies and case series have shown that the morbidity and mortality of laparoscopic pancreaticoduodenectomy are comparable to those of the equivalent open operation. [4, 5, 6] Although the procedure has become common in some centers, there remains some controversy surrounding its complication rates and its inconclusive oncologic outcomes. [7]
Several centers have published their results with laparoscopic distal pancreatectomy and have found that, in comparison with an open approach, operating time is increased, blood loss decreased, and length of hospital admission shortened. [8, 9, 10, 11, 12]
The publication of the Clinical Outcomes of Surgical Therapy (COST) trial has led many centers to perform increasingly complex laparoscopic operations in an attempt to decrease length of stay and reduce the incidence of complications associated with open abdominal operations. [13]
The International Study Group on Minimally Invasive Pancreas Surgery (I-MIPS) has proposed guidelines for minimally invasive pancreas resection, [14] which are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology.
Laparoscopic distal pancreatectomy is now considered a safe and effective tool for tumors arising from the body and the tail of the pancreas. [15]
Indications
Indications for laparoscopic pancreatectomy are the same as those for corresponding open procedures, as follows:
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Malignant or benign exocrine tumors
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Malignant or benign endocrine tumors
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Symptomatic serous cystadenoma
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Mucinous tumors
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Intraductal papillary mucinous tumor (IPMT)
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Cystic pancreatic neoplasms
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Solid pseudopapillary tumor of the pancreas [16]
However, the choice of proceeding with a laparoscopic approach relies heavily on the surgeon's judgment and experience.
Contraindications
Contraindications for laparoscopic pancreatectomy are the same as those 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 (SMA).
Technical Considerations
Procedural planning
Preoperative nutritional optimization should be performed, if possible.
Preoperative imaging, including computed tomography (CT), positron emission tomography (PET)/CT, endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS), magnetic resonance cholangiopancreatography (MRCP), and angiography, can be helpful for determining the resectability of pancreatic lesions, as well as for staging 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; involvement of the 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, 17, 18, 19]
Distal pancreatectomy with celiac axis resection (DP-CAR) is carried out to achieve an R0 resection for locally advanced pancreatic body cancer that invades the celiac axis. However, obstruction of the field of vision at the root of the celiac axis may render this procedure challenging. Kiguchi et al described a retroperitoneal-first laparoscopic approach (Retlap)-assisted DP-CAR that was technically feasible, with adequate surgical margins, and also facilitated the evaluation of resectability. [20]
Robotic surgery is being used commonly for pancreatectomy, and technical advances (as in the da Vinci SP system; Intuitive, Sunnyvale, CA) have made it possible to carry out distal pancreatectomy with a single-port robot plus one port. [21] Choi et al successfully performed this procedure in three patients and found it to be safe and feasible, with acceptable outcomes.
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 yielded mixed results in clinical trials. [22, 23, 24, 25]
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. [26, 27]
Outcomes
Laparoscopic pancreatectomy for benign disease has been shown to yield long-term results that are comparable to those of equivalent open procedures, with shorter hospital stays and quicker return to full activity. [17, 28, 29, 30, 31, 32, 33]
Whereas the short-term benefits of minimally invasive surgery have also been observed in patients with malignant lesions, there remains a need for rigorous study of the long-term oncologic outcomes. [1, 34]
Stauffer et al reported that laparoscopic distal pancreatectomy for pancreatic adenocarcinoma 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 laparoscopic procedure (69%, 41%, and 41%, respectively) and the open procedure (78%, 44%, and 32%, respectively). [35]
Raoof et al, in a propensity score-matched comparison of oncologic outcomes between laparoscopic and open distal pancreatic resection, found that the outcomes of the two approaches were comparable with respect to median number of days to chemotherapy (50 vs 50), median number of nodes examined (12 vs 12), 30-day mortality (1.2% vs 0.9%), 90-day mortality (2.8% vs 3.7%), 30-day readmission rate (9.6% vs 9.2%), and positive margin rate (14.9% vs 18.5%). [36] However, median duration of hospital stay was shorter in the laparoscopic group (6 vs 7 days).
Jiang et al, in a systematic review and meta-analysis of eight studies (N = 15,278), compared the oncologic outcomes and clinical efficacy of laparoscopic pancreaticoduodenectomy and open pancreaticoduodenectomy in patients with pancreatic ductal adenocarcinoma. [37] The two procedures did not differ significantly with respect to 5-year overall survival. The laparoscopic procedure resulted in a higher rate of R0 resection and was associated with comparable rates of postoperative pancreatic fistula and hemorrhage, a larger number of harvested lymph nodes, shorter hospital stays, and less estimated blood loss.
In a single-institution study of laparoscopic pancreatectomy for benign or low-grade malignant pancreatic tumours from a single institution. Cai et al reviewed a total of 164 patients, of whom 83 underwent laparoscopic pylorus-preserving pancreaticoduodenectomy, 41 underwent laparoscopic spleen-preserving distal pancreatectomy, and 20 underwent laparoscopic central pancreatectomy; 20 patients were excluded. [38] Overall, they found laparoscopic surgery to be safe and feasible in all these procedures, with excellent long-term outcomes.
A meta-analysis by Zhou et al 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. [39]
A retrospective analysis by Najafi et al compared robotic-assisted with laparoscopic distal pancreatic resection and enucleation for potentially benign pancreatic neoplasms and found that the former was comparable in terms of safety while increasing the rate of splenic-vessel preservation and reducing the likelihood of conversion to open surgery. [40]
In a systematic review and meta-analysis that included six retrospective studies addressing robotic versus laparoscopic distal pancreatectomy, Feng et al reported that the former is technically and oncologically safe and feasible in selected patients with pancreatic ductal adenocarcinoma. [41]
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Dissection below the inferior border of pancreatic tail from lateral to medial direction.
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Continued posterior dissection in a cephalad direction, separating the tail of pancreas from Gerota fascia. Tumor is visible at left lower corner.
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Further dissection revealed the splenic vein traversing the superior border of the tail of pancreas.
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Transection of the tail of pancreas with endostapler.
