Laparoscopic Pancreatectomy

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 for laparoscopic pancreatectomy are the same as those for corresponding open procedures, as follows: 

• Chronic pancreatitis
• 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 ^[16]
• Malignant pancreatic tumors

However, the choice of proceeding with a laparoscopic approach relies heavily on the surgeon's judgment and experience.

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).

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]

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]

The operative theater should have the standard laparoscopic equipment, video monitors, a selection of straight and angled lenses, standard laparoscopic graspers, dissectors, and scissors. Depending on surgeon preference, laparoscopic staplers, sutures, and energy devices should also be available.

Standard operative equipment for the open procedure should also be readily available.

The patient should be kept on NPO (nil per os) status from midnight the night before surgery. Intravenous access and infusion of fluid should be started preoperatively. A nasogastric tube for gastric decompression and a urinary catheter should be placed before the operation is begun. Standard patient padding and deep vein thrombosis (DVT) prophylaxis should be observed. Consideration of invasive monitoring, including an arterial line and central venous access, is tailored to the patient’s conditions.

Laparoscopic pancreatectomy should be performed with the patient under general endotracheal anesthesia. The patient should be supine or in the lithotomy position, depending on the type of resection planned and on the individual surgeon's preference.

In the postoperative period, a complete blood count and metabolic panel, including amylase, lipase, and a liver function panel, should be performed daily. Critically ill patients may require more frequent laboratory checks, as well as arterial blood gas monitoring.

The outpatient follow-up is dictated by the disease process being treated.

Laparoscopic distal pancreatectomy is performed with four trocars. The camera is placed through a 12-mm trocar in the umbilicus, and the surgeon’s instruments are placed through a 5- to 12-mm left and a 5-mm right subcostal trocar. The fourth trocar is the left paraxiphoid trocar that the assistant uses for retraction.

After pneumoperitoneum has been achieved and assessment for metastatic disease has been carried out, the lesser sac is entered through the gastrocolic ligament/omentum (see the image below).

The pancreas is then explored through the lesser sac. A linear laparoscopic ultrasound device can be used to find the appropriate level of resection and to assess the liver for small metastatic lesions.

To gain further exposure of the pancreas, the short gastric vessels are taken up to the level of the esophagogastric junction. If the spleen is to be preserved, the short gastric vessels are preserved.[42, 43]

The splenic flexure is mobilized to expose the inferior edge of the tail of the pancreas. The pancreas is then mobilized out of the retroperitoneum by incising the peritoneum from the inferior edge of the pancreas to the inferior pole of the spleen (see the image below).

The pancreatic tail is then mobilized and retracted medially (see the image below).

This dissection allows the splenic artery and vein to be isolated and divided with a vascular stapler or between clips.

In the case of splenic preservation, the splenic vessels may be spared. This requires division and coagulation of the pancreatic vascular branches from the splenic artery and vein. It is possible to spare the spleen and ligate the splenic artery and vein (Warshaw procedure),[44] ; the spleen will be maintained by the preserved short gastric vessels. A meta-analysis by Li et al suggested that the Warshaw procedure may not be as safe as preserving the splenic vessels[45] ; however, existing data are limited, and further study is required.

The pancreas is then divided with a vascular stapler (see the image below).

If the spleen is to be taken, it is mobilized by incising its suspending ligaments, and the entire specimen is placed in an extraction bag and removed through an extension of one of the 12-mm trocar sites or a Pfannenstiel incision. The spleen can be morcellated to allow extraction through a smaller incision.

If a drain is desired, it is placed in the resection bed and brought out through a 5-mm trocar site.[9, 46]

The operative procedure is similar to an open pylorus-preserving pancreaticoduodenectomy, with the exception that the inferior border of the pancreas and the superior mesenteric vein (SMV) are dissected before the Kocher maneuver is performed.

Pneumoperitoneum can be achieved by using either the Veress needle or the open Hasson technique, with the remainder of the ports placed under direct vision in a supraumbilical midline position and the camera port initially placed just above the umbilicus.

The operating ports include a 5- to 12-mm trocar between the umbilicus and the xiphoid to the left of the midline to allow for liver retraction and a 5-mm trocar at the same level along the anterior axillary line. Two 5- to 12-mm trocars are placed at the level of the umbilicus at the anterior axillary line and the midclavicular line for dissection and bowel retraction. An additional 12-mm trocar is placed in the left lower quadrant in the midclavicular line for the left hand when creating the jejunal roux loop.

Before the start of any resection, a thorough inspection of the liver and abdomen and biopsy of any suspicious lesions should be performed to assess for evidence of metastatic spread of disease, which would obviate the therapeutic benefits of resection. Laparoscopic ultrasonography (US) is useful to assess the liver for any small (< 1 cm) lesion that might have been missed on preoperative computed tomography (CT).

The first step involves entering the lesser sac through the gastrocolic ligament. This is performed during the inspection of the abdomen to visualize the caudate lobe, hepatic artery, and lymph nodes of the portal, perigastric, and celiac regions.

The hepatic flexure/right colon is mobilized, and dissection of the infrapancreatic SMV and portal vein confluence is performed.

According to surgeon preference, arterial branches are controlled with clips, ligatures, electrocautery, or stapling.

A cholecystectomy is than performed.

The Kocher maneuver is performed, followed by the portal dissection and division of the right gastroepiploic artery and the gastroduodenal artery.

The adventitia of the superior mesenteric artery (SMA) is dissected from the uncinate process, and the ligament of Treitz is mobilized.

The common bile duct is identified and ligated.

The antrectomy, in the standard pancreaticoduodenectomy, or division of the first portion of the duodenum, in the case of pylorus preservation, is performed with an endoscopic stapler.

The duodenojejunal junction is divided at the ligament of Treitz, which has previously been mobilized.

The pancreatic neck is divided with electrocautery and clips or ultrasonic shears.

The peripancreatic inferior vena cava (IVC) and aorta, the common hepatic artery, the proximal 3 cm of the SMA, the celiac axis, and the portal vein are skeletonized up to the porta hepatis.

The lymphofatty tissues are removed with the specimen.

The specimen is then placed into a bag and delivered through a utility incision in the right lower quadrant or by extending the umbilical incision.

An end-to-side pancreaticojejunostomy is performed, in addition to an end-to-side hepaticojejunostomy with either running or interrupted sutures, according to the surgeon's preference.

The gastrojejunostomy or duodenojejunostomy is performed in either an antecolic or a retrocolic fashion by using an endoscopic stapler or handsewn stitches.

Typically, drains are left near the pancreaticojejunostomy, as well as the hepaticojejunostomy.[34, 47]

The perioperative mortality of pancreaticoduodenectomy is less than 5%. The perioperative morbidity was reported as 41%, with reported complications as follows[48, 49, 50, 51] :

• Delayed gastric emptying (18%)
• Pancreatic fistula (12%)
• Wound infection (7%)
• Intra-abdominal abscess (6%)
• Cardiac event (3%)
• Pancreatitis (2%)
• Bile leak (2%)
• Pneumonia (2%)
• Hemobilia (2%)
• Reoperation (2.7%)