Laparoscopic Distal Pancreatectomy
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).
Dissection below the inferior border of pancreatic tail from lateral to medial direction.
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).
Continued posterior dissection in a cephalad direction, separating the tail of pancreas from Gerota fascia. Tumor is visible at left lower corner.
The pancreatic tail is then mobilized and retracted medially (see the image below).
Further dissection revealed the splenic vein traversing the superior border of the tail of pancreas.
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]
Laparoscopic Pancreaticoduodenectomy
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]
Complications
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] :
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Delayed gastric emptying (18%)
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Pancreatic fistula (12%)
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Wound infection (7%)
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Intra-abdominal abscess (6%)
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Cardiac event (3%)
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Pancreatitis (2%)
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Bile leak (2%)
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Pneumonia (2%)
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Hemobilia (2%)
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Reoperation (2.7%)
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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.
