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Miller PN, Romero-Hernandez F, Conroy P, Calthorpe L, Yilma M, Mohamedaly S, Kelly YM, Feng J, Hirose K, Kirkwood K, Maker AV, Corvera C, Nakakura E, Alseidi A, Adam MA. Hand-Assisted Versus Pure Minimally-Invasive Distal Pancreatectomy: Is There a Downside to Lending a Hand? World J Surg 2023; 47:750-758. [PMID: 36402918 DOI: 10.1007/s00268-022-06835-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Hand-assisted laparoscopic distal pancreatectomy (HALDP) is suggested to offer similar outcomes to pure laparoscopic distal pancreatectomy (LDP). However, given the longer midline incision, it is unclear whether HALDP increases the risk of postoperative hernia. Our aim was to determine the risk of postoperative incisional hernia development after HALDP. METHODS We retrospectively collected data from patients undergoing HALDP or LDP at a single center (2012-2020). Primary endpoints were postoperative incisional hernia and operative time. All patients had at minimum six months of follow-up. Outcomes were compared using unadjusted and multivariable regression analyses. RESULTS Ninety-five patients who underwent laparoscopic distal pancreatectomy were retrospectively identified. Forty-one patients (43%) underwent HALDP. Patients with HALDP were older (median, 67 vs. 61 years, p = 0.02). Sex, race, Body Mass Index (median, 27 vs. 26), receipt of neoadjuvant chemotherapy, gland texture, wound infection rates, postoperative pancreatic fistula, overall complications, and hospital length-of-stay were similar between HALDP and LDP (all p > 0.05). In unadjusted analysis, operative times were shorter for HALDP (164 vs. 276 min, p < 0.001), but after adjustment, did not differ significantly (MR 0.73; 0.49-1.07, p = 0.1). Unadjusted incidence of hernia was higher in HALDP versus LDP (60% vs. 24%, p = 0.004). After adjustment, HALDP was associated with an increased odds of developing hernia (OR 7.52; 95% CI 1.54-36.8, p = 0.014). After propensity score matching, odds of hernia development remained higher for HALDP (OR 4.62; 95% CI 1.28-16.65, p = 0.031) p = 0.03). CONCLUSIONS Compared with LDP, HALDP was associated with increased likelihood of postoperative hernia with insufficient evidence that HALDP shortens operative times. Our results suggest that HALDP may not be equivalent to LDP.
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Affiliation(s)
- Phoebe N Miller
- Department of Surgery, University of California, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Fernanda Romero-Hernandez
- Department of Surgery, University of California, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Patricia Conroy
- Department of Surgery, University of California, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Lucia Calthorpe
- Department of Surgery, University of California, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Mignote Yilma
- Department of Surgery, University of California, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Sarah Mohamedaly
- Department of Surgery, University of California, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Yvonne M Kelly
- Department of Surgery, University of California, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Jean Feng
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Kenzo Hirose
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Kimberly Kirkwood
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Ajay V Maker
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Carlos Corvera
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Eric Nakakura
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Adnan Alseidi
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Mohamed A Adam
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA.
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Postlewait LM, Ethun CG, Mcinnis MR, Merchant N, Parikh A, Idrees K, Isom CA, Hawkins W, Fields RC, Strand M, Weber SM, Cho CS, Salem A, Martin RC, Scoggins C, Bentrem D, Kim HJ, Carr J, Ahmad S, Abbott D, Wilson GC, Kooby DA, Maithel SK. The Hand-Assisted Laparoscopic Approach to Resection of Pancreatic Mucinous Cystic Neoplasms: An Underused Technique?. Am Surg 2018. [DOI: 10.1177/000313481808400123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pancreatic mucinous cystic neoplasms (MCNs) are rare tumors typically of the distal pancreas that harbor malignant potential. Although resection is recommended, data are limited on optimal operative approaches to distal pancreatectomy for MCN. MCN resections (2000–2014; eight institutions) were included. Outcomes of minimally invasive and open MCN resections were compared. A total of 289 patients underwent distal pancreatectomy for MCN: 136(47%) minimally invasive and 153(53%) open. Minimally invasive procedures were associated with smaller MCN size (3.9 vs 6.8 cm; P = 0.001), lower operative blood loss (192 vs 392 mL; P = 0.001), and shorter hospital stay(5 vs 7 days; P = 0.001) compared with open. Despite higher American Society of Anesthesiologists class, hand-assisted (n = 46) had similar advantages as laparoscopic/robotic (n = 76). When comparing hand-assisted to open, although MCN size was slightly smaller (4.1 vs 6.8 cm; P = 0.001), specimen length, operative time, and nodal yield were identical. Similar to laparoscopic/robotic, hand-assisted had lower operative blood loss (161 vs 392 mL; P = 0.001) and shorter hospital stay (5 vs 7 days; P = 0.03) compared with open, without increased complications. Hand-assisted laparoscopic technique is a useful approach for MCN resection because specimen length, lymph node yield, operative time, and complication profiles are similar to open procedures, but it still offers the advantages of a minimally invasive approach. Hand-assisted laparoscopy should be considered as an alternative to open technique or as a successive step before converting from total laparoscopic to open distal pancreatectomy for MCN.
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Affiliation(s)
- Lauren M. Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Cecilia G. Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mia R. Mcinnis
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nipun Merchant
- Division of Surgical Oncology, Department of Surgery, University of Miami, Miami, Florida
| | - Alexander Parikh
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chelsea A. Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William Hawkins
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew Strand
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Clifford S. Cho
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Robert C.G. Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Charles Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - David Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hong J. Kim
- Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Jacquelyn Carr
- Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Syed Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Cancer Institute, Cincinnati, Ohio
| | - Daniel Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Gregory C. Wilson
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Cancer Institute, Cincinnati, Ohio
| | - David A. Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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A systematic review and meta-analysis of spleen-preserving distal pancreatectomy with preservation or ligation of the splenic artery and vein. Surgeon 2016; 14:109-18. [DOI: 10.1016/j.surge.2015.11.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/24/2015] [Accepted: 11/20/2015] [Indexed: 01/19/2023]
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Laparoscopic Distal Pancreatectomy with or without Preservation of the Spleen for Solid Pseudopapillary Neoplasm. Case Rep Surg 2015; 2015:487639. [PMID: 26587305 PMCID: PMC4637475 DOI: 10.1155/2015/487639] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
Solid pseudopapillary neoplasm (SPN) is a rare tumor of the pancreas. Laparoscopic distal pancreatectomy (DP) is a feasible and safe procedure, and successful spleen preservation rates are higher using a laparoscopic approach. We hypothesized that certain patients with SPN would be good candidates for laparoscopic surgery; however, few surgeons have reported laparoscopic DP for SPN. We discuss the preoperative assessment and surgical simulation for two SPN cases. A simulation was designed because we consider that a thorough preoperative understanding of the procedure based on three-dimensional image analysis is important for successful laparoscopic DP. We also discuss the details of the actual laparoscopic DP with or without splenic preservation that we performed for our two SPN cases. It is critical to use appropriate instruments at appropriate points in the procedure; surgical instruments are numerous and varied, and surgeons should maximize the use of each instrument. Finally, we discuss the key techniques and surgical pitfalls in laparoscopic DP with or without splenic preservation. We conclude that experience alone is inadequate for successful laparoscopic surgery.
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Tanaka M, Tomikawa M, Nakamura M, Nakamura Y, Misawa T, Akahoshi T, Kinjyo N, Sumiyoshi H, Tsutsumi K, Tsutsumi N, Nakashima H, Higashida M, Fujiwara Y, Matsushita A, Matsumoto M. Gastroenterological Surgery: Pancreas. Asian J Endosc Surg 2015; 8:239-42. [PMID: 26303728 DOI: 10.1111/ases.12221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 04/10/2015] [Accepted: 04/10/2015] [Indexed: 12/31/2022]
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Retrospective analysis of short term outcomes after spleen-preserving distal pancreatectomy for sodid pseudopapillary tumours. Int J Surg 2015; 21 Suppl 1:S26-9. [PMID: 26118599 DOI: 10.1016/j.ijsu.2015.06.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 03/19/2015] [Accepted: 04/10/2015] [Indexed: 02/07/2023]
Abstract
Solid pseudopapillary pancreatic tumour (SPN) is a rare pancreatic tumour representing 0.1%-3% of all exocrine pancreatic tumours. Most SPN show benign and low-grade malignant behaviour; malignant degeneration is observed in 10-15% of the patients. More than 40% of SPN involve the tail of the pancreas leading to a minimal invasive distal pancreatectomy approach. In this report we present the case of a young 22 Caucasian woman suffering from SPN who successfully underwent laparoscopic spleen-preserving distal pancreatectomy. Postoperative course was uneventful. A CT scan control at six months was negative for recurrences. We have also made an analysis of all the laparoscopic treatment of SPN reported in English literature.
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Mohkam K, Farges O, Pruvot FR, Muscari F, Régimbeau JM, Regenet N, Sa Cunha A, Dokmak S, Mabrut JY. Toward a standard technique for laparoscopic distal pancreatectomy? Synthesis of the 2013 ACHBT Spring workshop. J Visc Surg 2015; 152:167-78. [DOI: 10.1016/j.jviscsurg.2015.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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8
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Zhang H, Zhu F, Shen M, Tian R, Shi CJ, Wang X, Jiang JX, Hu J, Wang M, Qin RY. Systematic review and meta-analysis comparing three techniques for pancreatic remnant closure following distal pancreatectomy. Br J Surg 2014; 102:4-15. [PMID: 25388952 DOI: 10.1002/bjs.9653] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 03/29/2014] [Accepted: 08/18/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Established closure techniques for the pancreatic remnant after distal pancreatectomy include stapler, suture and anastomotic closure. However, controversy remains regarding the ideal technique; therefore, the aim of this study was to compare closure techniques and risk of postoperative pancreatic fistula (POPF). METHODS A systematic review was carried out according to PRISMA guidelines for studies published before January 2014 that compared at least two closure techniques for the pancreatic remnant in distal pancreatectomy. A random-effects model was constructed using weighted odds ratios (ORs). RESULTS Thirty-seven eligible studies matched the inclusion criteria and 5252 patients who underwent distal pancreatectomy were included. The primary outcome measure, the POPF rate, ranged 0 from to 70 per cent. Meta-analysis of the 31 studies comparing stapler versus suture closure showed that the stapler technique had a significantly lower rate of POPF, with a combined OR of 0.77 (95 per cent c.i. 0.61 to 0.98; P = 0.031). Anastomotic closure was associated with a significantly lower POPF rate than suture closure (OR 0.55, 0.31 to 0.98; P = 0.042). Combined stapler and suture closure had significantly lower POPF rates than suture closure alone, but no significant difference compared with stapler closure alone. CONCLUSION The use of stapler closure or anastomotic closure for the pancreatic remnant after distal pancreatectomy significantly reduces POPF rates compared with suture closure. The combination of stapler and suture closure shows superiority over suture closure alone.
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Affiliation(s)
- H Zhang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei
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Clinical comparison of distal pancreatectomy with or without splenectomy: a meta-analysis. PLoS One 2014; 9:e91593. [PMID: 24682038 PMCID: PMC3969315 DOI: 10.1371/journal.pone.0091593] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 02/12/2014] [Indexed: 12/14/2022] Open
Abstract
Objective A distal pancreatectomy has routinely been used for removing benign/borderline malignant tumors of the body and tail of the pancreas; however, controversy exists whether or not the spleen should be saved. Therefore, we conducted this meta-analysis for comparing the clinical outcomes of patients who underwent distal pancreatectomy with or without splenectomy. Methods A literature research from the databases of Medline, Embase, and Cochrane library was performed to evaluate and compare the clinical outcomes between spleen-preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (DPS). Pooled odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (95% CI) were calculated using fixed-effects or random-effects models. Results Eleven non-randomized controlled studies involving 897 patients were selected to satisfy the inclusion criteria; 355 patients underwent SPDP and 542 patients underwent DPS. Compared with DPS, SPDP required a shorter hospital stay (WMD = 1.16, 95% CI = −2.00 to −0.31, P = 0.007), and had a lower incidence of intra-abdominal abscesses (OR = 0.48, 95% CI = 0.27 to 0.83, P = 0.009). In addition, spleen infarctions occurred in SPDP, most of which involved use of the Warshaw method for preserving the spleen. There were no differences between the SPDP and DPS groups with respect to operative time, operative blood loss, requirement for blood transfusion, pancreatic fistulas, thromboses, post-operative bleeding, wound infections and re-operation rates. Conclusion SPDP should be performed due to the benefits of the immune system and quick post-operative recovery. It is also essential to preserve the splenic artery and vein. Large randomized controlled trials are further needed to verify the results of this meta-analysis.
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10
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Abe N, Mori T, Sugiyama M. Tips on laparoscopic distal pancreatectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:E41-7. [DOI: 10.1002/jhbp.95] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Nobutsugu Abe
- Department of Surgery; Kyorin University School of Medicine; 6-20-2 Shinkawa, Mitaka Tokyo 181-8611 Japan
| | - Toshiyuki Mori
- Department of Surgery; Kyorin University School of Medicine; 6-20-2 Shinkawa, Mitaka Tokyo 181-8611 Japan
| | - Masanori Sugiyama
- Department of Surgery; Kyorin University School of Medicine; 6-20-2 Shinkawa, Mitaka Tokyo 181-8611 Japan
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Cirocchi R, Partelli S, Coratti A, Desiderio J, Parisi A, Falconi M. Current status of robotic distal pancreatectomy: a systematic review. Surg Oncol 2013; 22:201-7. [PMID: 23910929 DOI: 10.1016/j.suronc.2013.07.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 07/03/2013] [Accepted: 07/06/2013] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this systematic review is to determine the potential advantages of robotic distal pancreatectomy (RDP). STUDY SELECTION Both randomized and non-randomized studies. DATA EXTRACTION Two investigators independently selected studies for inclusion by article abstraction and full text reviewing. DATA SYNTHESIS Five non-RCTs were included in the review. The feasibility of RDP (95.4%) and spleen-preserving rate is between 50% and 100%. Mean OT varied between 298 min and 398 min with only completely robotic procedures, whereas mean OT was 293 in "laparoscopic/robotic" technique. Postoperative length of hospital stay ranged from 7 days to 13.7 days. The 30-day postoperative overall morbidity resulted between 0 and 18% of patients. CONCLUSIONS RDP is an emergent technology for which there are not yet sufficient data to draw definitive conclusions with respect to conventional or laparoscopic surgery. The mean duration of RDP is longer with Da Vinci robot, but hospital stay is shorter even if it is influenced by hospital protocols. We cannot make any conclusions comparing the outcomes to laparoscopic or open procedures here, since none of these studies are randomized, and we all know that most of these surgeons selected the easier cases for robotic procedures. For these reasons randomized controlled trials are recommended to better evaluate RDP cost-effectiveness.
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Affiliation(s)
- Roberto Cirocchi
- Digestive Surgery and Liver Unit, S. Maria Hospital, Via Tristano di Joannuccio n.4, Terni 05100, Italy.
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Jain G, Chakravartty S, Patel AG. Spleen-preserving distal pancreatectomy with and without splenic vessel ligation: a systematic review. HPB (Oxford) 2013; 15:403-10. [PMID: 23458666 PMCID: PMC3664043 DOI: 10.1111/hpb.12003] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 10/15/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Splenic preservation during a distal pancreatectomy (SPDP) may be performed with splenic vessel ligation, known as Warshaw's Technique (WT) or splenic vessel preservation (SVP). The consensus on which approach is best is divided. A systematic review of evidence in the literature was undertaken with the aim of analysing the merits and disadvantages of both WT and SVP. METHODS A systematic search of medical literature from 1985-2011 was undertaken to identify all comparative studies and case series on SPDP. Non-English papers, series with < 5 patients, technical reports and reviews were excluded. The remaining articles were reviewed considering the study design, surgical technique, outcomes and complications. RESULTS In 23 relevant studies, 356 patients underwent WT and 572 underwent SVP. In WT patients, the mean operating time (160 versus 215 min, P < 0.001), mean estimated blood loss (301 versus 390 ml, P < 0.001) and length of stay (8 versus 11 days, P < 0.001) was significantly less than the SVP patients, respectively. Considering complications, splenic infarction and splenectomy occurred more frequently in WT patients (P < 0.05). DISCUSSION WT is technically easier to perform than SVP but has a higher incidence of subsequent splenectomies. Surgeons should be able to perform both procedures and tailor the technique according to the patient.
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Affiliation(s)
- Gaurav Jain
- Institute of Minimal Access Surgery, King's College Hospital, London, UK
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13
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Gumbs AA, Croner R, Rodriguez A, Zuker N, Perrakis A, Gayet B. 200 consecutive laparoscopic pancreatic resections performed with a robotically controlled laparoscope holder. Surg Endosc 2013; 27:3781-91. [PMID: 23644837 DOI: 10.1007/s00464-013-2969-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 04/03/2013] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Because of the potential benefit of robotics in pancreatic surgery, we review our experience at two minimally invasive pancreatic surgery centers that utilize a robotically controlled laparoscope holder to see if smaller robots that enable the operating surgeon to maintain contact with the patient may have a role in the treatment of pancreatic disease. METHODS From March 1994 to June 2011, a total of 200 laparoscopic pancreatic procedures utilizing a robotically controlled laparoscope holder were performed. RESULTS A total of 72 duodenopancreatectomies, 67 distal pancreatectomies, 23 enucleations, 20 pancreatic cyst drainage procedures, 5 necrosectomies, 5 atypical pancreatic resections, 4 total pancreatectomies, and 4 central pancreatectomies were performed. Fourteen patients required conversion to an open approach and eight a hand-assisted one. A total of 24 patients suffered a major complication. Sixteen patients developed a pancreatic leak and 19 patients required reoperation. Major complications occurred in 14 patients and pancreatic leaks occurred in 13 patients. Ten patients required conversion to a lap-assisted or open approach and six patients required reoperation. CONCLUSIONS Currently, a robotically assisted approach using a camera holder seems the only way to incorporate some of the benefits of robotics in pancreatic surgery while maintaining haptics and contact with the patient.
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Affiliation(s)
- Andrew A Gumbs
- Department of Surgical Oncology, Summit Medical Group, Berkeley Heights, NJ, 07922, USA,
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Jensen EH, Portschy PR, Chowaniec J, Teng M. Meta-analysis of bioabsorbable staple line reinforcement and risk of fistula following pancreatic resection. J Gastrointest Surg 2013; 17:267-72. [PMID: 22948840 DOI: 10.1007/s11605-012-2016-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 08/17/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Stapled pancreatic transection is widely used although pancreatic fistula remains a common post-surgical complication. METHODS We performed a meta-analysis of existing data regarding pancreatic fistula following stapled pancreatic transection, comparing bare metal staples to reinforced staple loads. RESULTS We identified ten manuscripts between 2007 and 2009 reporting outcomes following stapled division of the pancreas (five retrospective reviews, five prospective case series). A total of 483 stapled pancreatic resections are included in this meta-analysis. Of these, 234(48 %) were reinforced (REINF) and 249 (52 %) were bare staples (STPL). Out of 483 cases, there were a total of 100 documented pancreatic leaks (21 %). Sixty-one leaks were reported out of 249 STPL divisions (24 %), while 39 leaks were reported following REINF division (17 %). The overall relative risk of developing a pancreatic fistula following distal pancreatectomy was not significantly different comparing STPL to REINF when all studies were combined (RR 1.00, 95% CI 0.65-1.53). We further evaluated the data stratifying by study design (prospective or retrospective) and found that prospective studies reported a significantly higher risk of pancreatic fistula with STPL compared to REINF technique (RR 14.45, 95 % CI 3.15-66.21). CONCLUSION Reinforced staples may be a preferred method of pancreatic stump closure following distal pancreatectomy.
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Affiliation(s)
- Eric H Jensen
- University of Minnesota Medical Center, 420 Delaware Street SE, MMC 195, Minneapolis, MN 55455, USA.
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15
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Fisher SB, Kooby DA. Laparoscopic pancreatectomy for malignancy. J Surg Oncol 2012; 107:39-50. [PMID: 22991263 DOI: 10.1002/jso.23253] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 08/09/2012] [Indexed: 12/15/2022]
Abstract
Utilization of laparoscopic techniques for resection of the pancreas has slowly gained acceptance in specific situations and is now being applied to more challenging endeavors, such as pancreaticoduodenectomy for cancer. This review provides a summary of laparoscopic applications for pancreatic malignancy, with specific attention to the most common methods of pancreatic resection and their respective oncologic outcomes, including margin status, lymph node retrieval, and survival.
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Affiliation(s)
- Sarah B Fisher
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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16
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The minimally invasive approach to surgical management of pancreatic diseases. Gastroenterol Clin North Am 2012; 41:77-101. [PMID: 22341251 DOI: 10.1016/j.gtc.2011.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Laparoscopic pancreas surgery has undergone rapid development over the past decade. Although acceptability among traditional surgeons has been low, emerging specialty centers are reporting excellent outcomes for advanced and complex operations, such as pancreaticoduodenectomy. A note of caution is necessary: These outstanding results are from skilled surgeons, many of whom are pioneers in the field, who have overcome the learning curve over many years of innovation. As the procedures gain wider practice, outcomes need to be carefully watched because many of these procedures are extremely demanding technically. Although many have suggested that controlled, randomized studies comparing laparoscopic pancreatic resections with open resections are necessary to establish the efficacy of laparoscopic procedure, the cumulative data on the safety and efficacy of the laparoscopic procedure argues against such an approach. The logistic difficulties of conducting such studies will be considerable given patient preferences, the need for multicenter studies, and the rapid adoption of the laparoscopic procedure among experienced pancreatic surgeons. A more reasonable approach to truly evaluate the safety of these procedures is the establishment of a national registry that can measure progress of the field and record outcomes in the wider, nonspecialty community. Hepatobiliary training programs should also establish a minimal standard of training for many of the advanced procedures, such as the pancreaticoduodenectomy, so that the benefit of laparoscopic surgery can be made available outside of just a few specialty centers.
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Hand-assisted Laparoscopic Partial Splenectomy Using an Endopath Monopolar Sealer. Surg Laparosc Endosc Percutan Tech 2011; 21:e291-4. [DOI: 10.1097/sle.0b013e3182311ee4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hong J, Wang J, Keleman AM, Imagawa DK, Xu K, Wang W, Liu E, Niu W, Wang J, Sun I, Wang J, Peng C, Zhao W, Niu J. Endoscopic Versus Surgical Treatment of Downstream Pancreatic Duct Stones in Chronic Pancreatitis. Am Surg 2011. [DOI: 10.1177/000313481107701146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pancreatic duct stone is thought not only to be the cause of abdominal pain but also to be a risk factor for pancreatic cancer. Several treatment options have been implemented in the treatment of pancreatic duct stones. Stone location is a critical factor in selecting treatment. We present the results of 27 endoscopic treatments and 35 surgical treatments performed in three hospitals at a single university between January 2000 and January 2005. The results were compared retrospectively in terms of success rate of stone removal, length of hospital stay, complications, pain relief, and changes of pancreatic functions. In our study, endoscopy resulted in a similar success rate of stone removal and short-term pain relief rate as the surgical approach and with a shorter length of hospital stay. However, the surgical group had a more favorable long-term clinical result, as well as a lower number of hospital readmissions at the 5-year follow-up point. Based on long-term results, surgical treatment is more effective than endoscopy.
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Affiliation(s)
- Jianguo Hong
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Jian Wang
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Alex M. Keleman
- Department of Hepatobiliary and Pancreas Surgery, University of California, Irvine Medical Center, Orange, California
| | - David K. Imagawa
- Department of Hepatobiliary and Pancreas Surgery, University of California, Irvine Medical Center, Orange, California
| | - Kesen Xu
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Wenhua Wang
- Center for Health Management and Policy, Shandong University, Jinan, Shandong, China
| | - Enyu Liu
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Weibo Niu
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Jinshen Wang
- Department of Gastrointestinal Surgery, Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Iang Sun
- Department of General Surgery, the Second Hospital of Shandong University, Jinan, Shandong, China
| | - Jiayong Wang
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Cheng Peng
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Wanni Zhao
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Jun Niu
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
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Tsiouris A, Cogan CM, Velanovich V. Distal pancreatectomy with or without splenectomy: comparison of postoperative outcomes and surrogates of splenic function. HPB (Oxford) 2011; 13:738-44. [PMID: 21929675 PMCID: PMC3210976 DOI: 10.1111/j.1477-2574.2011.00369.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Published data on splenic preservation during distal pancreatectomy have been inconsistent. We hypothesized that patients undergoing spleen-preserving distal pancreatectomy (SPDP) would have fewer infectious and non-infectious complications than those undergoing en bloc distal pancreatectomy with splenectomy (DPS), and that their haematological parameters would be consistent with splenic function. METHODS Of 97 patients who underwent either SPDP using the Warshaw technique or en bloc DPS, 78 met our study inclusion criteria. Records were reviewed for data on age, gender, resection, indications for resection, operative time, blood loss, transfusion requirements, hospital stay, infectious complications, any other complications, postoperative white blood cell (WBC) and platelet counts. Data were analysed using the chi-squared test, the two-sided Mann-Whitney-Wilcoxon text, and simple and multiple logistic regression analyses. A P-value of <0.05 was considered significant. RESULTS Patients undergoing SPDP had a shorter length of stay and shorter operative time, were more likely to be completed laparoscopically, less likely to require re-operation, and had fewer infectious and non-infectious complications. However, these differences were not statistically significant. In multiple logistic regression analyses, patient age and length of hospital stay were both significant predictors of the occurrence of non-infectious complications (P= 0.04 and P= 0.006, respectively). Blood transfusion was a significant predictor of postoperative morbidity (P= 0.013 for infectious complications; P= 0.018 for non-infectious complications). White blood cell count was a statistically significant predictor of infectious (P= 0.02) and non-infectious (P= 0.04) complications, whereas platelet count was not. Patients who underwent DPS had statistically significantly higher WBC and platelet counts immediately postoperatively and at 6 months compared with SPDP patients. Postoperative mortality in both the SPDP and DPS groups was 0%. None of the 30 SPDP patients had evidence of splenic infarction. Pancreatic leaks occurred in 18% of patients in the SPDP group, compared with 8% in the DPS group (P < 0.05). CONCLUSIONS Spleen-preserving distal pancreatectomy using the Warshaw technique is associated with lower postoperative morbidity than DPS. Lower WBC and platelet counts suggest better splenic function in SPDP patients.
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Affiliation(s)
| | - Chad M Cogan
- Department of General Surgery, Henry Ford HospitalDetroit, MI, USA
| | - Vic Velanovich
- Division of General Surgery, University of South FloridaTampa, FL, USA
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Abstract
AIMS Laparoscopic distal pancreatectomy is becoming a more commonly used procedure, which may involve the use of four to seven ports, depending on the technique. Initial data on feasibility, safety and outcome with the three-port laparoscopic distal pancreatectomy are presented. METHODS The patient is placed in a partial thoracoabdominal position exposing the left flank in a reverse Trendelenberg position. A 10-mm Hassan trocar is inserted through a subcostal anterior axillary incision. A 5-mm midclavicular and 10-mm posterior axillary line trocar are placed. The specimen is retrieved from the anterior axillary line port. RESULTS Ten women and seven men, aged 26-88 years (mean 61 years), were evaluated. Their body mass indexes ranged from 18-37 (mean 27). Pancreatic lesion size ranged from 1.0-5.5 cm (mean 3.0 cm). Operative time was 116-296 min (mean 170 min). Blood loss was 10-300 ml (mean 142 ml). No operation required conversion or additional trocar placement. Post-operative stay was 2-7 days (mean 4 days). No patient developed a pancreatic fistula. CONCLUSION Operative time, blood loss and post-operative stay of this three-port technique compare favourably with published data.
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Affiliation(s)
- Gokulakkrishna Subhas
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, MI 48075, USA
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21
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Asbun HJ, Stauffer JA. Laparoscopic approach to distal and subtotal pancreatectomy: a clockwise technique. Surg Endosc 2011; 25:2643-9. [PMID: 21487886 DOI: 10.1007/s00464-011-1618-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 02/03/2011] [Indexed: 12/28/2022]
Abstract
BACKGROUND Laparoscopic surgery is becoming a more widely used approach for benign and malignant lesions in the neck, body, and tail of the pancreas. Recent literature reports appear to demonstrate that laparoscopic distal pancreatectomy (LDP) has clear benefits compared with open distal pancreatectomy (ODP). However, the procedure is relatively new and in some patients may remain a technically demanding operation. METHODS Twenty-nine LDPs were performed by a single surgeon during the course of 12 months by using a multistep clockwise technique described in detail below. The technique appears to simplify and standardize the approach for both the simpler and the more difficult procedure. Retrospective analysis was performed regarding perioperative outcomes. RESULTS Twenty-three procedures were performed for a neoplastic process with five patients having pancreatic adenocarcinoma. There was no conversion to ODP, but one patient required a hand-assist method. Splenectomy was performed in 26 patients. Median operative time, estimated blood loss, and length of stay was 182 min, 50 ml, and 4 days respectively. Overall morbidity and pancreatic fistula rate was 17.2% and 10.3%, respectively. Median number of lymph nodes was 14, concomitant left adrenalectomy was performed in 3 patients, and margins were negative in 28 patients. CONCLUSIONS LDP has been shown to be an acceptable approach to both benign and malignant disease of the distal pancreas. The technique used in this manuscript appears to facilitate a reliable and safe five-step method to perform this procedure and ensures that appropriate oncologic principles are followed through each step. Even though this is a small feasibility series focused on surgical technique, our results appear to demonstrate an acceptable pancreatic leak rate.
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Affiliation(s)
- Horacio J Asbun
- Division of General Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Ammori BJ, Ayiomamitis GD. Laparoscopic pancreaticoduodenectomy and distal pancreatectomy: a UK experience and a systematic review of the literature. Surg Endosc 2011; 25:2084-99. [PMID: 21298539 DOI: 10.1007/s00464-010-1538-4] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Accepted: 12/02/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND Advances in operative techniques and technology have facilitated laparoscopic distal pancreatectomy (LDP) and laparoscopic pancreaticoduodenectomy (LPD). METHODS All distal pancreatectomies were attempted laparoscopically, while selected patients underwent LPD. The literature was systematically reviewed. RESULTS Between 2002 and 2008, 21 patients underwent LDP (n=14) or LPD (n = 7). The mean operating time, blood loss, and hospital stay after LDP were 265 min, 262 ml, and 7.7 days, respectively, and after LPD they were 628 min, 350 ml, and 11.1 days, respectively. The conversion, morbidity, pancreatic fistula, readmission, reoperation, and mortality after LDP were 7.1, 35.7, 28.4, 28.4, 0, and 7.1% respectively, and after LPD they were 0, 28.6, 14.3, 28.6, 0, and 0% respectively. The literature review identified 987 LDP and 126 LPD. Most LDP were for benign disease (83.9%) while most LPD were for malignancy (91.5%). The mean operating time, morbidity, pancreatic fistula, mortality, and hospital stay after LDP were 221.5 min, 24.7%, 16.4%, 0.4%, and 7.7 days, respectively, and after LPD they were 448.3 min, 28.6%, 11.6%, 2.1%, and 16 days, respectively. CONCLUSION LDP, particularly for benign disease and low-grade malignancy, is increasingly becoming the gold standard approach in experienced hands. In selected patients, LPD is feasible and safe. Long-term follow-up data are needed.
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Affiliation(s)
- Basil J Ammori
- Department of Hepato-Pancreato-Biliary Surgery, North Manchester General Hospital, and The University of Manchester, Delaunays Road, Manchester, UK.
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Metaanalysis of trials comparing minimally invasive and open distal pancreatectomies. Surg Endosc 2010; 25:1642-51. [PMID: 21184115 DOI: 10.1007/s00464-010-1456-5] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Accepted: 10/19/2010] [Indexed: 02/05/2023]
Abstract
BACKGROUND The current literature suggests that minimally invasive distal pancreatectomy (MIDP) is associated with faster recovery and less morbidity than open surgery. However, most studies have been limited by a small sample size and a single-institution design. To overcome this problem, the first metaanalysis of studies comparing MIDP and open distal pancreatectomy (ODP) has been performed. METHODS A systematic literature review was conducted to identify studies comparing MIDP and ODP. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates, blood loss) constituted the study end points. Metaanalyses were performed using a random-effects model. RESULTS For the metaanalysis, 10 studies including 349 patients undergoing MIDP and 380 patients undergoing ODP were considered suitable. The patients in the two groups were similar with respect to age, body mass index (BMI), American Society of Anesthesiology (ASA) classification, and indication for surgery. The rate of conversion from full laparoscopy to hand-assisted procedure was 37%, and that from minimally invasive to open procedure was 11%. Patients undergoing MIDP had less blood loss, a shorter time to oral intake, and a shorter postoperative hospital stay. The mortality and reoperative rates did not differ between MIDP and ODP. The MIDP approach had fewer overall complications [odds ratio (OR), 0.49; 95% confidence interval (CI), 0.27-0.89], major complications (OR, 0.57; 95% CI, 0.34-0.96), surgical-site infections (OR, 0.32; 95% CI, 0.19-0.53), and pancreatic fistulas (OR, 0.68; 95% CI, 0.47-0.98). CONCLUSIONS The MIDP procedure is feasible, safe, and associated with less blood loss and overall complications, shorter time to oral intake, and shorter postoperative hospital stay. Furthermore, the minimally invasive approach reduces the rate of pancreatic leaks and surgical-site infections after ODP.
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Aly MYF, Tsutsumi K, Nakamura M, Sato N, Takahata S, Ueda J, Shimizu S, Redwan AA, Tanaka M. Comparative study of laparoscopic and open distal pancreatectomy. J Laparoendosc Adv Surg Tech A 2010; 20:435-40. [PMID: 20518689 DOI: 10.1089/lap.2009.0412] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) has been shown to be an effective surgical option for benign lesions in the body and tail of the pancreas. However, its advantages and disadvantages have not been well characterized. In this study, we compared the outcomes of LDP and open pancreatectomy performed in our clinic. MATERIALS AND METHODS Peri- and postoperative outcomes were retrospectively compared between patients with benign pancreatic disorders who underwent open distal pancreatectomy (ODP) (n = 35) and those who underwent LDP (n = 40). The peri- and postoperative factors analyzed included operative time, blood loss, hospital stay, postoperative recovery, biochemical findings, and complications. RESULTS LDP was associated with significantly less operative blood loss (363 versus 606 mL; P = 0.001) and shorter hospital stay (22 versus 27 day; P = 0.009), but longer operative time (342 versus 250 min; P = 0.000), compared with ODP. There were no significant differences between the two groups in complication rates or postoperative recovery, except for the significantly shorter duration of postoperative pain-killer intake and earlier improvement of the biochemical analysis in LDP than in ODP. CONCLUSIONS LDP appears to be a safe, desirable procedure for the management of benign pancreatic diseases, with outcomes similar to ODP.
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Affiliation(s)
- Mohamed Y F Aly
- Department of Endoscopic Diagnostics and Therapeutics, Kyushu University Hospital, Fukuoka, Japan
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Cavallini A, Alvise C, Butturini G, Giovanni B, Daskalaki D, Despoina D, Salvia R, Roberto S, Melotti G, Gianluigi M, Piccoli M, Micaela P, Bassi C, Claudio B, Pederzoli P, Paolo P. Laparoscopic pancreatectomy for solid pseudo-papillary tumors of the pancreas is a suitable technique; our experience with long-term follow-up and review of the literature. Ann Surg Oncol 2010; 18:352-7. [PMID: 20848223 DOI: 10.1245/s10434-010-1332-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Solid pseudopapillary tumors (SPTs) are rare pancreatic neoplasms of low malignant potential that occur mainly in young women. Only 17 cases of SPT treated laparoscopically have been published in the literature and long-term follow-up data are still lacking. METHODS Retrospective analysis of ten patients (8 women, 2 men; mean age, 25.4 years) (DS: 12.1; minimum 11, maximum 51) who underwent laparoscopic distal pancreatectomy with a definitive histological diagnosis of SPT. Long-term follow-up data were collected. RESULTS The average tumor size was 43.8 mm (minimum 20, maximum 65 mm). The mean operative time was 177.5 minutes (DS: 53.7; minimum 120, maximum 255). In all, five patients underwent distal splenopancreatectomy; five patients underwent spleen-preserving distal pancreatectomy of whom three with splenic vessel preservation and two with the Warshaw technique. The conversion rate was nil and no case of perioperative mortality was recorded. The mean hospital stay was 7 days (DS: 2.7; minimum 4, maximum 12). Six patients had an uneventful postoperative course and four had postoperative complications. Two of them underwent reoperation, and the other two had nonsurgical complications. After a median follow-up of 47 (range, 5-98) months, all patients were alive and disease-free. CONCLUSIONS Laparoscopic pancreatic resection is a safe and feasible procedure that could become the treatment of choice for patients affected by pancreatic SPT. Distal pancreatectomy should be performed, if possible, with spleen-preserving technique, especially in young patients. To avoid metastatic spread, laparoscopic or laparotomic biopsy should not be performed in patients affected by SPT.
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Affiliation(s)
- Alvise Cavallini
- Surgical Department, Chirurgia Generale B-Policlinico GB Rossi-Borgo Roma, Verona University, Verona, Italy
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Abstract
The rapid growth of minimally invasive technology and experience in recent decades has revolutionized many aspects of oncologic surgery. Adoption of laparoscopic pancreatectomy has been slow due to the inherent anatomic complexity of pancreatic surgery, as well as concerns of perioperative complications and compromised oncologic results. With increasing surgeon experience and growing data, laparoscopic pancreatic resection is generating considerable attention and enthusiasm. This article provides an overview of laparoscopic pancreatic tumor surgery with respect to tumor biology and technical approaches. Current applications of laparoscopic approaches to left pancreatectomy, tumor enucleation, central pancreatectomy, and pancreaticoduodenectomy for treatment of pancreatic tumors are considered in light of available evidence demonstrating feasibility, safety, and oncologic efficacy. Future directions in minimally invasive pancreatic surgery are explored.
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Affiliation(s)
- Carrie K Chu
- Department of Surgery, Emory University School of Medicine, 1364 Clifton Road, NE, H120, Atlanta, GA 30322, USA
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Mukherjee K, Morrow SE, Yang EY. Laparoscopic Distal Pancreatectomy in Children: Four Cases and Review of the Literature. J Laparoendosc Adv Surg Tech A 2010; 20:373-7. [DOI: 10.1089/lap.2009.0247] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kaushik Mukherjee
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Stephen E. Morrow
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Edmund Y. Yang
- Department of Pediatric Surgery, Cardinal Glennon Children's Medical Center at St. Louis University, St. Louis, Missouri
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Kang CM, Kim DH, Lee WJ. Ten years of experience with resection of left-sided pancreatic ductal adenocarcinoma: evolution and initial experience to a laparoscopic approach. Surg Endosc 2010; 24:1533-41. [PMID: 20054579 DOI: 10.1007/s00464-009-0806-7] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Accepted: 11/12/2009] [Indexed: 12/16/2022]
Abstract
BACKGROUND With increasing laparoscopic experience, laparoscopic distal pancreatectomy with or without splenectomy is being regarded as a safe and effective treatment for benign and borderline malignant lesions of the pancreas; however, its application for left-sided pancreatic ductal adenocarcinoma (PDAC) is still debatable. METHODS We analyzed patients who underwent conventional distal pancreatectomy with splenectomy (DPS) for distal pancreatic cancer at our institution. We have performed laparoscopic DPS partly based on radical antegrade modular pancreatosplenectomy (RAMPS) for well-selected left-sided PDAC since 2007. We compared laparoscopic DPS to conventional DPS according to various clinicopathologic factors. RESULTS From January 1999 to December 2008, 45 patients underwent conventional DPS for resectable left-sided PDAC, and 18 needed combined adjacent organ resection for potential margin negative (R0) resection. The median survival of resected left-sided PDAC was 27.9 months with a 5-year survival of 28.9%. A small amount of intraoperative bleeding [< or =760 ml Exp(beta) = 6.312, p = 0.001] and R0 resection [Exp(beta) = 4.349, p = 0.090] were the most significant prognostic factors. To achieve bloodless and R0 resection, the potential indication for laparoscopic DPS was suspicious pancreatic cancer confined to the pancreas that could be removed by DPS without resection of the adjacent organs. Five patients underwent laparoscopic/robot-assisted DPS for left-sided PDAC. Compared to conventional DPS, only the operation time (p = 0.011) and tumor size (p = 0.031) were significantly different, but other clinicopathologic variables were comparable. All patients still are alive. Four patients have lived without tumor recurrence (follow-up = 4-22 months), and only one experienced multiple liver metastasis and subsequent retroperitoneal local recurrence. CONCLUSION Laparoscopic/robot-assisted modified anterior RAMPS may be technically feasible for well-selected PDAC. The oncologic feasibility still remains to be determined due to limited experience.
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Affiliation(s)
- Chang Moo Kang
- Department of Surgery, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 120-752, Korea.
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Laparoscopic distal pancreatectomy with splenic conservation: an operation without increased morbidity. Gastroenterol Res Pract 2009; 2009:846340. [PMID: 20049337 PMCID: PMC2798083 DOI: 10.1155/2009/846340] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2009] [Accepted: 09/28/2009] [Indexed: 12/11/2022] Open
Abstract
Objectives. The advent of minimally invasive techniques was marked by a paradigm shift towards the use of laparoscopy for benign distal pancreatic masses. Herein we describe one center's experience with laparoscopic distal pancreatectomy. Methods. A retrospective chart review was performed for all distal pancreatectomies completed laparoscopically from 1999 to 2009. Outcomes from those cases completed with a concurrent splenectomy were compared to the spleen-preserving procedures. Results. Twenty-four patients underwent laparoscopic distal pancreatectomy. Seven had spleen-conserving operations. There was no difference in the mean estimated blood loss (316 versus 285 mL, P = .5) or operative time (179 versus 170 minutes, P = .9). The mean tumor size was not significantly different (3.1 versus 2.2 cm, P = .9). There was no difference in the average hospital stay (7.1 versus 7.0 days, P = .7). Complications in the spleen-preserving group included one iatrogenic colon injury, two pancreatic fistulas, and two cases of iatrogenic diabetes. In the splenectomy group, two developed respiratory failure, three acquired iatrogenic diabetes, and two suffered pancreatic fistulas (71% versus 41%, P = .4). Conclusions. The laparoscopic distal pancreatectomy is a safe operation with a low morbidity. Splenic conservation does not significantly increase the morbidity of the procedure.
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Merchant NB, Parikh AA, Kooby DA. Should all distal pancreatectomies be performed laparoscopically? Adv Surg 2009; 43:283-300. [PMID: 19845186 DOI: 10.1016/j.yasu.2009.02.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite the relatively slow start of laparoscopic pancreatectomy relative to other laparoscopic resections, an increasing number of these procedures are being performed around the world. Operations that were once considered impossible to perform laparoscopically, such as pancreaticoduodenectomy and central pancreatectomy are gaining momentum. Technology continues to improve, as does surgical experience and prowess. There are both enough experience and data (though retrospective) to confirm that LDP with or without spleen preservation appears to be a safe treatment for benign or noninvasive lesions of the pancreas. Based on the fact that LDP can be performed with similar or shorter operative times, blood loss, complication rates, and length of hospital stay than ODP, it can be recommended as the treatment of choice for benign and noninvasive lesions in experienced hands when clinically indicated. It is very difficult to make clear recommendations with regard to laparoscopic resection of malignant pancreatic tumors due to the lack of conclusive data. As long as margins are negative and lymph node clearance is within accepted standards, LDP appears to have no untoward oncologic effects on outcome. Certainly more data, preferably in the manner of a randomized clinical trial, are needed before additional recommendations can be made. Potential benefits of laparoscopic resection for cancer include the ability to inspect the abdomen and abort the procedure with minimal damage if occult metastases are identified. This does not delay the onset of palliative chemotherapy, which would be the primary treatment in that circumstance. In fact, there is evidence to suggest that there is a greater likelihood of receiving systemic therapy if a laparotomy is avoided in patients who have radiologically occult metastases. Patients may also undergo palliative laparoscopic gastric and biliary bypass if indicated. Faster wound healing may also translate into a shorter waiting time before initiating adjuvant chemotherapy and/or radiation therapy. If the patient develops a wound infection, the infection should be more readily manageable with smaller incisions. Although not proven clinically relevant in humans, the reduction in perioperative stress associated with laparoscopic resection may translate to a cancer benefit for some patients. One report compared markers of systemic inflammatory response in 15 subjects undergoing left pancreatectomy. Eight had hand-access laparoscopic procedures and the rest had standard open surgery. The subjects in the laparoscopic group had statistically lower C-reactive protein levels than the open group on postoperative days one (5.5 mg/dL versus 9.7 mg/dL, P = .006) and three (8.5 mg/dL versus 17.7 mg/dL, P = .003), suggesting that the laparoscopic approach to left pancreatectomy is associated with less inflammation. While this report is underpowered, it supports the notion that MIS cancer surgery may induce less of a systemic insult to the body than standard open cancer surgery. More work in this area is necessary before any firm conclusions can be drawn. An important issue to consider is that of training surgeons to perform these complex procedures laparoscopically. Not all pancreatectomies are amenable to the laparoscopic approach, even in the most skilled hands. As such, only a percentage of cases will be performed this way and expectations to educate surgeons adequately to perform advanced laparoscopic procedures can be unrealistic, resulting in more "on-the-job" training. Another aspect that draws some controversy is that of the totally laparoscopic procedure versus the hand-access approach. No laparoscopic instrument provides the tactile feedback possible to obtain with the hand. The HALS approach allows for this, and the opportunity to control bleeding during the procedure. HALS also provides a way to improve confidence during the learning-curve phase of these operations. Finally, it is important to remember that if the procedure is failing to progress laparoscopically, or if cancer surgery principles are likely to be violated, the surgeon (and the patient) must be willing to abort the laparoscopic approach and complete the operation using standard open technique. During the next few years we can expect to see more robust outcome data with laparoscopic pancreatectomy. The expectation is that more data will come to light demonstrating benefits of laparoscopic pancreatic resection as compared with open technique for selected patients. Several groups are considering randomized trials to look at these endpoints. Although more retrospective and prospectively maintained data will certainly be presented, it is less likely that randomized data specifically examining the question oflaparoscopic versus open pancreatectomy for cancer will mature, due to some of the limitations discussed above. Additional areas of discovery are in staple line reinforcement for left pancreatectomy and suturing technology for pancreatico-intestinal anastomosis. Robotic surgery may have a role in pancreatic surgery. Improving optics and visualization with flexible endoscopes with provide novel surgical views potentially improving the safety of laparoscopy. Another area in laparoscopic surgery that is gaining momentum is that of Natural Orifice Transluminal Endoscopic Surgery (NOTES). NOTES represents the "holy grail" of incisionless surgery. Can we enucleate a small tumor off the pancreatic body by passing an endoscope through the gastric (or colonic) wall, and bring the specimen out via the mouth or anus? Can we use this approach for formal left pancreatectomies? Pioneers have already developed a porcine model of left pancreatectomy. This technology must clear several hurdles before it is cancer ready; however, technology is moving at a rapid pace.
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Affiliation(s)
- Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building, 2220 Pierce Avenue, Nashville, TN 37232-6860, USA.
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Laparoscopic and robotic donor pancreatectomy for living donor pancreas and pancreas-kidney transplantation. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:97-100. [DOI: 10.1007/s00534-009-0146-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 04/30/2009] [Indexed: 11/26/2022]
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Sekimoto M, Nishikawa A, Taniguchi K, Takiguchi S, Miyazaki F, Doki Y, Mori M. Development of a compact laparoscope manipulator (P-arm). Surg Endosc 2009; 23:2596-604. [PMID: 19357921 DOI: 10.1007/s00464-009-0460-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Revised: 03/08/2009] [Accepted: 03/14/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Laparoscope manipulating robots are useful for maintaining a stable view during a laparoscopic operation and as a substitute for the surgeon who controls the laparoscope. However, there are several problems to be solved. A large apparatus sometimes interferes with the surgeon. The setting and repositioning is awkward. Furthermore, the initial and maintenance costs are expensive. This study was designed to develop a new laparoscope manipulating robot to overcome those problems. METHODS We developed a compact robot applicable for various types of laparoscopic surgery with less expensive materials. The robot was evaluated by performing an in vitro laparoscopic cholecystectomy using extracted swine organs. Then, the availability of the robot to various operations was validated by performing a laparoscopic cholecystectomy, anterior resection of the rectum, and distal gastrectomy using a living swine. The reliability of the system was tested by long-time continuous running. RESULTS A compact and lightweight laparoscope manipulating robot by the name of P-arm was developed. The surgical time of an in vitro laparoscopic cholecystectomy with and without the P-arm was not different. The three types of operations were accomplished successfully. During the entire procedure, the P-arm worked without trouble and did not interfere with the surgeons. Continuous 8-h operating tests were performed three times and neither discontinuance nor trouble occurred with the system. CONCLUSIONS The P-arm worked steadily for various swine operations, without interfering with surgeon's work.
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Affiliation(s)
- Mitsugu Sekimoto
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka Suita, Osaka, 565-0871, Japan.
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Laparoscopic resection of uncinate process of the pancreas. Surg Endosc 2009; 23:1391-2. [PMID: 19263119 DOI: 10.1007/s00464-009-0390-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Revised: 12/11/2008] [Accepted: 01/12/2009] [Indexed: 12/15/2022]
Abstract
BACKGROUND Solid pseudopapillary neoplasm of the pancreas is an uncommon but distinctive pancreatic neoplasm with low metastatic potential [1]. Therefore, whenever feasible, an organ-preserving operation should be performed. As previously reported, women with solid pseudopapillary neoplasm of the pancreas may be best treated by more conservative procedures [2]. Recently, laparoscopic pancreatic resections became more common and are being performed in highly specialized centers. There are only six cases of laparoscopic resection for solid pseudopapillary neoplasm of pancreas published in the English literature and, to our knowledge, laparoscopic resection of uncinate process of the pancreas has never been reported [3-6]. This video demonstrates the technical aspects of a totally laparoscopic resection of the uncinate process of the pancreas in a patient with solid pseudopapillary neoplasm. METHODS A 26-year-old woman with a 4-cm solid pseudopapillary pancreatic neoplasm was referred for surgical treatment. According to preoperative echoendoscopy, there was a safe margin between neoplasm and main pancreatic duct. The patient was placed in supine position with the surgeon standing between her legs. Four trocars, one 10-mm and three 5-mm, were used. At inspection, the inferior vena cava, transverse colon, duodenum, and pancreas are clearly identified. A Kocher maneuver was performed with complete exposure of pancreatic head and uncinate process. The uncinate process was dissected from the superior mesenteric vein and venous branches were divided between metallic clips or by use of laparoscopic coagulation shears (LCS; Ethicon Endo Surgery Industries, Cincinnati, OH, USA). Blood supply of the duodenum was preserved by ligature of small pancreatic branches from inferior pancreatoduodenal artery. Transection of pancreatic parenchyma was performed using laparoscopic coagulation shears, which is an effective tool for cutting the pancreas [7, 8]. Surgical specimen was removed through a suprapubic incision inside a retrieval bag. A hemostatic absorbable tissue (Surgicel; Ethicon Inc., Cincinnati, OH) was placed in the cutting pancreatic surface, and one round 19F Blake abdominal drain (Ethicon) was left in place. RESULTS Operative time was 180 minutes and blood loss estimated in 40 ml with no blood transfusion. Hospital stay was 4 days. The patient did not have postoperative pancreatitis or pancreatic leakage, and the abdominal drain was removed on the tenth postoperative day. Final pathology confirmed the diagnosis of solid pseudopapillary neoplasm of pancreas with free surgical margins. The patient was well and asymptomatic 2 months after the procedure. CONCLUSIONS Laparoscopic resection of uncinate process of the pancreas is safe and feasible and should be considered for patients suffering from pancreatic neoplasms.
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Abstract
Laparoscopic (lap) organ resection is now commonly performed for the management of solid tumors of the kidney, colon, adrenal glands and prostate. Surgeons have been slower to adopt minimally invasive approaches to the pancreas owing to operative complexity and complication potential. The majority of existing reports concerning lap pancreatectomy are single-center studies that describe experience with fewer than 20 cases. Only recently have larger experiences surfaced demonstrating the safety and efficacy of lap tumor enucleation and lap left pancreatectomy. As neoplastic disease is the most common indication for pancreatic resection, understanding the effects of the lap approach to pancreatectomy on cancer outcome is crucial. In addition to concerns of port-site tumor recurrence and tumor dissemination due to lap manipulation in the setting of pneumoperitoneum, adequacy of resection as defined by margin status and nodal assessment must be considered. This review covers the development and current state-of-the-art of lap pancreatic surgery for cancer. Existing data are reviewed for both open and lap pancreatic resections, with particular attention to pancreatic ductal adenocarcinoma. Projections of future advances in the field of lap pancreatic surgery are provided.
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Affiliation(s)
- David A Kooby
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Shukla PJ, Maharaj R, Sakpal SV. Current status of laparoscopic surgery in gastrointestinal malignancies. Indian J Surg 2008; 70:261-4. [PMID: 23133081 DOI: 10.1007/s12262-008-0080-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 10/30/2008] [Indexed: 10/21/2022] Open
Abstract
Laparoscopy has become a significant tool in a surgeon's armamentarium since the first laparoscopic cholecystectomy in 1989. Oncological surgeons have been slow in adopting laparoscopy for fear of inadequate cancer operation and occurrence of port site metastasis. Neither of these concerns have stood the test of time. Laparoscopy is being used increasingly in oncological surgery both for staging and respective surgery. This article outlines the present use of laparoscopy in GI cancer surgery.
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Affiliation(s)
- Parul J Shukla
- Department of Gastrointestinal and Hepatopancreatobiliary Surgical Oncology, Tata Memorial Hospital, Mumbai, India
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