Abstract
Benign pancreatic tumor enucleations have been performed since 1996. Endocrine tumors (ET) are rare yet they represent about 2/3 of the laparoscopic enucleations, a topic still in debate. Preoperative imaging routinely comprises a CT scan but endoscopic ultrasound is mandatory for localizing the tumor and guided biopsy-aspiration. Trocars have to be positioned to avoid “fencing” with the instruments. A Kocher maneuver may be necessary for accessing deep or posterior tumors. Bipolar electrocautery and harmonic scalpel ensure better hemostasis than the monopolar cautery hook. The raw surface can be covered with hemostatics or fibrin glue. The mean operating time is 2 hours. Forced conversions, due mainly to hemorrhage or insufficient exposure, are rare (9%). Pancreatic fistula, the main postoperative complication, affects up to one third of the patients and does not depend on the choice of dissection instruments, management of the remaining cavity or somatostatin use. A risk factor is the location of the tumor at less than 2mm from the main pancreatic duct. Necrotic pancreatitis, pancreatic pseudocyst and duodenal fistula contribute to a surgical morbidity of 60%. Although safe and technically feasible enucleation still has to be considered a low mortality but high morbidity procedure.
Highlights
The laparoscopic approach in major pancreatic surgery dates back to the mid ’90, but it still represents an option only in few tertiary specialised centres due to the complexity of the approach (Underwood and Soper, 1999)
Mucinous and serous cystadenomas and other benign tumours appear in casereports (Giger et al, 2006)
The supplemental dissection of the superior pancreatic margin allows an appropriate enucleation in selected cases (Costi et al, 2013 a)
Summary
The laparoscopic approach in major pancreatic surgery dates back to the mid ’90, but it still represents an option only in few tertiary specialised centres due to the complexity of the approach (Underwood and Soper, 1999). In the light of general tissue preserving surgery, laparoscopic enucleation and atypical resection for benign pancreatic tumours have gained acceptance and have been performed since 1996 (Costi et al, 2013a). Preoperative imaging routinely includes a CT scan, but endoscopic ultrasound is mandatory for localizing the tumour and allowing, if considered necessary, a guided biopsy/aspiration (Costi et al, 2013 a). The flexible laparoscopic ultrasound offers vital information on the position and relations of the tumour with the pancreatic duct and vessels. The supplemental dissection of the superior pancreatic margin allows an appropriate enucleation in selected cases (Costi et al, 2013 a). If the distance to the duct is safe, the superior and inferior margins of the pancreas are dissected in order to allow the enucleation (Costi et al, 2013 a).
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