Laparoscopic Distal Pancreatectomy Research Articles

External validation of difficulty scoring system for laparoscopic distal pancreatectomy: Korea-Japan collaborative study meeting

External validation of difficulty scoring system for laparoscopic distal pancreatectomy: Korea-Japan collaborative study meeting

Comparison of infectious complications after spleen preservation versus splenectomy during laparoscopic distal pancreatectomy for benign or low-grade malignant pancreatic tumors

Comparison of infectious complications after spleen preservation versus splenectomy during laparoscopic distal pancreatectomy for benign or low-grade malignant pancreatic tumors

Laparoscopic distal pancreatectomy in elderly patients with left-sided resectable pancreatic ductal adenocarcinoma

Laparoscopic distal pancreatectomy in elderly patients with left-sided resectable pancreatic ductal adenocarcinoma

Robotic vs laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: A propensity score-matched analysis

Robotic vs laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: A propensity score-matched analysis

Reappraisal of single port laparoscopic distal pancreatectomy

Reappraisal of single port laparoscopic distal pancreatectomy

Common hepatic artery approach in complicated laparoscopic distal pancreatectomy

Common hepatic artery approach in complicated laparoscopic distal pancreatectomy

Single-port robot plus one port (SP + 1) distal pancreatectomy using the new da Vinci SP system.

Single-incision laparoscopic distal pancreatectomy has not been widely applied due to technical challenges and increased operative risks. The newly released da Vinci SP system has been introduced to overcome these limitations and offer improvements for established robotic single-site procedures. We report our experience of robotic single port plus one port distal pancreatectomy using the da Vinci SP system. We performed robotic distal pancreatectomy in three patients using the da Vinci SP surgical system with one additional port used for applying the energy device and stapling. Technical and clinical feasibility were examined. The mean age and body mass index were 70.7years and 27.8kg/m2, respectively. The mean operation time was 215min. The estimated blood loss was less than 500mL. All patients underwent combined splenectomy. The postoperative course of all patients was uneventful. Robotic distal pancreatectomy using the da Vinci SP system is safe and feasible, with acceptable perioperative outcomes.

Learning Curves in Open, Laparoscopic, and Robotic Pancreatic Surgery: A Systematic Review and Proposal of a Standardization.

To depict and analyze learning curves for open, laparoscopic, and robotic pancreatoduodenectomy (PD) and distal pancreatectomy (DP). Formal training is recommended for safe introduction of pancreatic surgery but definitions of learning curves vary and have not been standardized. A systematic search on PubMed, Web of Science, and CENTRAL databases identified studies on learning curves in pancreatic surgery. Primary outcome was the number needed to reach the learning curve as defined by the included studies. Secondary outcomes included endpoints defining learning curves, methods of analysis (statistical/arbitrary), and classification of learning phases. Out of 1115 articles, 66 studies with 14,206 patients were included. Thirty-five studies (53%) based the learning curve analysis on statistical calculations. Most often used parameters to define learning curves were operative time (n = 51), blood loss (n = 17), and complications (n = 10). The number of procedures to surpass a first phase of learning curve was 30 (20-50) for open PD, 39 (11-60) for laparoscopic PD, 25 (8-100) for robotic PD (P = 0.521), 16 (3-17) for laparoscopic DP, and 15 (5-37) for robotic DP (P = 0.914). In a three-phase model, intraoperative parameters improved earlier (first to second phase: operating time -15%, blood loss -29%) whereas postoperative parameters improved later (second to third phase: complications -46%, postoperative pancreatic fistula -48%). Studies with higher sample sizes showed higher numbers of procedures needed to overcome the learning curve (rho = 0.64, P < 0.001). This study summarizes learning curves for open-, laparoscopic-, and robotic pancreatic surgery with different definitions, analysis methods, and confounding factors. A standardized reporting of learning curves and definition of phases (competency, proficiency, mastery) is desirable and proposed.

Laparoscopic radical distal pancreatosplenectomy with celiac axis excision following neoadjuvant chemotherapy for locally advanced pancreatic cancer

A recent successful prospective randomized control study comparing open distal pancreatectomy with laparoscopic distal pancreatectomy (LDP) has shown that LDP is a safe and effective surgical modality in treating left-sided pancreatic pathological conditions requiring surgical extirpation. With the accumulating surgical experiences and improved surgical techniques, we recently reported several cases of successful LDP in advanced pancreatic cancer following neoadjuvant chemotherapy. Herein, we report a case of LDP with celiac axis resection (LDP-CAR) in locally advanced pancreatic cancer (LAPC) following neoadjuvant chemotherapy. A 58-year-old female with LAPC was referred to our institution. Computed tomography (CT) findings revealed a 24-mm mass in the pancreatic body that showed celiac artery (CA), common hepatic artery abutment. There was no abutment with superior mesenteric artery, superior mesenteric vein, and portal vein. From these findings, Neoadjuvant chemotherapy (FORFIRINOX) was performed biweekly. After 8 cycles of chemotherapy, the tumor size was slightly decreased (24 mm to 16 mm), but still abutting to CA. After 14 cycles of chemotherapy, CT revealed the same tumor size (16 mm) still abutting to CA. LDP-CAR was performed. Intraoperative ultrasonography gastric perfusion and hepatic perfusion were confirmed using indocyanine green. The patient recovered without complications and was discharged from the hospital nine days after the surgery.

Retroperitoneal-first laparoscopic approach (Retlap)-assisted distal pancreatectomy with celiac axis resection (DP-CAR): A novel minimally invasive approach for achieving adequate dorsal surgical margin

BackgroundDistal pancreatectomy with celiac axis resection (DP-CAR) is a procedure to secure a surgical margin for a locally advanced pancreatic body cancer that invades the celiac axis. However, in patients with cancer close to the root of the celiac axis, obtaining adequate surgical margins can be difficult because the tumor obstructs the field of vision to the root of the celiac axis. Previously, we described the retroperitoneal-first laparoscopic approach (Retlap) to achieve both accurate evaluation of resectability for locally advanced pancreatic cancer requiring DP-CAR [1] and adequate surgical margin for laparoscopic distal pancreatectomy [2]. In this video, we introduce Retlap-assisted DP-CAR as a minimally invasive approach for performing an artery-first pancreatectomy [3, 4] and achieving sufficient dorsal surgical margin (Fig. 1). MethodsOur patient is a 67-year-old man with a 55 × 29-mm pancreatic body tumor after chemotherapy. Preoperative computed tomography revealed a tumor close to the root of the celiac axis. Because the area of tumor invasion on preoperative images was near the root of the celiac artery, Retlap-assisted DP-CAR was performed to determine whether the celiac axis can be secured and obtain an adequate dorsal surgical margin (Fig. 2). ResultsThe operative time and estimated blood loss was 715 min and 449 mL, respectively. In spite of the advanced tumor's location and size, R0 resection was achieved in a minimally invasive way. ConclusionRetlap-assisted DP-CAR is not only technically feasible and useful for achieving accurate evaluation of resectability but also facilitates obtaining an adequate surgical margin.

Pancreatic injuries following laparoscopic splenic flexure mobilization.

To call awareness to pancreatic injury occurring following laparoscopic splenic flexure mobilization (LSFM) and to discuss the mechanisms which led to such an injury. Retrospective review of patients who underwent LSFM as part of their colectomy procedure and sustained pancreatic injuries at a colorectal surgery referral center during 2014-2021. Of 1022 (0.6%) LSFM performed during the study period, six (0.6%) patients were identified in which clinically significant injuries to the pancreas occurred. Two patients had partial transection of the tail of the pancreas and underwent laparoscopic distal pancreatectomy during the index operation. Three patients developed a post-operative pancreatic fistula after their pancreatic injury went undiagnosed during surgery and required percutaneous drainage, one of whom eventually required a distal pancreatectomy for a persistent pancreatic fistula. Another patient developed a peripancreatic fluid collection which resolved with conservative treatment. Pancreatic injury is rare and a potentially major complication of LSFM. Anatomical misperception, retroperitoneal bleeding, a large bulky splenic flexure tumor, and a "difficult flexure" were recognized as possible mechanisms of such injury.

Converted laparoscopic distal pancreatectomy: is there an impact on patient outcome and total cost?

PurposeRecent studies have reported worse outcomes of converted laparoscopic distal pancreatectomy (CLDP) with respect to total laparoscopic (TLDP) and open (ODP). The aim of the study was to evaluate the impact of conversion on patient outcome and on total cost.MethodsPatients requiring a conversion (CLDP) were compared with both TLDP and ODP patients. The relevant patient- and tumour-related variables were collected for each patient. Both intra and postoperative data were extracted. Propensity score matching (PSM) analysis was carried out to equate the groups compared.ResultsTwo hundred and five patients underwent DP, 105 (51.2%) ODPs, 81 (39.5%) TLDPs, and 19 (9.3%) CLDPs. After PSM, 19 CLDPs, 38 TLDPs, and 38 ODPs were compared. Patients who underwent CLDP showed a significantly longer operative time (P < 0.001), and an increase in blood loss (P = 0.032) and total cost (P = 0.034) with respect to TLDP, and a significantly longer operative time (P < 0.001), less frequent postoperative morbidity (P = 0.050), and a higher readmission rate (P = 0.035) with respect to ODP.ConclusionTotal laparoscopic pancreatectomy was superior regarding operative findings and total costs with respect to CLDP; ODP showed a higher postoperative morbidity rate and a lower readmission rate with respect to CLDP. However, the reasons for the readmission of patients who underwent CLDP were mainly related to postoperative pancreatic fistula (POPF) grade B which is usually due to pancreas texture. Thus, the majority of distal pancreatectomies can be started using a minimally invasive approach, performing an early conversion if necessary.

Laparoscopic radical antegrade modular pancreatosplenectomy: Ukrainian single center experience

Background: Laparoscopic standard distal pancreatectomy nowadays is a standard operation technic in management of malignant and benign lesions of pancreatic body and tail. But promising data about advantages of radical antegrade modular pancreatosplenectomy (RAMPS) such as higher R0 resection rate and number of lymph nodes gives us new field to implement this technic in our practice in laparoscopic way. We think that performing by experienced laparoscopic HPB surgeon laparoscopic RAMPS can be as safe as laparoscopic standard distal pancreatectomy is.

401 consecutive minimally invasive distal pancreatectomies: lessons learned from 20 years of experience

BackgroundThis study aimed to discuss and report the trend, outcomes, and learning curve effect after minimally invasive distal pancreatectomy (MIDP) at two high-volume centres.MethodsPatients undergoing MIDP between January 1999 and December 2018 were retrospectively identified from prospectively maintained electronic databases. The entire cohort was divided into two groups constituting the “early” and “recent” phases. The learning curve effect was analyzed for laparoscopic (LDP) and robotic distal pancreatectomy (RDP). The follow-up was at least 2 years.ResultsThe study population included 401 consecutive patients (LDP n = 300, RDP n = 101). Twelve surgeons performed MIDP during the study period. Although patients were more carefully selected in the early phase, in terms of median age (49 vs. 55 years, p = 0.026), ASA class higher than 2 (3% vs. 9%, p = 0.018), previous abdominal surgery (10% vs. 34%, p < 0.001), and pancreatic adenocarcinoma (PDAC) (7% vs. 15%, p = 0.017), the recent phase had similar perioperative outcomes. The increase of experience in LDP was inversely associated with the operative time (240 vs 210 min, p < 0.001), morbidity rate (56.5% vs. 40.1%, p = 0.005), intra-abdominal collection (28.3% vs. 17.3%, p = 0.023), and length of stay (8 vs. 7 days, p = 0.009). Median survival in the PDAC subgroup was 53 months.ConclusionIn the setting of high-volume centres, the surgical training of MIDP is associated with acceptable rates of morbidity. The learning curve can be largely achieved by several team members, improving outcomes over time. Whenever possible resection of PDAC guarantees adequate oncological results and survival.

Indocyanine green fluorescence angiography-guided simultaneous laparoscopic distal gastrectomy and spleen-preserving distal pancreatectomy for conserving the gastrosplenic ligament: A case report.

Introduction and importanceIndocyanine green (ICG) fluorescence angiography is being increasingly performed intraoperatively to detect restricted blood flow intraoperatively for the prevention of postoperative organ ischemia and anastomotic leakage. This is the first case report of simultaneous laparoscopic distal gastrectomy (LDG) and spleen-preserving distal pancreatectomy (LSPDP) involving ICG angiography use to avoid the remnant stomach ischemia.Case presentationA 55-year-old man was diagnosed with early cancer of the stomach body and intraductal papillary mucinous neoplasms of the pancreatic tail. We performed simultaneous LDG with D2 dissection and LSPDP to conserve the gastrosplenic ligament and preserve blood supply to the remnant stomach. Intraoperatively, blood flow to the remnant stomach was visualized using ICG fluorescence angiography, after which Roux-en-Y reconstruction was performed. There was no perioperative remnant stomach ischemia.Clinical discussionDespite the preserved splenic artery and vein, complete splenic infarction occurs after LSPDP possibly due to thrombus formation during surgical procedures. In this patient, we conserved the gastrosplenic ligament for the short gastric artery, which supplied blood to the remnant stomach; however, remnant stomach ischemia may occur. Therefore, we performed ICG fluorescence angiography during this operation to ensure that sufficient blood supply to the remnant stomach was maintained.ConclusionOur experience demonstrates that ICG angiography may be useful for the prevention of remnant stomach ischemia.

Laparoscopic versus Open Distal Pancreatectomy for Left-sided Pancreatic Lesions: A Retrospective Analysis of 206 Cases

Backgrounds: Previous studies report successful application of laparoscopic distal pancreatectomy (LDP). However, its application for left-sided pancreatic lesions is still being debated and considered as challenging procedure. Our study aimed to evaluate the safety and clinical efficacy of laparoscopic versus open distal pancreatectomy(ODP) for left-sided lesions. Methods: From January 2014 to March 2019, 206 patients with left-sided pancreatic lesions in Tongji Hospital, Wuhan, China were enrolled into our study. 128 (62.14%) patients with LDP were compared with 78 (37.86%) patients who underwent ODP retrospectively. Results: Compared with ODP group, the operation time of LDP group was shorter (P = 0.029), the amount of bleeding was less, and the proportion of blood transfusion was lower. There was no perioperative death in both groups. The incidences of grade III and IV complications were 12.8% and 21.1% in ODP and LDP group respectively, with no significant difference (P = 0.198). In terms of postoperative pancreatic fistula, there were 16 (20.5%) cases in ODP group, 26 (20.3%) cases in LDP group with no significant difference (P = 0.952). There was no significant difference between the two groups in other postoperative complications. The length of first hospitalization in ODP group was 28 (22-36) days, and that in the LDP group was 25 (19.5-30) days, with statistical difference (P = 0.04). Conclusion: LDP for left-sided lesions is associated with reduced operation time, blood loss, and hospital stay than ODP. LDP can be performed safely and effectively in selected patients with left-sided lesions.

Laparoscopic Spleen Preserving Distal Pancreatectomy: Is There a Better Technique?

Introduction: Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) can be accomplished with either resection or preservation of the splenic vessels. Our study aims to compare the Warshaw Technique with the preservation of the splenic vessels in LSPDP. Methods: We performed a retrospective chart review of adults undergoing laparoscopic spleen preserving distal pancreatectomy at a single institution from 2009 to 2021. Primary outcomes were operating time and estimated blood loss. Secondary outcomes included success of spleen-preserving procedures, length of hospital stay, and 30-day major morbidity (Clavien-Dindo grade 3, 4, and 5). Results: We retrieved 105 cases (median age 63.2 years) of LSPDP (60 Warshaw Technique, 45 vessel preservation). Median operative time was shorter with the Warshaw Technique (140 vs. 177 minutes, p<0.05). The rate of successful spleen preservation was greater with the Warshaw Technique group (77% vs. 69%, p<0.05). There was no significant difference in the median blood loss, or length of hospital stay between the two techniques. Seven cases required conversion to open laparotomy (3 in the Warshaw Technique group). Postoperative complications of grade 3 or greater occurred in a total of thirteen cases (9 in the Warshaw Technique Group). Conclusion: Our preliminary results suggest both techniques are safe and effective in preserving the spleen in laparoscopic distal pancreatectomy. Our experience suggests that the Warshaw Technique is not inferior to the vessel sparing technique for LSPDP and may be more efficient with respect to use of hospital resources.

A Prognostic Impact of Splenectomy in Laparoscopic Distal Pancreatectomy on Benign/Borderline Pancreatic Tumors: A Change of the Era.

PurposeIn the past, spleen preservation during distal pancreatectomy (DP) was preferred; however, more recent studies reported comparable results between splenectomy and spleen preserving. We retrospectively reviewed patients in a single center who underwent laparoscopic DP with/without splenectomy, and evaluated the chronologic changes of surgical outcomes of the two procedures.Materials and MethodsPatients who underwent laparoscopic DP with or without splenectomy due to benign/borderline tumor from 2005 to 2019 were included in this study. We divided this period into Era 1 (2005–2012) and Era 2 (2013–2019), and compared the chronological evolution of surgical outcomes of laparoscopic distal pancreatosplenectomy (LDPS) to those of laparoscopic spleen-preserving distal pancreatectomy (LSpDP), including the long-term postoperative immunologic profiles.ResultsA total of 198 cases were included (LSpDP: 80 cases; LDPS: 118 cases). As the period changed from Era 1 to Era 2, the ratio of LSpDP decreased and the surgical outcomes of LDPS improved. In Era 1, LSpDP group showed superior results compared to LDPS group in terms of hospital days and postoperative pancreatic fistula ratio; however, in Era 2, the surgical outcomes showed no statistical differences. No significant differences were observed in all of the immunologic markers.ConclusionWe carefully conclude that during laparoscopic DP, combined splenectomy can be equivalent to spleen preserving in surgical and immunological outcomes, and inevitable splenectomy can be safely conducted.

Robotic versus Laparoscopic Distal Pancreatectomy for Upfront Resectable Pancreatic Cancer: An International Retrospective Cohort Study

Introduction: Robotic distal pancreatectomy (RDP) is an upcoming alternative for laparoscopic distal pancreatectomy (LDP). Yet, the oncological efficacy of RDP is uncertain. We compared the oncological and surgical outcomes between RDP and LDP. Methods: An international retrospective cohort study in 34 high-volume centers from 11 countries (2010-2019). The primary outcomes were R0-resection and lymph node yield. Kaplan-Meier estimates were used for survival rates. Results: Overall, 542 patients were included, 103 (19%) underwent RDP and 439 (81%) LDP. Preoperative characteristics were similar. RDP had a higher median lymph-node yield (18 vs 16, P=0.021) and a comparable R0-resection rate (76% vs 69%, P=0.40). RDP had a longer operative time (290 min vs 240 min, P<0.001) and less conversions (5% vs 17%, P=0.001) without emergency conversions (i.e. for bleeding), whereas 29% of conversions during LDP were emergency. RDP had a higher rate of major morbidity (Clavien-Dindo ≥3a) (26% vs 16%, P=0.017), but 30-day mortality and in-hospital mortality showed no significant difference. Median length of hospital stay was longer following RDP (10 vs 8 days, P=0.001). The 3-year survival rate [34% vs 38%, P=0.73] and median overall survival [22 months (95% CI, 12-32) vs 29 months (95% CI, 24-34), P=0.60] did not differ significantly. Conclusion: For upfront resectable pancreatic cancer, RDP was associated with a similar R0-resection rate, but a higher lymph node yield compared to LDP. Given the contradicting outcomes in conversion rate, morbidity rate, operative time, and hospital stay, randomized trials are required in centers that have surpassed the learning curve.

Feasibility and Safety of Laparoscopic Distal Pancreatectomy for Elderly Patients

Background: The feasibility and safety of laparoscopic distal pancreatectomy (Lap-DP) for elderly patients remains unknown. Methods: A total of 66 patients underwent Lap-DP at our institute from April 2014 to December 2020. Among them, 16 patients were aged 80 or older (elderly-group), and 50 patients were less than 80 years old (young-group). Clinical characteristics and perioperative outcomes were compared between the two groups. Results: The median age was 83 years (80-89) in elderly-group, and 68 years (30-79) in young-group. In elderly-group, seven patients were performed Lap-DP for pancreatic ductal adenocarcinoma (44%), and with 12 patients (24%) in young-group (P=0.139). The median operative time in elderly-group and young-group was 302min (133-446) and 290min (165-477) (P=0.812), and median operative blood loss in elderly-group and young-group was 104ml (5-600) and 82ml (1-1975) (P=0.590). The incidence of clinically relevant POPF occurred in six patients (9.1%), with no patients (0%) in elderly-group and six patients (12%) in young-group (P=0.061). We have never experienced POPF grade C. The major morbidity (Clavien–Dindo classification grade ≥III) occurred in nine patients (13.6%), with no patients (0%) in elderly-group and nine patients (18%) in young-group (P=0.020). The median postoperative hospital stay in elderly-group and young-group was 14days (6-29) and 12days (8-33) (P=0.176). Conclusions: The incidence of clinically relevant POPF and major complication were both less in the elderly-group than the young-group. Lap-DP was feasible and safe for selected elderly patients older than 80 years of age.