Laparoscopic Pancreatic Resection Research Articles

Laparoscopic pancreatic resection – The new “gold standard” for distal pancreatic resection

Laparoscopic pancreatic resection – The new “gold standard” for distal pancreatic resection

Laparoscopic pancreatic resection: single-institution experience of 7 patients

Laparoscopic pancreatic resection: single-institution experience of 7 patients

Laparoscopic robot-assited pancreatic resections for pancreatic and periampullary cancer

R. Gradiz , A.M. Abrantes , A.C. Mamede , M.F. Botelho , A. Mota-Pinto . General Pathology Service, Faculty of Medicine, University of Coimbra, Coimbra, Portugal 2 Biophysics' Unit, IBILI, Faculty of Medicine, University of Coimbra, Coimbra, Portugal 3 CICS-UBI, Health Sciences Research Centre, University of Beira Interior, Covilha, Portugal 4 CIMAGO – Research Center for Environment, Genetics and Oncobiology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal

Laparoscopic distal pancreatic resection: Is there a learning curve?

Laparoscopic distal pancreatic resection: Is there a learning curve?

Systematic Review and Meta-Analysis of Case-Matched Studies Comparing Open and Laparoscopic Distal Pancreatectomy

Distal pancreatectomies and enucleations have become the most popular laparoscopic pancreatic resections and in some centers outnumber the traditional open approach. The aim of this study was to systematically review the literature on the safety of laparoscopic distal pancreatectomies (LDP) in relation to open distal pancreatectomies in the management of adult patients and, where possible, perform a meta-analysis of reported outcomes. We searched MEDLINE, EMBASE, Web of knowledge, and the Cochrane Database of Systematic Reviews using the following keywords: pancreas, pancreatectomy, pancreatic, laparoscopic, laparoscopy. Publication dates and language restrictions were applied. The Newcastle Ottawa scale was used for study quality assessment. Four eligible studies were identified with a total of 665 patients. On average, LDPs had a longer operation time by 17.7 minutes (9.5%) and a reduced hospital stay by 2.7 days. Morbidity and mortality were low using both approaches. This study represents the strongest evidence (level 3a) to date that LDPs are a safe operation. However, there is still a need for randomized controlled trials to confirm this.

Ressecção laparoscópica dos cistoadenomas pancreáticos

Laparoscopic pancreatic resections have become increasingly frequent with good results reported by several centers. However, few studies have focused on laparoscopic treatment of pancreatic cystic lesions. To analyze the results of minimally invasive treatment of pancreatic cystic lesions. Were included all laparoscopic pancreatic resections performed at three centers. Surgical procedures included resection of the pancreas and left enucleations (with or without splenectomy). The post-operative complications were classified according to the classification proposed by Clavien and Dindo6. The diagnosis of pancreatic fistula was confirmed if the amylase dosage of the drainage liquid in the third postoperative day was more than three times the amount of serum amylase. Were performed 44 laparoscopic pancreatic resections. Fifteen patients underwent surgery for suspected pancreatic cystadenoma and 13 had this diagnosis confirmed. There were 12 women (92%), and the average age of patients was 50 years. Six patients had minor postoperative complications. There were five (38%) pancreatic fistulas, neither considered as severe (C), and only one patient required hospital readmission and radiological drainage. In this series, there were no conversions, reoperations, or mortality. The laparoscopic approach is a safe and effective option for the treatment of pancreatic cystic lesions. The incidence of pancreatic fistula has good evolution and not diminishes the benefits of minimally invasive surgery.

Laparoscopic Distal Pancreatectomy with Splenic Preservation

Minimally invasive techniques are now being vastly applied in the pediatric population. Laparoscopic pancreatic resections were initially performed in the 1990s in the adult population. Since then, laparoscopic pancreatic procedures were applied to pancreatic trauma and tumors of the distal pancreas. Increasing success reported to be ~80% for laparoscopic distal pancreatectomy with splenic preservation in the adult population has helped to pave its application in the pediatric population. As such, laparoscopic pancreatic procedures performed in children included resection of tumors as well as in blunt pancreatic injuries. Here we demonstrate in a 5-minute video a laparoscopic distal pancreatectomy with splenic preservation in a child with cysts in the tail of the pancreas found incidentally after a traumatic fall. Our patient is an 11-year-old boy who was evaluated in the emergency department after a 10-foot fall onto a rubber mat while indoor rock climbing. He complained of nonspecific abdominal and low-back pain. The results of physical examination were unremarkable. Computed tomography (CT) of the abdomen and pelvis was performed based on the mechanism. CT findings demonstrated only a focal cluster of nontraumatic cysts in the tail of the pancreas. Two dominant cysts were 6 mm in diameter. The overall area encompassed by cysts was ~1.9×1.1×1.0 cm. He was discharged home with follow-up magnetic resonance imaging of the abdomen at 4 months to reduce radiation exposure. Results at that time showed no change in the size of the cysts. Follow-up ultrasonography of the abdomen performed at 4 and 8 months demonstrated an increase in the size of the cysts. The patient remained asymptomatic. Due to increase in size of the cyst and concerns of the family, laparoscopic distal pancreatic resection with splenic preservation was elected to be performed. The patient was positioned in a modified right lateral decubitus position with a bean bag and kidney rest. A 10-mm versa step port was placed at the umbilicus. Three 5-mm working ports were placed. The gastrocolic ligament was opened with the LigaSure, and the stomach was retracted superiorly. The pancreas was identified. The left renal vein was identified at the inferior border of the pancreas, and the splenic artery and vein at the superior border. The splenic vessels were dissected, mobilizing the tail of the pancreas. The superior mesenteric artery and vein were identified posteriorly. A window was created to the left of these vessels, and a penrose drain was placed around the tail of the pancreas, used for traction. Using the assistance of radiologic imaging with identification of the superior mesenteric vessels, an area was marked with the cautery to the left of the vessels. An endoscopic gastrointestinal anastomosis 2.5-mm stapler was used to divide across the tail of the pancreas. A Jackson Pratt drain was left in the left upper quadrant. A clear liquid diet was initiated on postoperative day 3 (POD3). Regular diet was introduced on POD4, and the drain was removed. He was discharged on POD5. No competing financial interests exist. Runtime of video: 5 mins

1029 ATP-binding Cassette Transporter Inhibition by Tyrosine Kinase Inhibitor Nilotinib

s / Pancreatology 12 (2012) 502–597 550 Introduction: Da Vinci surgical system overcomes most of technical limitations of laparoscopy and provides the unique opportunity to test whether this approach can improve outcomes of pancreatic resections. Aim: In selected patients laparoscopic robot-assisted pancreatic resection can be safely performed. Methods: 105 consecutive robotic pancreatectomies were performed between 10/2008 and 02/2012. There were 40 males and 65 females, with mean age of 58 yrs. 39 patients underwent pancreaticoduodenectomy (PD), 49 distal pancreatectomy (DP), 9 total pancreatectomy, 5 tumor enucleation, 3 central pancreatectomy. Since our activity spans over a 3year period, data were analyzed to verify the learning curve. Results: No conversion were performed. Mean operative time (OT) was 437.8 minutes. In the first year OT was 512 min for PD and 420 for DP. The meannumberof lymphnodes (LN) examinedwas 16.8. Pancreaticfistula (PF) occurred in41%of patients. In the secondyearOTwas596min for PDand402 forDP. The LNexaminedwas16.7. PFoccurred in36.3%ofpatients. In the third year OT was 443 min for PD and 394 for DP. The LN examined was 28.7. PF occurred in 37% of patients. 61 patients were diagnosed with benign or lowgrade tumors, 44 with cancer. Surgical margins were always negative. Postoperative mortality was nil, morbidity 52%. Mean hospital-stay was 16 days. Conclusions: Despite the existence of a learning curve, experienced pancreatic surgeons are not expected to pay to robotics the same price that they would have been asked for by laparoscopy.

Laparoscopic single-branch resection of the pancreas for intraductal papillary mucinous neoplasm.

Although laparoscopic pancreatic resections have become more common, laparoscopic minimally invasive and function-preserving pancreatic resections have not been widely accepted. Branch-type intraductal papillary mucinous neoplasm (IPMN) has a low-grade malignant potential and shows a favorable prognosis. In branch-type IPMN, minimal resection techniques with preservation of the pancreatic functional reserve have advantages over the more conventional pancreaticoduodenectomy. We describe herein laparoscopic single-branch resection of the pancreas for branchtype IPMN. This surgical procedure is a novel and an ideal minimally invasive method for the resection of branch-type IPMN. In addition, our endoscopic nasopancreatic drainage (ENPD) tube-guided technique is useful for precise resection of the tumor and for the prevention of pancreatic fistula.

Major venous resection during total laparoscopic pancreaticoduodenectomy

BackgroundThe feasibility of total laparoscopic pancreaticoduodenectomy (TLPD) has been established. Laparoscopic major venous resection during TLPD has not been reported. The aim of the present study was to describe the technique and outcomes of patients undergoing TLPD with major venous resection. MethodsRetrospective review of all consecutive patients undergoing TLPD and major venous resection from July 2007 to December 2010 was performed. Patient demographics and peri-operative outcomes were retrieved. Data are presented as mean ± standard deviation (SD) or median with range. ResultsOut of 129 patients undergoing TLPD, major venous resection was performed in 11 patients with a mean age of 71 years. Median operative time and blood loss was 413 (301–666) min and 500 (75–2800) ml, respectively. Venous resection included tangential (n= 10) and segmental resection (n= 1). Venous reconstruction included patch (n= 4), suture (n= 4), stapled (n= 2) and a left renal vein interposition graft (n= 1). Median mesoportal clamp time was 35 (10–82) min. There was no 30-day or in-hospital mortality. Post-operative imaging was available in 10 patients with 100% patency at the venous reconstruction site. ConclusionsLaparoscopic major venous resection during TLPD is feasible in selected patients. Extensive experience with complex laparoscopic pancreatic resection and reconstruction is advocated before attempting this procedure.

Laparoscopic Ultrasound Enhances Diagnosis and Localization of Insulinoma in Pancreatic Head and Neck for Laparoscopic Surgery With Satisfactory Postsurgical Outcomes

This study explored the value of laparoscopic ultrasonography (LUS) for tumor localization in laparoscopic pancreatic surgery of insulinomas, especially for tumors located at anatomically unfavorable positions. Twenty-eight patients with insulinomas were enrolled in this study between July 2007 and March 2009. Various image examinations were performed preoperatively. An iU22 ultrasound system equipped with a 5.0–9.0 MHz transducer was used for LUS. The tumor localization and postsurgical outcomes were evaluated. Intraoperative LUS precisely localized 33 insulinomas in 26 of 28 patients, whereas the preoperative imaging studies detected 27 of 33 (82%) tumors. No definite tumor in the pancreas and extra-pancreatic organs was identified in two patients by both preoperative and intraoperative imaging examinations. Of 33 tumors, 32 (97%) were localized in the pancreas (14 in the head and neck, 18 in the body and tail), whereas one (3%) was found in the duodenal ligament. Successful laparoscopic resection of insulinoma was performed in 21 of 26 patients, including resection of 11 tumors located in the head and neck of the pancreas. Five patients required conversion to open surgery. All insulinomas were benign with a mean size 13.8 mm. Four patients had pancreatic-related complications that spontaneously healed within 3 weeks after surgery. The median hospital stay was 8.5 days. Our study demonstrates that laparoscopic pancreatic resection under the guidance of advanced LUS is not only feasible and safe for tumors located at the body and tail but also for tumors located at the head and neck of the pancreas.

Laparoskopische Pankreaskopfresektion

Whereas pancreatic tail resection is routinely and safely performed in several institutions, laparoscopic resection of the pancreatic head is only performed by a handful of surgeons worldwide, none of them in Germany. We review our experience with 9 laparoscopic pancreatic head resections (lap-PPPD) performed between March and September 2010. The operations were performed using a hybrid approach with complete laparoscopic pylorus-preserving pancreatic head resection and successive reconstruction via a small retrieval incision. Perioperative outcome was compared to 605 open pancreatic head resections (1997-2010). In the group lap-PPPD 3 out of 9 conversions had to be performed due to oncologic reasons. There were no significant differences in perioperative outcome when comparing open-PPPD to lap-PPPD. Laparoscopic pancreatic head resection with hybrid open reconstruction combines the potential advantages of laparoscopic resection with the safety of an open pancreatic anastomosis. Even at the beginning of the learning curve the procedure can be performed with no concessions to safety or duration of the operation.

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

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. 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. 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. 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.

Laparoscopic Distal Pancreatectomy in Children: Four Cases and Review of the Literature

Laparoscopy has been utilized for children with pancreatic masses and blunt transection. In this article, we report our technique and experience. With supine positioning, an umbilical trocar and three 5-mm trocars are positioned across the epigastrium. The gastrocolic ligament is opened completely and the stomach is retracted superiorly. A vessel-sealing electrosurgical device is used to dissect along the inferior margin of the pancreas. Dissection proceeds proximally or distally, depending on the location of the pathology. The proximal pancreatic duct is oversewn or stapled closed. The distal pancreas is mobilized from the splenic vessels. If the vessels cannot be mobilized from the pancreas, they are divided and a laparoscopic splenectomy is performed. The specimen is removed through the umbilical trocar by using a retrieval bag. Drains are placed prior to closure. CASE EXPERIENCE: We report 4 cases: 2 with pseudopapillary tumors and 2 with traumatic injuries. One patient was male; the mean age was 13.0 +/- 1.4 years. Two spleens were removed due to pathology. Mean operative time was 256 +/- 46.6 minutes, with no open conversion or mortality. Patients initiated oral intake 2.0 +/- 1.4 days postoperatively. Hospital stay was 6.2 +/- 3.9 days. One patient required 15 days of total parenteral nutrition to resolve a pancreatic fistula. Laparoscopic pancreatic resection in children is feasible, safe, and leads to rapid recovery without significant morbidity. The spleen can often be spared, minimizing the risk of overwhelming postsplenectomy sepsis. This initial experience should encourage wider use of laparoscopy for pancreatic resection in children.

Laparoscopic Enulceation and Distal Pancreatectomy for Pancreatic Insulinomas

Pancreatic insulinomas, albeit rare, are the commonest functioning neuroendocrine tumors of the pancreas. They are frequently solitary, typically small, and invariably benign and are evenly distributed in the pancreas. Surgical treatment usually requires a relatively large incision to reach the pancreas deep-seated in the retroperitoneum and to perform a thorough exploration of the whole pancreas to look for occult tumor not localized by preoperative localization or multiple tumors.1-4 New technology has facilitated the application of various open surgical procedures to their equivalents in a minimally invasive fashion. Laparoscopic pancreatic resection has been shown to be feasible, safe and effective for benign conditions of the pancreas with enhanced postoperative recovery.5-15 Pancreatic insulinoma is one of the most commonly reported pancreatic pathology in which laparoscopic resection can be adopted with good outcome.5-7

Laparoscopic distal pancreatic resection: Our own experience in the treatment of solid tumors

A laparoscopic resection is a new treatment for pancreatic tumors. Articles by surgeons who are writing about their first experience in carrying out this treatment have appeared in the literature, reporting that laparoscopic surgery can be used for the treatment of pancreatitis, benign lesions, and solid tumors. This is a study of three patients with pancreatic tumors who were treated by means of a laparoscopic distal pancreatic resection with preservation of the spleen and splenic vessels. In three cases a laparoscopic distal resection was performed for the tumor. The histologic examinations showed one insulinoma and two mucinous cystadenomas. No patient suffered from intra- or postoperative complications. A laparoscopic resection of the distal pancreas is a new alternative for the treatment of pancreatic tumors. This method takes advantage of the benefits of minimally invasive surgery.

Robotic Resection of Intraductal Neoplasm of the Pancreas

Minimally invasive techniques have been revolutionary and provide clinical evidence of decreased morbidity and comparable efficacy to traditional open surgery. Computer-assisted surgical devices have recently been approved for general surgical use. The aim of this study was to report the first known case of pancreatic resection with the use of a computer-assisted, or robotic, surgical device in Latin America. A 37-year-old female with a previous history of radical mastectomy for bilateral breast cancer due to a BRCA2 mutation presented with an acute pancreatitis episode. Radiologic investigation disclosed an intraductal pancreatic neoplasm located in the neck of the pancreas with atrophy of the body and tail. The main pancreatic duct was enlarged. The surgical decision was to perform a laparoscopic subtotal pancreatectomy, using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA). Five trocars were used. Pancreatic transection was achieved with vascular endoscopic stapler. The surgical specimen was removed without an additional incision. Operative time was 240 minutes. Blood loss was minimal, and the patient did not receive a transfusion. The recovery was uneventful, and the patient was discharged on postoperative day 4. The subtotal laparoscopic pancreatic resection can safely be performed. The da Vinci robotic system allowed for technical refinements of laparoscopic pancreatic resection. Robotic assistance improved the dissection and control of major blood vessels due to three-dimensional visualization of the operative field and instruments with wrist-type end-effectors.

Updated Minimally Invasive Surgery for Gastro-Intestinal Diseases

The minimally invasive surgical technique, like innovative technology, continues to evolve and be refined. New concepts in the surgery of benign and malignant gastrointestinal diseases will stimulate GI surgeons to deliver effective treatment in more minimally invasive procedures. 1. Laparoscopic gastrectomy for malignancy: With growing experience, laparoscopic gastric resections have become common procedures in certain high-volume hospitals and have encouraged the use of laparoscopy in the resection of gastric malignancy. However, the long-term oncologic outcome has not been established in large series. 2. Laparoscopic resection of colorectal cancer: Laparoscopically assisted colon resection was first reported in 1991. Since then laparoscopic resection of both benign and malignant colorectal diseases has been systematically evaluated. The cornerstone in the treatment of colorectal cancer establishes in surgical colon resection with a laparoscopic approach. Whereas the short-term outcome of laparoscopic versus open resection of colorectal malignancy has been evaluated, the long-term outcome still needs further evidence. 3. Bariatric surgery: The increasing use of bariatric procedures in the treatment of morbidly obese patients has undergone common practice. In general, restrictive, mal-absorptive, or combined restrictive and mal-absorptive procedures are the domain for the surgical treatment of diseased obesity. Both methods are the most common procedures for weight reduction at present. 4. Laparoscopic liver resection; Laparoscopic hepatectomy could avoid the disadvantages of open hepatectomy and is beneficial for the patient's life quality as a minimally invasive procedure. The indications for the laparoscopic approach are the tumor of less than 5cm, and it's location at the left or anterior sector superficially. The clinical long-term follow-up, either for laparoscopic or traditional liver resection for hepatocellular carcinoma, has been evaluated, and has failed to show significant differences between the laparoscopic and traditional groups. 5. Laparoscopic surgery in liver-donor hepatectomy: The most controversial topic in liver surgery has been the performance of living donor hepatectomy. The mortality of this procedure has varied from 0.5 to 1.0% based on reporting andperformance of hepatectomy: left lateral section, left hepatectomy or right hepatectomy. 6. Role of minimally invasive surgery in pancreatic diseases: Laparoscopic pancreatico-duodenectomy or central pancreatectomy for pancreatic tumor have been performed in specialized centers of the world. Additionally, studies that specifically evaluate and compare the oncologic outcomes of laparoscopic and open pancreatic resections are needed. In addition, natural orifice transluminal endoscopic surgery (NOTES) has the potential to redefine minimally invasive surgery. Application in human subjects is seen in sporadic reports. Rapid development of laparoscopic minimally invasive surgery and robot surgery will in all probability provide the greatest benefit for surgical science in the near future.

Laparoscopic Pancreatic Resections for Solid Pseudopapillary Tumor in Children

The aim of this study is to investigate the effectiveness of laparoscopic pancreatic resections for solid pseudopapillary tumors (SPT) in children. Two 13-year-old girls suffered from recurrent episodes of abdominal pain. Ultrasound and CT revealed a well-circumscribed heterogeneous mass arising from the neck of the pancreas in one and a solid homogeneous tumor with small cystic areas in the pancreatic tail in the other. Both patients underwent laparoscopic procedures. In the first case, after resection of the tumor a two-layer anastomosis between the distal pancreatic body and the posterior gastric wall was performed. In the second case, a spleen-preserving distal pancreatectomy was carried out. Histopathological examinations demonstrated SPT of the pancreas in both cases. Both procedures were completed laparoscopically. The operation times were 240 min and 150 min, respectively. The suction drains were removed on 7th postoperative day. Realimentation was started on day 5. The postoperative course was uneventful. Control CT scans at 6 months and 2 years were normal. As experience with minimally invasive techniques continues to grow, laparoscopic pancreatic resections appear to be safe and feasible in children with SPT. Laparoscopic central pancreatectomy with distal pancreaticogastrostomy can be used to treat tumors of the middle pancreas. For tumors located in the pancreatic tail, laparoscopic spleen-preserving distal pancreatectomy may well become the approach of choice.

Laparoscopic pancreatic resection: some benefits of evolving surgical techniques

Laparoscopic pancreatic resection began to be reported in the first half of the 1990s, with subsequent reports focusing primarily on the safety and usefulness of laparoscopic distal pancreatectomy (Lap-DP) for benign and low-malignancy lesions of the pancreatic body and tail (such as chronic pancreatitis, neuroendocrine tumor, mucinous cystic neoplasm, and intraductal papillary mucinous neoplasm). Recently we have also begun to see retrospective case-control studies comparing these techniques with open surgery, with Lap-DP showing advantages not only in terms of esthetics related to the surgical wound, but also with regard to reduced intraoperative bleeding, postoperative recovery time, and days of postoperative hospitalization. Prospective randomized controlled trials are still needed for confirmation, but it appears likely that this technique will become a standard surgical procedure for the treatment of diseases of the pancreatic body and tail. In contrast, laparoscopic pancreatoduodenectomy (Lap-PD) remains controversial in the minds of many pancreatic surgeons. This is primarily due to the difficulty of laparoscopic reconstruction following resection. However, there have recently been a number of single-center reports on the use of this procedure in at least 20 patients per center, showing that Lap-PD is associated with considerable reduction in intraoperative bleeding. Our own experience has been similar. In carefully selected patients, we find Lap-PD to be a useful surgical procedure.