Laparoscopic Pancreas Surgery
Laparoscopic pancreas surgery can be difficult to learn, but once mastered and applied appropriately, the approach yields clinical benefits for patients: namely, reduced wound complications and decreased postoperative pain. In the author’s experience in performing 270 laparoscopic pancreas operations at Johns Hopkins Hospital, the wound infection rate is 1%, in comparison with 11% for open pancreas surgery. In addition, the laparoscopic approach is associated with decreased postoperative narcotic utilization, decreased time to ambulation, and increased activity level at discharge: patientcentered outcomes that are improved over those of open surgery. These benefits have implications for other outcomes because wound complications and decreased activity are risk factors for secondary complications and increased costs. Infection is an independent predictor of hospital readmission, and the presence of a wound complication often delays postoperative adjuvant therapy. Furthermore, the decrease in pain is of value, in view of the goal of a good quality of life for many patients with cancer and a poor prognosis. Kendrick and Cusati (2010), in one series, reported that laparoscopic pancreas surgery was associated with no superficial surgical site infections and a reduced length of stay. Other authors have also reported significantly decreased rates of incisional hernia and postoperative bowel obstruction, complications that occur in as many as 20% of patients after open surgery. Another benefit of laparoscopy may be improved cosmesis, an outcome of particular value in young patients who classically present with a pancreas cyst or neuroendocrine tumor. Many of the outcomes favorably influenced by laparoscopy (surgical infection, pain level, and patient satisfaction) are metrics increasingly being used by both surgical registries and payers to measure quality in surgery. In addition, the author has found that the 12-times magnification of new laparoscopic high-definition cameras allows the surgeon to visualize the anatomy better than does open surgery. LAPAROSCOPIC WHIPPLE The percentage of Whipple procedures performed laparoscopically at Johns Hopkins Hospital is increasing, and it is expected that the majority of Whipple operations will be performed laparoscopically by 2025. The laparoscopic approach is offered as the procedure of choice for patients who require a Whipple operation and do not have large (>5â•¯cm) tumors or in whom tumors do not involve the large segment of the portal vein. Although other authorities have described laparoscopic resection of a long segment of the portal vein, the author’s experience has been limited to partial vein resections managed with a laparoscopic side-biting vascular clamp. The steps of a laparoscopic Whipple procedure (in order) are listed here and described afterwards: 1. Perform staging laparoscopy 2. Open the lesser sac 3. Resect a common hepatic artery lymph node 4. Divide the gastroduodenal artery 5. Divide the distal stomach 6. Dissect the portal structures 7. Perform cholecystectomy, and divide common bile duct 8. Divide the pancreas after separation from superior mesenteric vein 9. Perform Kocher maneuver 10. Divide jejunum 11. Mobilize the ligament of Treitz 12. Identify the superior mesenteric artery 13. Divide the uncinate/retroperitoneal attachments, and extract specimen 14. Extract jejunum through ligament of Treitz defect 15. Perform retrocolic pancreaticojejunostomy and hepaticojejunostomy 16. Perform antecolic (retrogastric) gastrojejunostomy 17. Drain placement Technique Peritoneal access is achieved through the caudal aspect of the umbilicus in a Hassan technique. Once the abdomen is distended, a left subcostal 12-mm bladeless VersaStep port (Covidien, Mansfield, Mass) is placed followed by a 5-mm bladeless VersaStep port left of the umbilicus so that there are two working ports on the patient’s left side. The right-sided abdominal ports are then placed by insertion of a 5-mm port at the right subcostal region along the midclavicular line. Caudal to this port, two additional 12-mm ports are inserted so that there are two working ports on each side of the patient, as well as a port for a fan retractor to retract the duodenum and pylorus. A 10-mm, 45-degree laparoscope is used for visualization. The abdomen is explored for metastatic disease. The lesser sac is accessed through the gastrocolic ligament to the second part of the duodenum. The right colon, including hepatic flexure, is sometimes mobilized. The gastroduodenal artery is then skeletonized, and a silk suture and one or two 10-mm clips are used on the proximal side. The artery is divided with a sealant device. The stomach is then divided just proximal to the pylorus with an Endo GIA stapling device (Covidien) with green or black loads (at least 4.8-mm size) for a classic-type Whipple procedure. A cholecystectomy is then performed, and the common bile duct is divided proximal to the entry site of the cystic duct, which enables the gallbladder to remain with the specimen for subsequent extraction. The portal vein is then dissected from above the pancreas, and the superior mesenteric vein is dissected from below. A tunnel behind the pancreatic neck is created. The transverse mesocolon is then raised cephalad to identify the ligament of Treitz. At approximately 15â•¯cm distal to the ligament of Treitz, the small bowel is divided with an Endo GIA stapling device (Covidien) with a white load (2.5â•¯mm). Each stapled end of the jejunum is sewn together with a 10-cm air knot so that the distal segment can later be pulled through the ligament of Treitz defect for the eventual reconstruction. The small bowel mesentery is also divided proximally to the ligament of Treitz, which is mobilized. Turning attention to the patient’s right side, the surgeon then identifies the superior mesenteric artery, and the branches of the artery and vein going into the Whipple specimen are divided with the LigaSure (Figure 1) (Covidien); clips are used as needed on larger branches. The Whipple specimen is then extracted out in a 15-mm bag through the umbilicus. The jejunum is extracted intact initially. The fascia and skin defects are extended to approximately 3 to 4â•¯cm for the extraction. The small bowel is passed through the ligament of Treitz in order to perform an end-to-side pancreaticojejunostomy. This is performed in a handsewn manner over a pancreatic duct stent with the use of a 3F, 5F, or 8F pediatric feeding tube placed into the duct (Figure 2) and into a 2-mm to 3-mm opening in the side of the jejunum. Two running 3-0 barbed stitches (V-Loc sutures; Covidien) are used for the front and back side of the pancreaticojejunostomy. The hepaticojejunostomy is then performed with placement of a single layer of 4-0 Vicryl stitches handsewn in an interrupted manner. The gastrojejunostomy is then performed in an antecolic retrogastric manner along the posterior wall of the stomach in a stapled side-toside technique with an Endo GIA 60 stapler. The resulting defect is then closed with interrupted stitches. In patients in whom the pancreas is soft, a surgical drain is then placed near the anastomoses. All 12-mm port sites are closed at the level of the fascia. Of note, for all of the author’s advanced laparoscopic pancreas procedures, a No. 10 blade scalpel and Mayo scissors are always kept on the Mayo stand in case a rapid conversion to open procedure is necessary. Unlike other laparoscopic procedures, laparoscopic pancreas surgery may have to be converted expeditiously to an open approach because of the intimate proximity of the large vessels in the region. The author also makes sure that no pop-off stitches are used because these can easily pop off inadvertently while in the insufflated field. Care is taken to make sure hypercarbia is managed appropriately if it is noted from an elevated end-tidal CO2 level. The author does not use the robot for the laparoscopic Whipple procedure because of the longer operative time currently associated with robotic surgery; however, it may be a useful tool for performing the reconstruction, and future generations of robotic devices may yield advantages not yet realized. In the author’s most recent 50 laparoscopic Whipple procedures, mean operative time was 5 hours, 25 minutes. Postoperative management follows a similar pathway as for the open Whipple procedure, although narcotic utilization and activity level during the inpatient recovery are noticeably improved with the laparoscopic approach. LAPAROSCOPIC DISTAL PANCREATECTOMY Most distal pancreas tumors are ideal candidates for laparoscopic resection. The author offers a laparoscopic distal pancreatectomy to patients who have lesions that do not involve the celiac or mesenteric vessels and are less than 6 or 7â•¯cm in size. The author routinely attempts spleen preservation when there is no suspicion of malignancy, and the spleen can be spared in 70% of distal pancreatectomies in this setting (Figure 3 and 4). Of importance is that in cases in which malignancy is suspected on the basis of imaging studies or a family history of pancreas cancer, the author removes the spleen with the tail of the pancreas en bloc to achieve a wide resection of the lymph node basin in the area of the splenic vessels and splenic hilum. In the author’s experience, laparoscopic distal pancreatectomy can result in improved patient outcomes and an increased likelihood for splenic preservation in appropriate situations. Preoperative Tattooing For small lesions of the pancreatic neck, body, and tail, particularly those that are posterior, the author uses a novel technique to tattoo pancreatic lesions to facilitate identification at the time of laparoscopic surgery. In each patient scheduled for a laparoscopic distal pancreatectomy, the pancreatic lesion is tattooed via an endoscopic transgastric technique under endoscopic ultrasound guidance before surgery (Figure 5). Using an endoscopic 22-gauge needle, the surgeon injects a total of 5â•¯mL of concentrated purified carbon particles (GI Spot dye; GI Supply, Camp Hill, Pa) are injected into the pancreatic parenchyma immediately proximal to the tumor. The dye is injected to create a vertical line deep in the pancreas parenchyma because the dye may need to be identified from the posterior aspect of the gland during the dissection. Preoperative marking enables the surgeon to quickly identify the location of the tumor at the time of laparoscopy and guides the decision of where to divide the gland. The author has found that tattooing significantly decreases the author’s operative time for distal pancreatectomy. Furthermore, it helps avoid the awkward situation of missing a subtle tumor in the resected specimen—a hazard of the decreased tactile sense in laparoscopic palpation with long instruments. Even large tumors detected on computed tomography, which a surgeon can anticipate identifying easily, can be surprisingly difficult to find because of the homogeneous color of the pancreas and its retroperitoneal bed. Technique The laparoscopic distal pancreatectomy steps (in order) are listed as follows and described afterwards: ■ Perform staging laparoscopy ■ Open the lesser sac ■ Perform takedown of the splenic flexure of the colon ■ Distinguish the splenic vessels from the hepatic vessels ■ Divide splenic artery unless the spleen is preserved ■ Mobilize the distal pancreas, and divide splenic vein if splenectomy is performed ■ Extract specimen ■ Place a drain in the divided stapled pancreas The author places an infraumbilical port with a Hassan method. Two ports placed in the upper midline (or right of midline) and one port in the left lower quadrant are inserted under direct visualization (see Figure 4). The precise locations of these ports depend on the location of the tumor, the intention to preserve the spleen, and the patient’s body habitus. Once local landmarks are identified, the gastrocolic omentum and short gastric vessels are divided, followed by takedown of the splenic flexure of the colon to achieve wide visualization of the lesser sac. Mobilization of the gland is easiest from the inferior border of the gland (see Figure 5). Thus, beginning with the inferior approach facilitates dissection of the posterior aspect of the gland from the retroperitoneal bed. The splenic artery and vein branches can be visualized from underneath the pancreas, and the author alternates dissection of the splenic vessels from above and below the gland according to which exposure best offers visualization. Once the pancreas is clear from the splenic vessels to allow for division of the gland, the author attempts to dissect as much of the tail as possible, freeing the entire tail when feasible. The gland is divided with a stapler with a size chosen on the basis of the pancreas thickness. On occasion, the author has used a reticulating stapler reinforced with a bioabsorbable staple line material (GORE SEAMGUARD, Gore Medical, Newark, Del). The specimen is removed with an Endo Catch bag (Covidien), and a surgical drain is place at the cut end of the pancreas. Laparoscopic Distal Pancreatectomy With Splenectomy When a malignancy is suspected or a technical reason necessitates removal of the spleen, the author chooses to mobilize the spleen after individual division of the splenic artery, splenic vein, and gland. Care is taken to ensure that the splenic artery is not confused with the hepatic artery. Dissection of the splenic artery toward the spleen is sometimes necessary to ensure that the splenic artery is not mistaken for the hepatic artery. The splenic artery and the vein, respectively, are each ligated in turn with a vascular stapler; sometimes these vessels are approached from the posterior aspect of the gland. The spleen is mobilized from its attachments as the last step of the operation. When the spleen is removed for technical or anatomic (nononcologic) reasons, the author divides the pancreas from the spleen to morcellate (liquefy) the spleen for easy extraction from the peritoneum. The intact specimen is freely suspended in the insufflated abdomen, and then the spleen is divided from the tail of the pancreas with a series of GIA staplers fired close to the spleen to avoid leaving residual pancreatic tissue or lymph nodes on the spleen side. This intracorporeal separation allows for removal of the pancreas intact and the spleen by the morcellation technique. However, a stitch or orientation via the tattoo is needed to identify the true pancreatic margin. This piecemeal extraction method is not applicable when an oncologic margin could be threatened by the intracorporeal separation of the pancreas and spleen. In this case, the specimen is removed en bloc in an Endo Catch bag, which necessitates a small extension of the midline 12-mm port sites. A frozen-section analysis is performed intraoperatively to confirm a negative and adequate margin of resection before the operation is completed. At all times, an Endo GIA 2.5-mm (white vascular load) stapler is open, loaded, and ready to use in case of injury to the splenic vessels. Clips are avoided because stapling devices cannot engage on a clip. As a precaution, the author always keeps a fresh 10-blade scalpel and curved heavy Mayo scissors ready at all times in case a rapid conversion to an open operation is needed to control bleeding. Patient Outcomes Patients are admitted to the surgical floor for a typical hospital stay of 2 to 4 days after surgery. The author has observed that these patients behave clinically similar to patients who have undergone laparoscopic cholecystectomy and adrenalectomy: they often require little or no narcotic pain medication. Wound complications are rare after the laparoscopic technique; however, the pancreatic leak rate for all types of laparoscopic pancreas surgery is identical to that for the open operation. LAPAROSCOPIC CENTRAL PANCREATECTOMY Less common procedures such as a central pancreatectomy entail the same principles and indications as the open procedure. The author has found that these procedures are ideal in patients who are at risk for developing diabetes or worsening insulin dependence after pancreas surgery. To perform central pancreatectomy, central masses are approached in the same way as in a laparoscopic Whipple procedure, whereby the surgeon delineates the vascular anatomy and creates a tunnel behind the neck of the pancreas. LAPAROSCOPIC TOTAL PANCREATECTOMY WITH ISLET AUTOTRANSPLANTATION The author has found laparoscopy to be ideal for patients who require a pancreatectomy for chronic pancreatitis because of the decreased pain benefits, inasmuch as the pain is often challenging to manage. During the procedure, after the pancreas is resected with the techniques described previously, the author performs the hepaticojejunostomy and gastrojejunostomy while the islets are being prepared in the laboratory in the operating room. Once the islet solution is ready for autotransplantation into the liver, the author places a metal hollow-bore 16-gauge needle with intravenous tubing attached through a 12-mm port site. From within the peritoneal cavity, the author uses laparoscopic instruments to place the needle into the splenic or portal vein. The islet infusion is then delivered, the needle is subsequently removed, and direct pressure is applied to the puncture site of the vein to achieve hemostasis (Figure 6). OLDER AND HIGH-RISK PATIENTS The author has found that frail older patients and other high-risk patients are ideal candidates for the minimally invasive approach. For such patients, the author uses the lowest insufflation pressures (usually 9 to 11â•¯mmâ•¯Hg), which allows good visualization. Using appropriate monitoring, the author has observed that the recovery benefits of a laparoscopic resection are magnified in octogenarian patients who have undergone the procedure. As is true for young patients, laparoscopic distal pancreatectomy in frail older patients is a shorter procedure and is associated with less physiologic stress to the patient. Moreover, the decreased postoperative pain associated with laparoscopy allows patients to ambulate earlier and more frequently than patients who undergo open surgery, which decreases the risk of thrombosis. CONCLUSION The author’s technique and experience with laparoscopic pancreas surgery have been described. A strong foundation with open pancreas surgery is an important prerequisite for developing skills in laparoscopic pancreas surgery. In summary, when applied appropriately, laparoscopy is associated with decreased wound complications and less pain for patients, and it minimizes the risk for long-term complications such as incisional hernia and small bowel obstruction. In the setting of cancer, an adequate lymphadenectomy with an en bloc resection can be accomplished with a wide resection of the regional lymph nodes. Furthermore, in the absence of a large wound, laparoscopic distal pancreatectomy for cancer allows for a shorter interval to adjuvant therapy when indicated. Laparoscopy is particularly ideal for candidate patients with decreased physiologic reserve or cardiopulmonary risk factors. In the future, improved surgical techniques may decrease the learning curve and enable more patients to benefit from the decreased complications observed. S u g g e s t e d R e a d i n g s Boutros C, Ryan K, Katz S, et al: Total laparoscopic distal pancreatectomy: beyond selected patients, Am Surg 77(11):1526–1530, 2011. Bruzoni M, Sasson AR: Open and laparoscopic spleen-preserving, splenic vessel-preserving distal pancreatectomy: indications and outcomes, J Gastrointest Surg 12:1202–1206, 2008. Kendrick ML, Cusati D: Total laparoscopic pancreaticoduodenectomy: feasibility and outcome in an early experience, Arch Surg 145(1):19–23, 2010. Kooby DA, Gillespie T, Bentrem D, et al: Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches, Ann Surg 248:438–446, 2008. Makary MA, Warshaw AL, Centeno BA, et al: Implications of periotoneal cytology for pancreatic cancer management, Arch Surg 133:361–365, 1998. Newman NA, Lennon AM, Edil BH, et al: Preoperative endoscopic tattooing of pancreatic body and tail lesions decreases operative time for laparoscopic distal pancreatectomy, Surgery 148(2):371–377, 2010. Venkat R, Edil BH, Schulick RD, et al: Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis, Ann Surg 255(6):1048– 1059, 2012.
portal vein and superior mesenteric artery. (Gastroduodenal artery isclipped with the white clips above.)
Laparoscopic distal pancreatectomy. (© Jenny Wang,2008.)