Laparoscopic splenopancreatectomy assisted by augmented reality for pancreatic cancer

Soper et al. in 1994 were able to establish the safety and efficacy of laparoscopic distal pancreatectomy in an animal model, with no evidence of pancreatic leaks or fistulas. Later, in 1996, Cuschieri et al. described the technique they used to perform laparoscopic distal 70–80% pancreatectomy with en-bloc splenectomy in a group of five patients with intractable pain due to chronic pancreatitis. The authors demonstrated that this operation can be performed laparoscopically within an acceptable operating time and without major complications with advantages that include smaller incisions, less pain, and shorter postoperative recovery. Identification of anatomical landmarks is crucial for this kind of procedure expecially when treating cancer. Augmented reality is a new tool to improve oncological safety, confirming the ideal dissection plane and anatomical landmarks, and to maximize functional preservation. The objective of this video is to demonstrate how to perform a splenopancreatectomy with removal of pancreatic cancer while keeping sufficient safety margins. Augmented reality is used in order to clearly identify the position of the anatomical landmarks: the splenic vein and artery, as well as the exact position of the tumor so that a sufficient resection margin can be identified.

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Laparoscopic splenopancreatectomy assisted by augmented reality for pancreatic cancer

Authors

D Mutter, J Marescaux, L Soler

Abstract

Soper et al. in 1994 were able to establish the safety and efficacy of laparoscopic distal pancreatectomy in an animal model, with no evidence of pancreatic leaks or fistulas. Later, in 1996, Cuschieri et al. described the technique they used to perform laparoscopic distal 70–80% pancreatectomy with en-bloc splenectomy in a group of five patients with intractable pain due to chronic pancreatitis. The authors demonstrated that this operation can be performed laparoscopically within an acceptable operating time and without major complications with advantages that include smaller incisions, less pain, and shorter postoperative recovery.
Identification of anatomical landmarks is crucial for this kind of procedure expecially when treating cancer. Augmented reality is a new tool to improve oncological safety, confirming the ideal dissection plane and anatomical landmarks, and to maximize functional preservation. The objective of this video is to demonstrate how to perform a splenopancreatectomy with removal of pancreatic cancer while keeping sufficient safety margins. Augmented reality is used in order to clearly identify the position of the anatomical landmarks: the splenic vein and artery, as well as the exact position of the tumor so that a sufficient resection margin can be identified.

Classification

complex cases

Keywords

Laparoscopic splenopancreatectomy, augmented reality, spleen, pancreas resection

Media type

Surgical video

Duration

18'16''

Publication

2009-04

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E-publication

WeBSurg.com, Apr 2009;9(04).
URL: http://www.websurg.com/doi-vd01en2571.htm

Laparoscopic splenopancreatectomy assisted by augmented reality for pancreatic cancer

1. Clinical case presentation 00'08''

This is the case of a 58-year-old woman undergoing the resection of a tumor located at the junction between the body and the tail of the pancreas. A 3cm adenocarcinoma is suspected at this location. The objective of the procedure is to perform a splenopancreatectomy with removal of the lesion while keeping adequate safety margins. The patient is placed in a supine position. During the resection of the specimen, augmented reality is used in order to clearly identify the position of the anatomical landmarks: the splenic vein and artery, as well as the exact position of the tumor so that a resection line can be identified.

2. Lesser sac opening 00'48''

The lesser sac can be approached by using the ultrasonic Autosonix® scissors or the Ligasure device. The ultrasonic scissors allow to preserve colours, ensure a correct hemostasis, and dissect all the anatomical planes. The posterior aspect of the stomach is accessed and exposed.

3. Exposure of superior border of pancreas 01'08''

The superior border of the pancreas is exposed first in order to identify the splenic pedicle. The splenic artery is approached above the pancreas. The splenic vein will be approached later at the inferior portion of the pancreas.

4. Identification of anatomical landmarks using augmented reality 01'27''

As can be seen here, augmented reality helps to clearly identify the anatomical landmarks. The objective is to localize the vascular landmarks before these are identified in the patient himself.

5. Identification and dissection of splenic artery 02'20''

Dissection at the posterior aspect of the stomach above the celiac trunk helps to identify the splenic artery. This is the first anatomical landmark. This landmark is essential and the splenic artery is controlled to avoid an emergency hemostasis in the event of bleeding. The ultrasonic dissection enables to dissect all the lymph nodes surrounding the origin of the splenic artery. Once the superior and inferior borders of the splenic artery are dissected, a right-angled forceps is passed posterior to the artery. A vascular loop helps to control it safely. The artery is not clamped at this moment. Augmented reality helps to identify the position of the tumor and to find the area in which the pancreatic isthmus will be dissected.

6. Dissection of inferior border of pancreas 03'12''

The inferior pole of the pancreas is identified by sight and through augmented reality. The inferior border of the pancreas is approached. The objective is to dissect with a margin of at least 1cm. The ultrasonic dissector helps to free the inferior pole of the pancreas as well as its adipose attachments while preserving the transverse mesocolon. Here the duodenojejunal flexure (Treitz’s flexure) is identified: it ensures that the dissection of all the inferior portion of the pancreas has been carried out. The dissection can then be continued posteriorly along the pancreatic isthmus in search of the splenic vein. The pancreas is lifted up by the forceps held by the surgeon’s left hand while the dissection is performed by the ultrasonic scissors held by the surgeon’s right hand.

7. Vascular structures and tumor identification by 3D image 04'08''

The 3-dimensional view as well as the volume rendering confirm the anatomical landmarks. The 3D image helps to ideally identify the vessels and the tumor. The identified vascular structures are the inferior mesenteric vein, the renal vein, and the splenic vein at the posterior aspect of the pancreatic body.

8. Posterior dissection of the pancreas 04'40''

The pancreas is slightly retracted cephalad. The exposed structures as well as the posterior aspect of the pancreas are dissected progressively from the isthmus towards the pancreatic tail. The ultrasonic dissector allows for a perfect dissection and a complete hemostasis of all the fibrotic tracts. It helps to clearly identify the posterior aspect of the pancreas. Here the dissection is performed in contact to the tumor. Augmented reality confirms the position of the tumor in relation to the isthmus and the pancreatic tail. Dissection is continued away from the tail. The pancreatic isthmus is lifted up by the forceps held by the surgeon’s left hand and the posterior aspect of the pancreas is freed completely here.

9. Splenic vein identification 06'13''

The splenic vein is clearly visible here as it is also lifted up by the surgeon’s left hand. The dissection can then be continued on the superior portion of the pancreas, where the dissection was performed at the beginning of the procedure. The tumor is clearly visible here thanks to the augmented reality.

10. Dissection of pancreatic isthmus 06'32''

At this moment, the pancreatic isthmus can be dissected and skeletonized 1cm away from the tumor. A dissection performed in contact to the pancreas helps to progressively identify the splenic vein, which is a major anatomical structure. The splenic vein is dissected completely and controlled before the pancreatic isthmus is divided. Once again, the ultrasonic dissector provides an excellent dissection. The tumor encapsulated in the pancreas is also lifted up thanks to a forceps held by the assistant. This allows for the dissection of the entire pancreas. Augmented reality confirms the position and orientation of the splenic vein. The splenic vein is freed from the pancreatic body. The small direct venous tracts are controlled by clip application, bipolar coagulation or ultrasonic dissection. The objective is to obtain a complete hemostasis as well as a complete dissection of the splenic vein by freeing it from the pancreatic isthmus. The splenic vein is lowered and once again, a right-angled forceps is used to go around it. A loop is passed around the pancreatic isthmus to ensure its retraction. This loop is also used as an anatomical landmark. The loop is positioned in such a way that it avoids the previously dissected splenic artery and splenic vein. It allows for an exclusive retraction of the pancreatic isthmus. Such a retraction allows to isolate the pancreas and to skeletonize the vascular structures in order to control them before division of the pancreatic isthmus. Here the volume rendering image confirms the local anatomy as well as the position of the tumor in relation to the vessels. It also confirms that the splenic vein and artery can be controlled away from the tumor while preserving a sufficient safety margin.

11. Splenic artery division 09'04''

As is routinely performed, an absorbable suture is placed around the artery, which is controlled by a mechanical stapling device. White staples allow for a perfect hemostasis. We can see here the splenic artery that has been divided at its origin at the level of the pancreatic isthmus.

12. Splenic vein division 09'34''

Since the artery has been divided, the splenic vein can now be divided. The same technique can be performed to divide the splenic vein. This absorbable suture is used to make sure that the vein can be grasped completely in the stapler’s jaws during the placement of the stapling device. The stapler’s position is checked above and below the pancreas before the splenic vein is divided. The pancreatic tail and the spleen are now completely devascularized; the pancreatic isthmus can now be divided before the dissection is continued towards the pancreatic tail, along with the dissection and resection of the spleen. We make the most of a good exposure by continuing the anterior dissection of the superior portion of the pancreas.

13. Mobilization of gastric fundus 10'41''

We will also be performing a splenectomy as previously decided: we perform a complete mobilization of the fundus in order to amply retract the stomach during the pancreatic division. As a reminder, the spleen’s vascular control has been completed with the ligation of the splenic artery at its origin. The dissection of the fundus is performed preferably with the Ligasure device as it ensures an excellent coagulation at the level of the gastric fundus’ arterial pedicles. At the inferior and superior levels, the omentum is still fixed to the stomach. We will therefore mobilize the splenic flexure and completely free the spleen’s inferior pole.

14. Dissection of inferior pole of the spleen 12'19''

The dissection of the spleen’s inferior pole vascular pedicles is performed at that moment; the short gastric vessels are also divided following coagulation with the Ligasure device. The freeing of the inferior pole of the pancreatic tail can then be continued. The last elements fixing the omentum at the level of the splenic flexure are freed with consecutive coagulations. At this moment, the splenic flexure of the colon is well identified and protected.

15. En bloc resection of pancreatic tail and spleen 13'34''

The pancreatic tail and the spleen can then be resected in a single block. At this point in the procedure, the whole splenic flexure is lowered, all the inferior portion of the pancreas is lowered, and its superior portion has been freed. We can now perform the division of the pancreas at the level of its isthmus. To do so, we prefer to use an ultrasonic dissector: indeed, this ensures a coagulation of the pancreatic stump’s small vascular elements but it limits thermal spread and avoids the risk of postoperative pancreatitis. This dissection is performed gradually, step by step and while checking the ultrasonic dissector’s mobile blade in order to avoid unwanted coagulations. The Wirsung’s duct is not distinctively identified here. The pancreatic section is completed and thanks to the pancreas’ complete mobilization, the pancreas can be retracted easily. The small pancreatic arteries that have not been controlled by the ultrasonic dissector are done so by applying bipolar coagulation.

16. Suture of pancreatic stump 14'40''

Thanks to the extended mobilization, the pancreas can be lifted, and the pancreatic stump will be secured by stitches. These stitches are not entirely transfixing, but aim at bringing closer the anterior and the posterior border of the pancreas. The suture is performed with Vicryl 2/0 absorbable suture. The suturing technique is not significant, interrupted, running or figure-of-eight stitches can be performed here. The closure is excellent and the vascular control is complete. Nothing else will be performed or applied at this level. The posterior part of the pancreas can be freed as all the vascular elements were controlled inferiorly and superiorly, above and below. We will gradually free the pancreas’ posterior adhesions, then complete the freeing by dividing the lienorenal ligament posterior to the spleen. As the Ligasure device allows to grasp, apply traction and divide, it is particularly appropriate for this dissection. The area’s hemostasis is checked. The specimen is now completely free. The specimen is placed in an extraction bag in order to avoid parietal and peritoneal contamination. The pancreatic stump is protected by applying a Tachosil®. Thanks to its efficient and quick adhesional capabilities, it ensures a complementary control of the pancreatic stump. It was introduced rolled in a gauze and was humidified after its application. We follow the recommendations by applying pressure on the Tachosil® for 3 minutes until it is completely integrated. In this case, the control of the pancreatic stump is excellent. A simple drainage allows to control any small postoperative pancreatic fistula.

17. Specimen extraction 17'40''

The splenopancreatectomy specimen is extracted in a single block through an abdominal incision. The postoperative follow-up is uneventful and the patient is discharged on postoperative day 7.