Totally laparoscopic duodenal pancreatectomy for cancer

Since the early 1990s, laparoscopic techniques have been applied to a growing number of pancreatic surgeries. Laparoscopic pancreatic resections have been performed in patients with a variety of diseases including chronic pancreatitis, pancreatic trauma, congenital hyperinsulinism. Laparoscopic proximal pancreatectomies for cancer with or without duodenum preservation remain controversial. Although a laparoscopic pancreaticoduodenectomy is technically feasible, laparoscopic reconstruction after proximal pancreatectomies is not yet generally practicable but limited to personal experiences of highly skilled surgeons. This interesting video shows all steps and landmarks of a totally laparoscopic duodenopancreatectomy for cancer performed by a very experienced surgeon.

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Totally laparoscopic duodenal pancreatectomy for cancer

Authors

F Corcione, J Marescaux

Abstract

Since the early 1990s, laparoscopic techniques have been applied to a growing number of pancreatic surgeries. Laparoscopic pancreatic resections have been performed in patients with a variety of diseases including chronic pancreatitis, pancreatic trauma, congenital hyperinsulinism. Laparoscopic proximal pancreatectomies for cancer with or without duodenum preservation remain controversial. Although a laparoscopic pancreaticoduodenectomy is technically feasible, laparoscopic reconstruction after proximal pancreatectomies is not yet generally practicable but limited to personal experiences of highly skilled surgeons.
This interesting video shows all steps and landmarks of a totally laparoscopic duodenopancreatectomy for cancer performed by a very experienced surgeon.

Classification

complex cases

Keywords

Totally laparoscopic duodenal pancreatectomy, cancer

Media type

Surgical video

Duration

17'00''

Publication

2009-03

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E-publication

WeBSurg.com, Mar 2009;9(03).
URL: http://www.websurg.com/doi-vd01en2595.htm

Totally laparoscopic duodenal pancreatectomy for cancer

1. Start of the procedure 00'24''

The procedure begins with a wide Kocher’s maneuver to rule out pathological lymphadenopathy and aorto-caval plane infiltration. The gastro-colic ligament is dissected in order to enter the lesser sac and to expose the antral region. Following the middle colic vein, the superior mesenteric vein is reached below the inferior border of the pancreas and the retro-pancreatic tunnellization begins. Once the procedure’s feasibility has been verified, the right gastric artery and the lesser omentum are dissected and divided in order to expose the origin of the gastro-duodenal artery.

2. Hepatoduodenal ligament lymphadenectomy 03'07''

Now the lymphadenectomy of the hepatoduodenal ligament begins along the course of the proper hepatic artery. During the dissection, the origin of the right gastric artery is identified. The artery is again divided between clips.

3. Division of the gastro-duodenal artery 04'28''

The gastro-duodenal artery is divided in order to expose the anterior surface of the portal vein. The lymphadenectomy continues by removing all the lymphatic tissue surrounding the common bile duct up to the hepatic hilum.

4. Cholecystectomy and common bile duct transection 05'34''

The cholecystectomy is then performed by dividing the cystic artery and the hepatic peritoneal bed using an ultrasonic scalpel. To avoid having the gallbladder empty itself in the abdomen, and once the common bile duct is divided, a clip is applied on the cystic duct. This maneuver allows to empty the common bile duct while allowing the transection above the cystic duct’s outlet. The lymphadenectomy is continued on the anterior surface of the portal vein, exposing the right hepatic artery: its origin is atypical as it originates from the superior mesenteric artery.

5. Retropancreatic tunnellization 08'15''

The retropancreatic tunnellization is completed and a loop is passed around the pancreas.

6. Division of the gastric antrum 08'22''

The gastric antrum is divided using two 60mm Endo-GIA linear staplers, whose branches are covered with SeamGuard.

7. Pancreas transection 08'39''

The pancreas is transected with an ultrasonic scalpel. By using this device, a good hemostasis of the pancreatic stump is achieved. The Wirsung’s duct is identified and a small probe is inserted into it. The pancreatic remnant is mobilized from the vascular plane to facilitate the anastomosis of the jejunal loop.

8. Identification and division of the first jejunal loop 09'28''

At this point, the submesocolic area is reached, the first jejunal loop is identified, the Treitz’s ligament is dissected and the first jejunal loop is divided using a vascular stapler. The jejunal loop and the fourth duodenum are passed to the right side of the superior mesenteric vessels. The dissection of the retro-portal sheath begins by dividing the last adhesions of the first jejunal loop and the fourth duodenum from the posterior plane. The dissection of the retro-portal sheath, performed on the right side of the superior mesenteric artery, can be achieved by using simultaneously an ultrasonic scalpel, a radiofrequency scalpel and a bipolar grasper. A collateral venous vessel is dissected and divided between clips.

9. Completion of the dissection 13'06''

Once this step is completed, the specimen is inserted into an Endobag and placed on the liver. This is a view of the operative field at the end of the abovementioned step. The reconstruction begins by passing the jejunal loop needed for the anastomosis behind the superior mesenteric vessels.

10. Reconstruction 13'43''

The pancreatic anastomosis that is performed is a pancreatico-jejunal end-to-side double layer anastomosis. The first posterior layer is performed with a 4/0 polypropylene running suture. The second layer is a running suture performed with 4/0 Vicryl following a full-thickness jejunal wall opening. The first anterior layer is also a running suture performed with 4/0 Vicryl, with the probe in the pancreatic duct. The second anterior layer is a running suture performed with 4/0 polypropylene. The common bile duct anastomosis is performed on the same jejunal loop, around 30cm to the previous anastomosis. An end-to-side bilio-jejunal anastomosis in a single layer using two 4/0 Vicryl running sutures is performed on the probe. A fibrin glue is applied on the anastomosis lines. A transmesocolic Roux-en-Y gastrojejunal anastomosis is then performed. The jejunal loop is anastomosed vertically on the posterior gastric wall. The stapler’s entry hole is closed using a 4/0 Vicryl suture. A side-to-side jejuno-jejunal anastomosis is performed using a vascular stapler. The stapler’s entry hole is closed using a 4/0 Vicryl suture. Three drains are placed: one in the pelvis, one in the sub-hepatic space and a peri-anastomotic drain for the pancreatic and gastrojejunal anastomosis. This is a view of the specimen as seen at the end of the procedure.