Surg Today (2009) 39:359–362DOI 10.1007/s00595-008-3853-0

Reprint requests to: A. ChoReceived: August 12, 2008 / Accepted: September 18, 2008

A Totally Laparoscopic Pylorus-Preserving Pancreaticoduodenectomy and Reconstruction

AKIHIRO CHO, HIROSHI YAMAMOTO, MATSUO NAGATA, NOBUHIRO TAKIGUCHI, HIDEAKI SHIMADA, OSAMU KAINUMA, HIROAKI SOUDA, HISASHI GUNJI, AKINARI MIYAZAKI, ATSUSHI IKEDA, and TOMOKO TOHMA

Division of Gastroenterological Surgery, Chiba Cancer Center Hospital, 666-2 Nitona-cho, Chuo-ku, Chiba 260-8717, Japan

AbstractAlthough many reports have described laparoscopic pancreatic surgery, laparoscopic pancreaticoduodenec-tomy (PD) has not been widely employed because of technical diffi culties. This paper describes a totally laparoscopic pylorus-preserving PD performed for an intraductal papillary-mucinous neoplasm. After the laparoscopic resection, an end-to-side pancreaticojeju-nostomy including duct-to-mucosa anastomosis without a stenting tube, an approximation of the pancreas stump and jejunal wall, an end-to-side hepaticojejunostomy, and an end-to-side duodenojejunostomy were per-formed intracorporeally. The patient recovered without any complications and was discharged on the 14th post-operative day. The surgical margin was free of neoplas-tic changes. Although the experience is limited and the appropriate indications must await future studies, this case indicates that a laparoscopic pylorus-preserving PD can be feasible, safe, and effective in highly selected patients.

Key words Laparoscopy · Pancreaticoduodenectomy · Pylorus-preserving pancreaticoduodenectomy · Lapa-roscopic pancreaticoduodenectomy · Intraductal papillary-mucinous neoplasm

Introduction

The laparoscopic approach is becoming increasingly common for a distal pancreatectomy because the feasi-bility and safety has been proven, especially in cystic or endocrine neoplasms.1–4 In contrast, only a limited number of laparoscopic pancreaticoduodenectomies (PD) have been reported5–8 because of technical diffi -

culties, suspicions concerning patient benefi ts, and a lack of consensus regarding the adequacy of this approach for malignancy. Although a few cases of laparoscopy-assisted or hand-assisted PD have been reported,9,10 few reports of a totally laparoscopic PD have been published in Japan. This report describes a totally laparoscopic pylorus-preserving pancreatico-duodenectomy (PPPD) for an intraductal papillary-mucinous neoplasm (IPMN) with a successful outcome, representing the fi rst description of this laparoscopic procedure in Japan.

Patient and Methods

Patient

A 74-year-old woman was referred for the evaluation and treatment of a pancreatic cystic lesion. Abdominal computed tomography (CT) and magnetic resonance pancreatography demonstrated a 35-mm multilobular cystic lesion in the pancreatic head. Based on a diagno-sis of an intraductal papillary-mucinous neoplasm, she underwent a laparoscopic pylorus-preserving pancreati-coduodenectomy. The patient was informed of the possible advantages and complications of the new experimental method and the possibility of conversion to open surgery and thereafter gave her written informed consent, thereby choosing this method instead of con-ventional surgery. The procedure was approved by the local ethical review board.

Laparoscopic Resection

The operation was performed by one of the authors (AC) who had performed more than 30 laparoscopic hepatectomies including hepatic lobectomies11 and 10 laparoscopy-assisted PDs,12 in which the resection was performed intracorporeally and the reconstruction was

360 A. Cho et al.: Laparoscopic Pancreaticoduodenectomy

performed through a small midline incision. The present patient was the fi rst case in whom a totally laparoscopic PD was attempted. In addition, laparoscopic procedures were practiced in swine before this operation. Instru-ments were prepared for a conventional open PD in advance to convert to open surgery as rapidly as possi-ble in the event that such a conversion should be neces-sary. The patient was placed in a supine position with her legs apart. A 12-mm trocar was placed 1 cm below the umbilicus, through which CO2 gas was delivered. Pneumoperitoneum was controlled electronically to a pressure of 10 mmHg. The other four trocars were located as shown in Fig. 1. The gastrocolic ligament was divided with a LigaSure (Valleylab, Boulder, CO, USA) or laparoscopic coagulation shears (LCS; Ethicon Endo-Surgery, Cincinnati, OH, USA) and the omental bursa was then opened to visualize the anterior surface of the pancreas. A dissection was performed between the duo-denum and the colon and the hepatic fl exure of the colon was mobilized caudally. The right gastroepiploic vessels were dissected and divided. The hepatogastric ligament was opened, and the right gastric artery was dissected and divided. The duodenum was transected using a Linear Cutter (Ethicon EndoSurgery). Dissec-tion was performed along the superior surface of the pancreas to isolate the common hepatic, proper hepatic, and gastroduodenal arteries (Fig. 2). The gastroduode-nal artery was divided. After the cholecystectomy, the hepatoduodenal ligament was dissected to isolate the portal vein (PV) and the common bile duct (CBD; Fig. 3). The CBD was closed with clips (Ligaclip Allport,

Ethicon EndoSurgery) and transected. The dissection between the inferior border of the pancreas and ante-rior wall of the superior mesenteric vein (SMV) pro-ceeded from inferior to superior (Fig. 4). After separating the pancreatic neck from the SMV-PV, the pancreatic neck was transected with LCS. The proximal jejunum was transected using the Linear Cutter and the mesen-tery of the jejunum and duodenum was dissected proxi-mally. Duodenal kocherization was performed and the duodenum was thoroughly dissected. The proximal end of the jejunum was delivered into the right of the supe-rior mesenteric vessels. Finally, a dissection between the pancreatic head (including the uncinate process) and the superior mesenteric vessels was performed using the LigaSure and LCS (Fig. 5). A midline incision

Fig. 1. The location of trocar placement and a 4-cm mini-laparotomy, through which the specimen was delivered

Fig. 2. Dissection was performed along the pancreatic head to isolate the common hepatic artery (CHA) and the gastro-duodenal artery (GDA). P, pancreas

Fig. 3. The hepatoduodenal ligament was dissected and the portal vein (PV) and the common bile duct (CBD) were iso-lated behind the stump of the GDA (arrow)

A. Cho et al.: Laparoscopic Pancreaticoduodenectomy 361

of approximately 4 cm was made (Fig. 1) and covered using a Lap Protector (Hakko Shoji, Tokyo, Japan). The specimen was then removed through the midline incision.

Laparoscopic Reconstruction

The proximal jejunal end was delivered through a window in the transverse mesocolon. Child’s method of reconstruction, which included an end-to-side pancre-aticojejunostomy, an end-to-side hepaticojejunostomy, and an end-to-side duodenojejunostomy in a proximal-to-distal manner, were performed intracorporeally. In the end-to-side pancreaticojejunostomy, a duct-to-

mucosa anastomosis without a stenting tube13 was per-formed with six 5-0 monofi lament absorbable interrupted sutures (Fig. 6), and an approximation of the pancreas stump and jejunal wall by four 3-0 monofi lament nonabsorbable interrupted sutures was performed14 (Fig. 7). An end-to-side hepaticojejunostomy was per-formed with six posterior 5-0 monofi lament absorbable interrupted sutures and a running anterior 5-0 monofi la-ment absorbable suture. In the end-to-side duodenoje-junostomy, a layer-to-layer anastomosis was performed with running posterior and anterior 4-0 monofi lament absorbable suture lines. A drainage tube was placed over the pancreatic anastomosis.

Fig. 4. Dissection between the posterior surface of the pan-creas (P) and anterior wall of the superior mesenteric vein (SMV) proceeded from inferior to superior

Fig. 5. Dissection of the pancreatic head, including the unci-nate process (U), from the superior mesenteric artery (SMA) and the superior mesenteric vein (SMV). P, pancreas

Fig. 6. Duct-to-mucosa anastomosis without a stenting tube was performed with 5-0 monofi lament absorbable interrupted sutures. The pancreatic duct (arrow) was dilated. J, jejunum; P, pancreas

Fig. 7. An approximation of the pancreas stump and jejunal wall by 3-0 monofi lament nonabsorbable interrupted sutures was performed. J, jejunum; P, pancreas

362 A. Cho et al.: Laparoscopic Pancreaticoduodenectomy

Results

The procedure took 450 min and the blood loss was 200 g. No blood transfusion was required. The nasogas-tric tube was removed on the following day. An abdom-inal drainage tube was removed and oral intake was initiated on the 4th postoperative day. The patient recovered without any complications and was dis-charged on the 14th postoperative day. A histological examination showed the branch type of intraductal papillary-mucinous adenoma with moderate atypia. No neoplastic changes were observed in the surgical margin of the pancreas.

Discussion

Minimally invasive surgery has been widely accepted as an alternative to conventional open surgery in many gastrointestinal fi elds, even for malignancy. Recent technological developments and improved endoscopic procedures have greatly enlarged the application of a laparoscopic distal pancreatectomy. In contrast, a lapa-roscopic PD is still not universally accepted as an alternative approach for open surgery because of the diffi culty of oncologic resection and the complexity of the reconstruction. The use of endovascular stapler devices may facilitate uncinate process/pancreatic head dissection.15 However, no endovascular stapler devices were used in the current case for dissecting the uncinate process from the mesenterium to expose the pancreatic parenchymal remnant behind the superior mesenteric vessels. Oncological principles dictate the uncinate process should be carefully dissected from the superior mesenteric vessels using LigaSure and LCS. The clear margins in the specimen demonstrate that a successful standard oncologic resection was achieved. Recent reports have also noted that a laparoscopic PD is feasi-ble and safe for selected cases, yielding adequate surgi-cal margins and a lymphadenectomy.6,7 However, a formidable challenge remains for surgeons in laparo-scopic reconstruction, particularly a pancreaticojejunos-tomy, because pancreatic anastomotic leakage is closely associated with intra-abdominal hemorrhage and high mortality rates.16,17 A pancreaticojejunostomy was per-formed with duct-to-mucosa anastomosis without a stenting tube13 and an approximation of the pancreas stump and jejunal wall,14 since the pancreatic duct was slightly dilated in the present case. As in an open re-construction, care should be taken to avoid tearing the pancreatic duct and parenchyma. Our patient did not develop a pancreatic fi stula and enjoyed the usual benefi ts of laparoscopic surgery, such as less pain and a shorter hospital stay. Although experience is limited and appropriate indications must await future

studies, a laparoscopic pylorus-preserving PD appears to be feasible, safe, and effective in highly selected patients. However, the benefi ts of laparoscopic pylorus-preserving PD have yet to be defi nitively proven and careful selection of patients is essential to the successful performance of this surgical procedure.

References

1. Sa Cunha A, Rault A, Beau C, Laurent C, Collet D, Masson B. A single-institution prospective study of laparoscopic pancreatic resection. Arch Surg 2008;143:289–95.

2. Melotti G, Butturini G, Piccoli M, Casetti L, Bassi C, Mullineris B, et al. Laparoscopic distal pancreatectomy: results on a consecu-tive series of 58 patients. Ann Surg 2007;246:77–82.

3. Fernández-Cruz L, Cosa R, Blanco L, Levi S, López-Boado MA, Navarro S. Curative laparoscopic resection for pancreatic neo-plasms: a critical analysis from a single institution. J Gastrointest Surg 2007;11:1607–21.

4. Takaori K, Tanigawa N. Laparoscopic pancreatic resection: the past, present, and future. Surg Today 2007;37:535–45.

5. Gagner M, Pomp A. Laparoscopic pylorus-preserving pancreato-duodenectomy. Surg Endosc 1994;8:408–10.

6. Dulucq JL, Wintringer P, Mahajna A. Laparoscopic pancreatico-duodenectomy for benign and malignant diseases. Surg Endosc 2006;20:1045–50.

7. Palanivelu C, Jani K, Senthilnathan P, Parthasarathi R, Rajapan-dian S, Madhankumar MV. Laparoscopic pancreaticoduodenec-tomy: technique and outcomes. J Am Coll Surg 2007;205:222–30.

8. Menon KV, Hayden JD, Prasad KR, Verbeke CS. Total laparo-scopic pancreaticoduodenectomy and reconstruction for a chol-angiocarcinoma of the bile duct. J Laparoendosc Adv Surg Tech A 2007;17:775–80.

9. Uyama I, Ogiwara H, Iida S, Takahara T, Furuta T, Kikuchi K. Laparoscopic minilaparotomy pancreaticoduodenectomy with lymphadenectomy using an abdominal wall-lift method. Surg Laparosc Endosc 1996;6:405–10.

10. Kimura Y, Hirata K, Mukaiya M, Mizuguchi T, Koito K, Katsuramaki T. Hand-assisted laparoscopic pylorus-preserving pancreaticoduodenectomy for pancreas head disease. Am J Surg 2005;189:734–7.

11. Cho A, Asano H, Yamamoto H, Nagata M, Takiguchi N, Kainuma O, et al. Laparoscopy-assisted hepatic lobectomy using Glisso-nean pedicle transaction. Surg Endosc 2007;21:1466–8.

12. Cho A, Yamamoto H, Kainuma O, Miyazaki A, Ikeda A, Ryu M. Laparoscopy-assisted pylrous-preserving pancreaticoduodenec-tomy (in Japanese). Shujutsu 2008;62:1427–31.

13. Imaizumi T, Hatori T, Tobita K, Fukuda A, Takasaki K, Makuuchi H. Pancreaticojejunostomy using duct-to-mucosa anas-tomosis without a stenting tube. J Hepatobiliary Pancreat Surg 2006;13:194–201.

14. Kakita A, Yoshida M, Takahashi T. History of pancreaticojeju-nostomy in pancreaticoduodenectomy: development of a more reliable anastomosis technique. J Hepatobiliary Pancreat Surg 2001;8:230–7.

15. Kleeff J, Friess H, Büchler MW. Dissection of the uncinate process and pancreatic head behind the portal vein using endo-vascular staplers. J Hepatobiliary Pancreat Surg 2007;14:480–3.

16. Rumstadt B, Schwab M, Korth P, Samman M, Trede M. Hemor-rhage after pancreatoduodenectomy. Ann Surg 1998;227:236–41.

17. Cullen JJ, Sarr MG, Ilstrup DM. Pancreatic anastomotic leak after pancreaticoduodenectomy: incidence, signifi cance, and management. Am J Surg 1994;168:295–8.