Laparoscopic assisted central pancreatectomy with pancreaticogastrostomy reconstruction - An alternative surgical technique for central pancreatic mass resection

Abstract

Context: Central pancreatectomy has gained popularity in the past decade as treatment of choice for low malignant potential tumor in the midpancreas due to its ability to achieve optimal preservation of pancreatic parenchyma. Simultaneously, advancement in minimally invasive approach has contributed to numerous novel surgical techniques with significantly lower morbidity and mortality. With the purpose of improving patient outcomes, we describe a laparoscopic assisted central pancreatectomy with pancreaticogastrostomy as an alternative method to the previously described open central pancreatectomy with roux-en-y pancreaticojejunostomy reconstruction.

Case report: A 39 year old man presented to our clinic with a 2.5 cm neuroendocrine tumor at the neck of the pancreas. Laparoscopic assisted central pancreatectomy with pancreaticogastrostomy reconstruction was successfully performed. Operative time was 210 minutes with blood loss of 200 ml. Postoperative course was uneventful except for a minimal pancreatic leak which was controlled by an intraoperatively placed closed suction drain. At 2 week follow up, patient was asymptomatic with well preserved pancreatic endo and exocrine functions. Permanent pathology findings showed a well differentiated neuroendocrine tumor with negative margins and nodes.

Conclusions: Laparoscopic assisted central pancreatectomy with pancreaticogastrostomy reconstruction is feasible and safe for a centrally located tumor. Laparoscopic assisted technique facilitates application of minimally invasive approach by increasing surgical feasibility in typically complex pancreatic operations.

Keywords: Laparoscopic; central pancreatectomy; pancreaticogastrostomy.

Fig. 1

Laparoscopic trocars and handport placement. A, B = 5mm trocars for laparoscopic grasper and tissue dissector, C = 10mm trocar for telescope, and D = Handport.

Fig. 2

Solitary lesion within the neck of the pancreas, 2.5 mm in diameter. Intraoperative ultrasonography showed a full thickness lesion involving the major pancreatic duct rendering enucleation not feasible.

Fig. 3

Cannulation of the distal pancreatic duct with a 3 Fr Geenan™ stent. The remaining distal pancreas was approximated to the posterior wall of stomach (has been decompressed with a nasogastric tube) in preparation for pancreaticogastrostomy reconstruction. Stent was utilized to help maintain the integrity of the newly created anastomosis.

Fig. 4

Retrogastric pancreaticogastrostomy was performed with interrupted silk sutures in a single layer fashion. The use of handport significantly improved feasibility to perform the anastomosis. Nasogastric tube was left in place for gastric decompression postoperatively.