Pitfalls for laparoscopic pancreaticoduodenectomy: Need for a stepwise approach

Abstract

Because of today's advancements in surgical techniques and perioperative management skills, surgeons are beginning to explore the usefulness of the laparoscopic approach in managing periampullary tumors. However, as a result of its innate complexity and associated high surgery-related complications, its applicability to the general surgical community remains controversial. To date, only retrospective data from high-volume centers support the safety and feasibility of laparoscopic pancreaticoduodenectomy (Lap PD) for the treatment of benign conditions and malignant periampullary tumors. In addition, various surgical techniques in terms of port placement, dissection, and reconstruction have evolved in different centers depending on the preferred method commonly used by the surgeon through accumulated experience. In our center, we used a stepwise approach and standardized our surgical technique to overcome this technically demanding procedure. A collaborative implementation of video review and analysis, practice training and simulation, operating room didactics, and strict adherence to our stepwise approach in Lap PD, might potentially improve the surgical skills of young hepatobiliary surgeons and possibly overcome the volume-based learning curve of Lap PD.

Keywords: laparoscopic pancreaticoduodenectomy; pitfall; step‐wise approach; technique.

Figure 1

Indications and basis for selection of laparoscopic pancreaticoduodenectomy (Lap PD). *Only expert surgeon can carry out this level of difficulty during Lap PD

Figure 2

Placement of trocars and operator position. The surgeon stands at the right side of the patient during the entire surgical procedure. The laparoscopic camera is usually introduced through right‐sided 12‐mm ports (A and B) according to the target surgical field by Assist 1. Port a and port A (or B) will be the main working ports for the surgical procedure. Assist 2 can help to expose the surgical field using Ports b, c, and C. Port d can be added in case of robotic reconstruction. Two monitors (M1 and M2) are placed on the opposite side of the surgeons and nurses for ergonomic surgical interventions

Figure 3

(A) Dissection of the gastrocolic ligament up to the (B) pyloric area

Figure 4

(A) Dissection and (B) ligation of the right gastroepiploic vessels

Figure 5

(A) Dissection of the hepatogastric ligament exposes the (B) right gastric artery (RGA)

Figure 6

Division of the first portion of the duodenum using an Endo‐GIA stapling device (Medronics Inc, North Haven, CT, USA)

Figure 7

Dissection of the superior border of the pancreas. The portal vein (PV) can be exposed and identified by dissecting the triangle bordered by the superior border of the pancreas inferiorly and by the gastroduodenal artery (GDA) and common hepatic artery (CHA) superolaterally. PHA, proper hepatic artery

Figure 8

Dissection of the inferior border of the pancreas. SMV, superior mesenteric vein

Figure 9

A, Creation of a pancreatic window exposing the portal vein (PV) and splenic vein (SV). B, Completed taping of the pancreas. SMV, superior mesenteric vein

Figure 10

A, Dissection of the hepatoduodenal ligament follows the route of the hepatic arteries. B, The gastroduodenal artery is ligated and transected to facilitate exposure of the portal vein. C, In some cases, the gastroduodenal artery (white arrow) can be secured using an Endo‐GIA stapler (Medronics Inc, North Haven, CT, USA). D, A tape is encircled around the common hepatic duct. CBD, common bile duct; CHA, common hepatic artery; LHA, left hepatic artery; PHA, proper hepatic artery; RHA, right hepatic artery

Figure 11

Gastrocolic trunk (GCT). AIPDV, anterior inferior pancreaticoduodenal vein; GEV, gastroepiploic vein; SMV, superior mesenteric vein

Figure 12

Full kocherization. AA, abdominal aorta; IVC, inferior vena cava; RV; renal vein

Figure 13

Image after complete mobilization of the duodenum and pancreatic head. IVC, inferior vena cava; SMV, superior mesenteric vein

Figure 14

Para‐aortic lymph node sampling. AA, abdominal aorta; RV; renal vein

Figure 15

A, Division of the proximal jejunum. B, Ligation of mesenteric vessels (white arrow) using a LIGACLIP (Aesculap Incorporated, Center Valley, PA, USA)

Figure 16

Transection of the pancreatic neck

Figure 17

Dissection of the uncinate process (A) using indocyanine green (ICG) (B). C, Laparoscopic clips effectively secure the feeding vessels from the superior mesenteric artery (SMA) to the pancreatic head. D, Dissection of the lateral wall of the SMA using ICG. Note that ICG perfusion in the uncinate process can be differentiated from the SMA lateral border. IPDA, inferior pancreaticoduodenal artery; PV, portal vein; SMV, superior mesenteric vein

Figure 18

Transection of the common hepatic duct

Figure 19

Pancreaticojejunostomy anastomosis. A, Simple interrupted suture of prolene 5‐0 from the superior to inferior pancreas (yellow arrow). B‐C, After one or two sutures, two stay sutures in the 6 o'clock and 9 o'clock positions of the pancreatic duct are usually placed before completing the posterior layer sutures. D, Completed posterior layer sutures. E, Completion of the duct‐to‐mucosa anastomosis with a 3 o'clock suture. F, Placement of a stent. G, The 12 o'clock duct‐to‐mucosa suture. H, Completed pancreaticoduodenal anastomosis. White arrow, pancreatic duct; PV, portal vein

Figure 20

Hepaticojejunostomy anastomosis. A, Continuous running suture (Vicryl 5‐0, Ethicon Inc., Johnson and Jonson Medical, Somerville, NJ, USA) on the posterior side. B, Simple interrupted sutures (Vicryl 5‐0) on the anterior side

Figure 21

Postoperative wound after laparoscopic pancreaticoduodenectomy