Tips and tricks for a safe laparoscopic pancreatoduodenectomy

Abstract

Minimally invasive pancreatoduodenectomy has been revolutionized during the last decades and, although not as rapidly or widely adopted, the laparoscopic approach seems to be feasible with various potential advantages compared to traditional open pancreatoduodenectomy. Laparoscopic pancreatoduodenectomy is a technically demanding procedure with a steep learning curve mainly due to the fact that the technique is not standardized. Technical details as well as tips and tricks of the operation are described. Standardization of the procedure is the cornerstone of the learning curve of minimally invasive pancreatoduodenectomy. One of the largest barriers of this complex procedure is the reconstruction phase with the creation of three separate anastomoses. A hybrid approach may help surgeons - especially during the initial phase of the learning curve - to overcome the difficulties associated with a fully laparoscopic reconstruction, while retaining the advantages of laparoscopy.

Keywords: Whipple procedure; laparoscopic pancreatoduodenectomy; pancreatic adenocarcinoma; portal vein; superior mesenteric artery.

Photo 1

Trocar positioning during laparoscopic pancreatoduodenectomy. A + B: 12-mm trocar used for laparoscope/stapler insertion. a, b: 5-mm working trocars. 1, 2: 5-mm trocar exposure trocars. Black line: mini-laparotomy for the specimen’s extraction and reconstruction (hybrid technique)

Photo 2

A braided silk 0 transfixing stitch piercing the round ligament, inserted subxiphoidally with a suture passer, provides efficient suspension of the liver

Photo 3

Aortocaval dissection. A wide Kocher maneuver allows excellent exposure of the inferior vena cava, aortocaval space and right celiac plexus dissection (lymph node 16b1). Any suspicious peritoneal or liver nodule as well as lymph nodes at the left side of the superior mesenteric artery (SMA) and/or the aortocaval space are sent for frozen section

Photo 4

The gastroduodenal artery (GDA) is ligated with clips and/or stiches, near its origin from the common hepatic artery just above the superior margin of the pancreas. This step ensures proper recognition of the GDA before its transection. Grasping or any traction on the GDA should be avoided at all costs due to the fragility of the vessel

Photo 5

The avascular plane between the posterior aspect of the pancreatic neck and the portal vein is developed in a cephalad-to-caudal direction, thereby completing the retro-pancreatic “tunnel” from above

Photo 6

The uncinate process can be dissected free from the superior mesenteric artery (SMA) using an energy device; however, occasionally it will require clips or ligature. With the dissection along the superior mesenteric vessels, the mobilization of the specimen is completed

Photo 7

Endoscopic view of the major vasculature of the surgical field after the specimen’s complete mobilization

Photo 8

Superior mesenteric and splenic veins are controlled with vascular clamps. After resection of the invaded venous segment, the distance between the cut edges is measured. Reconstruction may be carried out with a monofilament continuous suture (e.g. Prolene 4/0 or 5/0). A defect between the proximal and distal vein edges > 4 cm is considered an indication for an interposition graft

Photo 9

For the pancreatojejunostomy, we perform a two-layer end-to-side duct-to-mucosa anastomosis. The anastomosis begins with the construction of the posterior trans-pancreatic/seromuscular anastomotic row, which is fashioned using a single-layer synthetic absorbable monofilament suture (polydioxanone 4/0). The jejunum loop is stitched 4–6 cm distal from the stump in the middle of the posterior semi-circle. The pancreatic stump is stitched approximately 1.5–2.0 cm distal to the cut edge depending on the texture and the size of the remnant. The distance between the sutures is 0.5–1.0 cm. Thereafter, a duct-to-mucosa pancreaticojejunostomy is created using a synthetic absorbable monofilament suture (polydioxanone 5/0) in an interrupted fashion. Six to eight sutures are usually placed, depending on the duct size