Is Laparoscopic Pancreaticoduodenectomy Feasible for Pancreatic Ductal Adenocarcinoma?

Abstract

Margin-negative radical pancreatectomy is the essential condition to obtain long-term survival of patients with pancreatic cancer. With the investigation for early diagnosis, introduction of potent chemotherapeutic agents, application of neoadjuvnat chemotherapy, advancement of open and laparoscopic surgical techniques, mature perioperative management, and patients' improved general conditions, survival of the resected pancreatic cancer is expected to be further improved. According to the literatures, laparoscopic pancreaticoduodenectomy (LPD) is also thought to be good alternative strategy in managing well-selected resectable pancreatic cancer. LPD with combined vascular resection is also feasible, but only expert surgeons should handle these challenging cases. LPD for pancreatic cancer should be determined based on surgeons' proficiency to fulfil the goals of the patient's safety and oncologic principles.

Keywords: laparoscopic; pancreatic cancer; pancreaticoduodenectomy.

Figure 1

Laparoscopic view after resection of pancreatic head cancer. BD; bile duct, PV; portal vein, CHA; common hepatic artery. P; pancreas, SV; splenic vein, SMV; superior mesenteric vein, SMA; superior mesenteric artery, LRV; left renal vein, IVC; inferior vena cava, gastroduodenal artery stump (white arrows), pancreatic duct (thick white arrow).

Figure 2

Intraoperative usage of indocyanine green (ICG) during obtaining the retroperitoneal margin of the pancreas. The ICG stained area is part of the uncinated process (a), which can be differentiated from the SMA to obtain the retroperitoneal margin (b). It can help the surgeon design surgical dissection. Note soft tissue around the SMA (retroperitoneal margin) is not stained by ICG. P; uncinated process of the pancreas, SMA; superior mesenteric artery, SMV; superior mesenteric vein, RPM; retroperitoneal margin.

Figure 3

Combined venous vascular resection during laparoscopic pancreaticoduodenectomy (LPD). Tangential wedge resection of SMV is performed after transient clamping venous system (a). Primary repair of resected venous system (b). Tangential resection line (white dotted line), tumor invasion (white *), primary repair (white arrows).

Figure 4

Model for determining surgical indication of LPD for pancreatic cancer. Regardless of laparoscopic or open PD for pancreatic cancer, surgical approach should be allowed only when surgeons’ technical feasibility can obtain the appropriate surgical extent for margin-negative resection. Therefore, indication of LPD can vary according to surgeons’ techniques and disease extent. OPD will be recommended in surgeon (A). Type 0 LPD can be done in surgeon (B). Type Ia LPD and Type Ib LPD can be allowed for surgeon (C) and surgeon (D), respectively. Anatomically resectable pancreatic cancer with intact fat plane between pancreas and major vascular structures is thought to be the ideal tumor conditions for LPD (Tumor conditions controlled by Type 0 LPD). Note: This author follows Fortner’s initial classification of regional pancreatectomy [96].

Figure 5

A case with extremely appropriate pancreatic cancer for LPD. A case of early pancreatic cancer in a 71-year-old, male patient, incidental finding of pancreatic duct dilatation during routine medical check-up. Preoperative image studies showed less than 1 cm sized pancreatic mass with secondary pancreatic duct dilatation (a,b). Type 0 LPD was performed on 24 October 2019, and discharged 9 days postoperatively. Pathological examination reported 3.0 mm-sized pancreatic ductal adenocarcinoma with good differentiation (×100, c). resected margins were free from malignant cells (safety margin ≥ 1 cm). No lymph node metastasis was noted among 23 retrieved lymph nodes.