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346
Table 20.1 (continued)
Author Country Year Design
Zhou [12] China 2019 Two centers Short- and
El Nakeeb
[13]
Han [14] Korea 2020 Single-center Short-term 104 lap,
Klompmaker
[15]
Yoo [16] Korea 2020 Single-center Short- and
Chen [17] China 2021 Single-center Short- and
Cheng [18] China 2021 Single-center,
Egypt 2020 Single-center Short- and
Europe 2020 Multicenter,
14 centers,
robotic cases
were also
included
only lap cases
Primary
outcome
long-term,
ADC
long-term
Short-term 412 lap,
long-term,
ampulla of
Vater
carcinoma
long-term,
ADC
Short- and
long-term, liver
cirrhosis
Baseline, nOutcomes after
79 lap,
230 open
37 lap,
74 open
113 open
729 open
76 lap,
283 open
128 lap,
288 open
28
cirrhotic,
325
control
N. Lluís et al.
PSM, lap vs open
• Lower delayed
gastric emptying
rate
• Similar rates of
major
complications
• Similar overall
survival
• Shorter LOHS
• Similar
oncologic
outcomes
and survival
• Similar
morbidity and
mortality
• Similar negative
resection margin
rate
• Similar LOHS,
major morbidity
and mortality
• Few minimally
invasive
procedures per
center
• Less use of
painkillers
• Fewer grade≥II
complications
• Shorter LOHS
• Similar overall
and recurrencefree survival
• Similar early
oncologic and
postoperative
outcomes
• Similar
recurrence rate
and overall
survival
• Cirrhotic
patients had
more
postoperative
complications
(continued)
20 Laparoscopic Pancreatoduodenectomy
Table 20.1 (continued)
Author Country Year Design
Dang [19] China 2021 Single-center Short- and
Ding [20] China 2021 Single-center Short-term 114 lap,
Katsuki [21] Japan 2021 Multicenter Short-term 96 lap,
Mazzola [22] Italy 2021 Single-center Short-term 52 lap,
Kim [23] Korea 2022 Two centers Short- and
Zhang [24] China 2022 Single-center Long-term,
ADC adenocarcinoma; NCDB National Cancer Data Base; LOHS length of hospital stays; ACSNSQIP American College of Surgeons-National Surgical Quality Improvement Program
Primary
outcome
long-term,
non-pancreatic
periampullary
ADC
long-term,
distal
cholangiocarcinoma
ADC
Baseline, nOutcomes after
172 lap,
316 open
140 open
2004
open
125 open
91 lap,
335 open
64 lap,
80 open
PSM, lap vs open
• Less LOHS
• Less 30-day and
90-day mortality
rate
• Similar
long-term
survival
• More harvested
lymph nodes
• Pancreatic stula
was more
common
• Similar LOHS
and
complications
• Higher total
hospitalization
costs
• Shorter LOHS
• Similar
morbidity and
postoperative
mortality
• Shorter LOHS
• Less harvested
lymph nodes
• Similar R0
resection rate
• Similar
long-term
survival
• Similar overall
survival
• Similar adjuvant
therapy
utilization
347
and readmission rates (benchmark <=21%) exceeded reference values in two of the
three centers, whereas other indicators, such as postoperative pancreatic stula
rates, ranged between 0% and 23% (benchmark <=19%). The remaining indicators
were within the reference values. More recently, the Miami International Evidencebased Guidelines on Minimally Invasive Pancreas Resection reiterated the need of
high-quality prospective data to continuously assess the outcomes of LPD
(Table20.2) [28].
348
Table 20.2 Recommendations of the Miami international evidence-based guidelines on minimally
invasive pancreas resection [28] on the use of minimally invasive (MIPD) vs open
pancreatoduodenectomy (OPD)
Recommendation Grade
• There is insufcient data to recommend MIPD over OPD.Centers performing
MIPD should be including all their MIPD outcomes data into national and
international registries, and prospectively maintained pancreas databases
• Both MIPD and OPD are valid approaches for selected patients with
adenocarcinoma
• No comparative data regarding MIPD vs OPD after neoadjuvant therapy exists
and further investigation is warranted
• Limited comparative data regarding vascular resection in MIPD vs OPD exist and
further investigation is warranted. MIPD with vascular resection should only be
performed by highly experienced surgeons and in high-volume centers
2A weak recommendation, high quality of evidence; 2B weak recommendation, moderate quality
of evidence; 1C strong recommendation, weak quality of evidence
N. Lluís et al.
2A
2B
Expert
opinion
1C
Randomized Controlled Trials
To date, four randomized controlled trials comparing short-term outcomes of LPD
versus OPD have been published (Table20.3). Two single-center trials (India [29]
and Spain [30]) and two multicenter trials (Netherlands [31] and China [32]) have
been performed. These studies focused on length of hospital stay, morbidity, mortality, and time to functional recovery. The Dutch series was terminated early due to
concerns regarding complication-related mortality [31]. In the design of this study,
participating surgeons were required to have done/participated in only 20 LPD
which was since conrmed not to be a sufcient experience to overcome the learning curve and may have played a role in the associated complication-related mortality for the laparoscopic arm. Length of hospital stay was signicantly shorter in the
laparoscopic arm in the remaining three trials that completed [29, 30, 32] although
this was a marginal benet in one of them [32]. Only one trial [30] showed a reduction in postoperative complications with the laparoscopic approach. Based on these
results, the laparoscopic approach has established itself as a solid alternative, in
experienced hands, to the open approach in terms of short-term postoperative outcomes. Future randomized controlled trials should determine with a higher level of
evidence the long-term and oncologic outcomes of LPD.
Surgical Technique
A detailed explanation of the surgical technique developed and used for over
20 years during LPD is described. The authors preferentially perform pyloruspreserving LPD although the technique can be adjusted in cases where a distal gastrectomy is performed. Surgical instruments and materials commonly used for this
procedure are listed in Table 20.4. Advanced laparoscopic skills are required to
perform LPD. However, with appropriate commitment and dedication, a surgeon
20 Laparoscopic Pancreatoduodenectomy
Table 20.3 Published randomized controlled trials comparing short-term outcomes after
laparoscopic versus open pancreatoduodenectomy
Study Country Year Design
PLOT [29] India 2017 Single-center,
PADULAP
[30]
LEOPARD-2
[31]
MITG-PCPAM [32]
LOHS, length of hospital stays
Spain 2018 Single-center,
Netherlands 2019 Multicenter,
China 2021 Multicenter,
open-label
open-label
patientblinded,
phases 2/3
open-label
Primary
outcome n
LOHS 32
LOHS 34
Safety
(phase 2),
functional
recovery
(phase 3)
LOHS 297
Postoperative
outcomes
• LOHS, median
(range): lap 7 (5–52)
lap vs
vs open 13 (6–30),
32
p=0.001
open
• Similar overall
complications and
mortality
• LOHS, median
(range): lap 13.5
lap vs
(5–54) vs open 17
32
(6–150), p=0.024
open
• Clavien-Dindo
grade complications
≥3: lap 5 vs open 11,
p=0.04
• Similar
oncological standards
• Complication-
50
related mortality: lap
lap vs
10% vs open 2%,
49
p=0.2
open
• Early terminated
• LOHS, median
(95% CI): lap 15
lap vs
(14–16) vs open 16
297
(15–17), p=0.02
open
• Similar short-term
morbidity and
mortality
349
can reach the level of expertise needed to perform a safe LPD procedure.
Furthermore, several areas of the world do not have access readily available to the
robotic platform due to the signicant cost involved. In these areas, surgeons have
chosen not to be marginalized by the hypothetical idea that one must be an absolute
maverick to reach the level of skill necessary. It is in these countries where LPD is
being done safely as it is performed in the hands of younger surgeons that have committed to learn the technique as the junior authors in this chapter. Additionally, the
authors feel that the magnication and better access to difcult areas offered by the
laparoscope ensure a meticulous resection of lesions located in the head of the pancreas and more precise anastomoses than in the open technique, when a small pancreatic duct is present.
1. Patient monitoring devices
Intravenous access is gained with two large-bore venous catheters and, when
needed because of patient comorbidities, a central venous line. An intra-arterial
350
Table 20.4 Surgical instruments and materials commonly used for laparoscopic
pancreatoduodenectomy
• Laparoscopic 5mm, 0°, camera mounted on an optical insufating port
• Laparoscopic 10mm, 45°, 4K camera with ICG capability (resection phase)
• Laparoscopic 10mm 3D camera (reconstruction phase)
• Smoke evacuator
• Insufators (x2)
• Laparoscopic liver retractor mounted on an iron intern retractor holder
• Energy devices: Ultrasonic shears, advanced bipolar, and bipolar
• Regular laparoscopic graspers
• Laparoscopic large bowel clamp
• Maryland curved dissector (3mm and 5mm)
• Laparoscopic right-angle dissector (3mm and 5mm)
• Laparoscopic staplers (vascular and enteric loads)
• Finger retractor
• Laparoscopic curved bulldog and bulldog applicator (10mm)
• Penrose drain (end cut in long, thin diagonal)
• Endoscopic Kittner
• Vessel loop
• Pediatric 5Fr pancreatic stent
• Needle driver, 3mm, mounted in 5mm shaft
• Sutures: Spiral barbed 3-0 and 4-0; polyglactin 5-0 with a TF (ophthalmologic) needle, and
other sutures according to surgeon’s preference
• Small, medium, and large-sized clips
• Indocyanine green (ICG)
• Laparoscopic ultrasound with Doppler capability
• Blake 15Fr drain (x2)
• Laparoscopic 15cm retrieval bag
N. Lluís et al.
catheter, a urinary catheter, and a pulse oximeter are used. General endotracheal
anesthesia is induced, and the stomach is decompressed with an orogastric tube.
No nasogastric tube is used postoperatively. Pneumatic compression stockings
are applied.
2. Patient positioning
The patient is placed in a supine, split-leg position, and carefully secured to the
operative table. Proper padding of pressure points is ensured. Table tilting
throughout the procedure and the use of gravity will be extremely helpful to
achieve proper exposure of the areas of interest and will avoid organ injury due
to unnecessary grasping. The proper height of the operative table, position of the
screen, as well as the angle of surgeon’s shoulders, elbows, and wrists are essential to ensure ergonomics are maintained throughout this long procedure.
3. Position of surgical team members
The surgeon stands between the patient’s legs for most of the procedure, except
during the biliary reconstruction, when the surgeon moves to the right side of the
patient. The rst assistant stands on the left side of the patient, and the second
20 Laparoscopic Pancreatoduodenectomy
assistant on the right. The scrub technician is in between the surgeon and the rst
assistant.
4. Port placement
A 5mm, 0°, optical insufating port, placed in the subxiphoid area and to the left
of midline, or in the mid left abdomen depending on body habitus, is used to
establish pneumoperitoneum. Its small opening at the tip of the trocar allows for
insufation without requiring the insertion of the entire trocar, avoiding organ
injury in case adhesions are present. The layers of the abdominal wall (skin,
subcutaneous fat, anterior fascia, rectus abdominis muscle, posterior fascia, and
pre-peritoneum) are visually evaluated as CO2 is insufated while advancing the
trocar. Standard intra-abdominal pressure is initially applied, although it should
be modied according to the patient’s tolerance of pneumoperitoneum. A total of
two 5 mm ports and four 12 mm ports are placed in a semicircular pattern
(Fig.20.2). The trocars are placed under direct visualization, initially keeping
the laparoscope in port 6. Ports 1 and 6 are 5mm; the rest are 12mm. Usually
ports 3, 4, and 5 are about 8cm apart from each other and at about 16cm from
the xiphoid for all body habitus types. Port 1 should be placed in the subcostal
region, high and lateral within the abdomen which will ease biliary reconstruction. The laparoscope is switched to a 10mm, 45°, inserted through port 4. The
hepatic surface and peritoneum are explored to rule out the presence of metastatic deposits.
351
Fig. 20.2 Port placement
(Figure reproduced with
permission of Horacio J
Asbun)
352
N. Lluís et al.
Resection Phase
The procedure starts with two maneuvers that will improve eld exposure. First, the
ligamentum teres is xed to the anterior abdominal wall using a nylon suture on a
Keith needle passed through the abdominal wall to encircle the structure. Second, a
table-mounted liver retractor is placed though port 1 and the liver retracted cephalad/anteriorly.
5. Omental division
The patient is now placed in a reverse Trendelenburg position. The greater
omentum is longitudinally split using ultrasonic shears, starting at the inferior
edge left of midline and directed toward the middle of hepatic segment III.The
plane of transection should be chosen bearing in mind an estimate of an anticipated location of the eventual antecolic duodenojejunostomy, which is usually
This maneuver will also facilitate exposure of the area of the ligament of Treitz.
Any adhesions here should be taken down now to facilitate jejunal mobilization
at a later stage.
6. Lesser sac entry
The lesser sac is entered through the gastrocolic ligament along the greater
curve, preserving the gastroepiploic arcade. Dissection proceeds to the right,
extending toward the area of the gallbladder. The rst assistant retracts the
stomach superiorly with a swiping maneuver using a grasper in port 1. The dissection is extended up to the area of the trunk of Henle. Omental adhesions to
the gallbladder or liver are taken down.
7. Colonic hepatic exure mobilization
The proximal transverse colon, hepatic exure, and part of the right colon are
mobilized from the retroperitoneum and retracted medially. The dissection is
carried through an avascular plane between the right mesocolon and retroperitoneal fat anterior to Gerota’s fascia. The duodenum and head of the pancreas
will then be exposed, which will later on facilitate the performance of the
Kocher maneuver.
8. Tributaries of the trunk of Henle division
The tributaries of the trunk of Henle are exposed better once the right colon has
identied, the tributaries are isolated using a nger-type retractor which is
passed very close to the duodenal wall (Fig.20.3). These structures are encircled en bloc with the surrounding adipose tissue, ligated, and divided using a
vascular stapler inserted through port 5. After this division, the near-complete
mobilized colon should now fall further because of gravity afforded by the
reverse Trendelenburg position and slight left-tilt of the table, giving adequate
exposure to the pylorus and duodenum.
9. Duodenum division
Dissection continues to free the rst portion of the duodenum. Small vessels
emanating from the head of the pancreas to the rst portion of the duodenum
20 Laparoscopic Pancreatoduodenectomy
Fig. 20.3 Tributaries of
the trunk of Henle are
encircled using a
nger-type retractor passed
very close to the duodenal
wall (Figure reproduced
with permission of Horacio
J Asbun)
Fig. 20.4 Numerous small
vessels emanating from the
head of the pancreas to the
rst portion of the
duodenum must be ligated
and divided. The use of
ultrasonic shears applied in
small bites under direct
visualization can be helpful
to avoid any major vascular
injury (Figure reproduced
with permission of Horacio
J Asbun)
353
may be encountered and must be ligated and divided (Fig.20.4). Important
vascular structures, such as the common hepatic artery or gastroduodenal artery
(GDA), might be encountered in this area as one proceeds posterior to the pylorus, and they should be avoided. The use of ultrasonic shears applied in small
bites under direct visualization can be helpful to avoid any vascular injury. The
pylorus should be clearly identied. The right gastric artery may be identied
and can be isolated and divided before or after division of the duodenum. Care
has been taken to preserve the gastroepiploic arcade avoiding entirely devascularizing the pylorus. A nger-type retractor is used to create a tunnel that encircles the rst portion of the duodenum. The orogastric tube is partially removed.
The duodenum is transversely transected, 2–3cm distal to the pylorus, using a
laparoscopic 60mm stapler with a blue load, inserted through port 5 (Fig.20.5).
An oblique transection of the bowel should be avoided since it would make the
duodenojejunostomy more technically challenging.
354
Fig. 20.5 Division of the rst portion of the duodenum. The authors preferentially perform
pylorus- preserving LPD, although the technique can be adjusted in cases where a distal gastrectomy is performed. The stapler is placed under direct visualization in a manner to optimize the
duodenal stump for the future gastrointestinal anastomosis (Figure reproduced with permission of
Horacio J Asbun)
N. Lluís et al.
10. Pylorus and antrum mobilization
is progressed through the pars accida toward the lesser curvature of the stomach. If still intact, the right gastric artery is ligated and divided. Dissection stops
before cutting the hepatic branch of the vagus nerve or nearing the left gastric
artery. The pylorus and antrum are now mobilized and are then folded anteriorly and superiorly into the left upper quadrant for the rest of the procedure.
This maneuver gives wide exposure of the duodenum, pancreas, and
retroperitoneum.
11. Gastroduodenal artery division
Attention is now turned to the hepatic hilar structures. The peritoneum over the
hepatoduodenal ligament is incised. Dissection of the hepatic artery lymph
node (station 8a) facilitates exposure of the common hepatic artery (Fig.20.6).
Frozen examination of this lymph node is recommended for staging purposes.
In turn, identication of the common hepatic artery serves as a landmark for the
GDA takeoff. Intraoperative ultrasound can aid identication of the GDA.If
there is any uncertainty a bulldog clamp can be placed across the presumed
GDA and Doppler ow assessed in the proper hepatic artery to assure the
hepatic artery was not confused for the GDA.The GDA is isolated and divided
close to its origin using a vascular stapler. Clips or sutures can be used instead
as well. Leaving a 5mm stump will facilitate endovascular embolization in case
of post-pancreatectomy hemorrhage due to pseudoaneurysm formation in this
area. Other small accessory branches to the pancreas in this area should be
identied and clipped when present, since they are potential sources of
pseudoaneurysms.
20 Laparoscopic Pancreatoduodenectomy
Fig. 20.6 Hepatic artery
lymph node dissection
facilitates exposure of the
common hepatic artery,
which serves as a landmark
for the GDA takeoff
(Figure reproduced with
permission of Horacio J
Asbun)
Fig. 20.7 Common bile
duct division. A curved
bulldog is inserted
proximally in the common
bile duct, previously
encircled by a nger-type
retractor (Figure
reproduced with
permission of Horacio J
Asbun)
355
12. Common bile duct division
Division of the GDA acts as a gateway to the structures of the porta hepatis, and
the portal vein is at times visible immediately deep to the GDA.The common
bile duct (CBD) is the next structure to be identied. A critical view of safety
technique is applied to identify and divide the cystic duct and cystic artery.
Completion of the cholecystectomy can be performed at a later stage and after
specimen extraction while margins are being evaluated. The cystic duct is followed down to its insertion at the CBD as needed to help delineate the CBD.It
is also found anterior and lateral to the portal vein, which may already have
been identied. A nger-type retractor is used to safely and individually encircle the CBD (Fig.20.7).
Extra attention must be paid to avoid injury to surrounding hepatoduodenal
structures located posteriorly (portal vein) or medially (proper and/or right