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23 Laparoscopic Distal Pancreatectomy
index (BMI) was found in patients undergoing LDP vs. ODP (28.5 ± 5.7 vs.
25.8±4.6, p=0.03). Operative BL was 329mL higher (p=0.08), and LOS was 2
days longer (9.4±4.7 vs. 7.4±3.4, p=0.006) in the ODP group. OS was similar in
the two groups (16months each, p=0.71), as well as the number of lymph nodes
retrieved (ODP 12.3±8.3 vs. LDP 14.0±8.0, p=0.41).
The Miami International Evidence-based Guidelines on Minimally Invasive
Pancreas Resection [20] previously mentioned and concluded that MIDP for PDAC
is feasible, safe, and equivalent to ODP in experienced hands when performed for
PDAC (grade 2B, expert agreement 95%, quality score 87%, audience agreement 96%).
A National Cancer Database-based study by our group [22] showed that LDP for
PDAC is not only safe, but it is also associated with oncological benets such as
lower margin positivity (odds ratio [OR] 0.581, p=0.005), increased adjuvant chemotherapy use (third quartile: OR 1.844, p = 0.026; fourth quartile; OR 2.144,
p=0.045), and fewer delays in administration of adjuvant chemotherapy (fourth
quartile: OR 0.786, p=0.045) in higher-volume centers.
409
Preoperative Planning
Several clinical and anatomical variables need to be evaluated before planning a
LDP. The IHPBA expert panel [16] identied ve categories of factors to assess:
surgeon related (individual and team experience), patient related (general health,
previous abdominal surgery, BMI, and preoperative diagnosis), procedure related
(visualization, wound issues, and adequate surgical equipment), tumor related
(benign vs. malignant, anatomy, local advancement, and multivisceral resection),
and society related (cost-effectiveness).
Clinical Considerations
Age alone should not be considered an absolute contraindication for LDP. It was
demonstrated that LDP may be safe and feasible for patients >70years old [23–25].
Sahakyan etal. [26] discussed how poor physical status, identied with how poor
physical status, identied with American Society of Anesthesiology (ASA) grade
3–4, is associated with medical complications after LDP, but not with overall/major
morbidity, surgical complications, or mortality.
The same authors [27] reported that obesity independently predicted prolonged
operative time and was signicantly associated with an increased intraoperative BL
after LDP, while conversion, LOS, and major morbidity did not differ signicantly
between normal weight, overweight, and obese patients. Most notably, multivariate
logistic regression analyses did not demonstrate an association between obesity and
postoperative morbidity (p= 0.09), conrming results from previous reports [28,
410
E. Panettieri et al.
29]. Others advocate that LDP may be particularly advantageous for obese patients
as it increases accessibility to the deep abdomen, reduces wound complications, and
is associated with the fastest recovery [30].
A study showed how LDP after previous upper abdominal surgery did not affect
intraoperative course, postoperative morbidity, mortality, or LOS [31]. According to
a global survey, surgeons routinely performing MIDP considered advanced age (2%
vs. 11%; p=0.001), ASA score>3 (16% vs. 28%; p=0.01), and a prior laparotomy
(11% vs. 19%; p=0.04) less often a contraindication for choosing this approach in
comparison to surgeons who did not have familiarity with the technique [32].
Similarly, a pan-European survey conrmed how patient selection is highly inuenced by personal preference and team expertise [33].
Anatomical Considerations
Regarding tumor and anatomical factors, most surgeons consider both multivisceral
and vascular involvement as critical contraindications for LDP, while a minority of
them believe there are no absolute contraindications [33]. Two papers offered an
insightful perspective on preoperative planning. The rst [34] identied three factors associated with open conversion at univariate analyses: site of the tumor, extent
of the resection, and adjacent organ involvement. Only extension into adjacent
organs remained signicant after multivariate analyses. The second [35] provided a
difculty scoring system, which reported ve signicant factors: type of resection,
resection line (i.e., transection near the portal vein that requires tunneling under the
pancreatic neck or more distal resection with no need for tunneling), proximity of
tumor to major vessels, tumor extension to peripancreatic tissue, and left-sided portal hypertension/splenomegaly. The authors also suggested to look for the following
on preoperative imaging: parenchymal thickness at the expected resection line, preoperative indicators of pancreatic texture (obstructive pancreatitis with a dilated
distal pancreatic duct and parenchymal atrophy, loss of lobulated parenchymal
structure, and calcications), and presence of a circumportal pancreas.
Similarly, Partelli etal. [36] demonstrated how a thick parenchyma at the resection line (p=0.014) and tumor proximity to major vessels (p=0.002) were signicant risk factors for the presence of ≥1 outcomes of surgical difculty.
An International Expert Consensus on Precision Anatomy for MIDP [37] recommended caution regarding celiac artery (CA) variations, origin, and course of the
splenic artery (SA) and dorsal pancreatic arteries (DPAs), as well as drainage pattern of the left gastric (LGV) and inferior mesenteric (IMV) veins. In this setting,
preoperative three-dimensional (3D) reconstruction can help to visualize the anatomy and is correlated with better depth perception, decreased physical demand
[38], BL, and operative time in small series [38, 39]. Nakata etal. [40] described
two variants based on the relationship between the root of the SA and the pancreatic
parenchyma: the buried type (60%) where the root of the SA was in close proximity
behind the pancreatic parenchyma, and the non-buried type (40%) where the root of
the SA is separated from the pancreatic parenchyma by a wide space. Using
23 Laparoscopic Distal Pancreatectomy
Table 23.1 A summary of radiologic features to look for when planning a laparoscopic distal
pancreatectomy
Location and size of the tumor
Proximity to major vessels
Extension to peripancreatic tissue
Multivisceral involvement
Distance of the expected resection line from the main portal vein
Parenchymal thickness at the expected resection line
Left sided portal hypertension/splenomegaly
Circumportal pancreas
Obstructive pancreatitis
Parenchymal atrophy
Loss of lobulated parenchymal texture
Calcications
411
preoperative 3D computed tomography (CT) for anatomical reconstruction, the buried type was associated with a signicantly longer median operative time, a higher
mean BL, and prolonged overall operative time.
Table 23.1 summarizes radiologic factors to consider when planning a
LDP.Figure23.1 shows a CT image of a mucinous cystadenoma of the tail of the
pancreas amenable to LDP. Figure 23.2 presents an example of preoperative
CT-based 3D reconstruction.
Surgical Technique
1. Patient position and placement of trocars:
In the author’s practice, the patient is placed in the French position, with arms
tucked and legs in stirrups. It can be helpful to rotate the patient 45° to the right
and have the patient in the reversed Trendelenburg position. A 12-mm optical
trocar is placed in the left paramedian location below the left costal margin.
Pneumoperitoneum is established with a pressure of 12–15mmHg. Three additional operative trocars are placed to the left of the midline as follows:
– A 12mm midline mid-epigastric camera port
– A 5mm subxiphoid assistant port
– A 5mm left anterior axillary port
2. Lateral-to-medial vs. medial-to-lateral approach
There are two approaches to expose the pancreas and allow for pancreatic
transection. The dissection can be carried out from lateral-to-medial or medialto- lateral [41–43].
(a) Lateral to medial
For the lateral-to-medial technique, the inferior border of the pancreas is
exposed by deecting the transverse mesocolon inferiorly. The splenic exure of the colon is grasped, and the gastrosplenic and splenocolic ligaments,
both avascular, are divided with help of an energy device using ultrasonic
412
Fig. 23.1 A computed
tomography image (arterial
phase) of a mucinous
cystadenoma at the tail of
the pancreas in a 68-yearold man. There is no
abnormal enhancement,
solid component, or
septation of the lesion. No
parenchymal atrophy of
ductal dilation is detected
Fig. 23.2 A computed
tomography based
three-dimensional
pancreatic vascular
reconstruction
E. Panettieri et al.
and bipolar energy. The left colon distal to the splenic exure is partially
mobilized along the white line of Toldt and deected medially. It is critical
to not accidently enter Gerota’s fascia or dissect the interspace between the
lateral abdominal wall and kidney. The greater omentum is incised to enter
the lesser sac. The splenic exure is peeled down off Gerota’s fascia, revealing the tail of the pancreas.
The dissection continues medially along the transverse colon, dividing
the attachments of the greater omentum to the greater curvature of the stomach near the origin of the right gastroepiploic artery. The greater omentum is
swept medially, gaining access to the lesser sac, and allowing access to the
body of the pancreas medial to the tail. The stomach is retracted superome-
23 Laparoscopic Distal Pancreatectomy
dially using a transxing free-eyed needle placed through the abdominal
wall [44].
In case of splenic vessel preservation, the splenic artery and vein are
carefully dissected off the posterior surface of the pancreas starting at the
splenic hilum. The dissection is carried out past the target lesion in the pancreas and then the pancreas transected. In case of splenic resection, the short
gastric arteries and lienorenal ligament are divided early, and the spleen is
resected “en bloc” with the specimen.
(b) Medial-to-lateral
For the medial-to-lateral dissection, the portal venous conuence is dissected out early by following the SMV and its branches to its drainage to the
portal vein. Working underneath the pancreas, the capsule is carefully
detached from the underlying SMV/splenic vein (SV) conuence. When the
tunnel is created, care must be taken to prevent injury to the celiac trunk. A
tunnel behind the neck of the pancreas is formed. An umbilical tape is passed
around the body of the pancreas, medial to the site of the tumor, through the
retro-pancreatic tunnel. Prior to stapling, one has to conrm that neither the
common hepatic artery nor celiac trunk are caught in the stapler. The neck
of the pancreas is transected using a stapler. The dissection continues to the
left toward the splenic hilum. Gentle traction on the spleen is applied medially to divide the splenorenal and splenophrenic ligaments. The short gastric
vessels are ligated.
3. Splenic vessel dissection
In case of splenic vessel preservation, the pancreas is detached from the
splenic artery and vein with careful dissection using a vessel sealer and bipolar
cautery. We have previously reported a detailed instructional video on successful
splenic vessel preservation [44]. Minimizing splenic vein manipulation is critical in reducing postoperative thrombosis.
4. Pancreatic transection and mobilization
According to the Miami guidelines [20], both stapler and non-stapler closure
can be used in LDP, with similar outcomes, and no evidence suggests a benet
of reinforcing the staple line (recommendation grade 2C).
5. Specimen retrieval and drain placement
The specimen is retrieved using an endoscopic retrieval bag through a midline
incision. Based on surgeons’ preference, a #19 Blake drain is left in the resection
zone and secured in the upper left quadrant, followed by closure of port sites in
a standard fashion.
Tips and tricks are summarized in Table23.2.
413
Table 23.2 Tips and tricks
Port placement high in the right upper quadrant
Wide colonic mobilization to facilitate exposure of the inferior border of the pancreas
Gastric retraction transxion needle to save ports
Careful division of splenic ligaments to avoid capsular tearing
Slow stapler closure and transection to reduce leaks
414
E. Panettieri et al.
Lymphadenectomy andRadical Anterograde
Modular Pancreatosplenectomy
According to the Japanese Pancreas Society [45], a standard lymphadenectomy for
PDAC should include lymph node stations 10, 11, and 18 for tumors located in the
body and tail of the pancreas. To increase the probability of achieving negative margins and harvesting an appropriate number of lymph nodes, Strasberg etal. [46]
introduced the radical anterograde modular pancreatosplenectomy (RAMPS). This
approach aims to perform a complete N1 lymph node dissection and to minimize a
positive retroperitoneal margin. During RAMPS, the division of the neck of the
pancreas and splenic vessels with celiac node dissection is performed rst. The dissection proceeds to the left of the CA and SMA to their origin. The posterior plane
of dissection can be carried out superior to the left adrenal gland and Gerota’s fascia
(anterior RAMPS) or can be posterior to the adrenal and Gerota’s fascia (posterior
RAMPS). The dissection then continues from right-to-left in two possible posterior
dissection planes based on the depth of invasion of the PDAC [47, 48]. According
to this technique, the N1 lymphadenectomy includes lymph nodes along the superior and inferior borders of the left-sided pancreas (10, 11, and 18), the celiac lymph
nodes (9), and the lymph nodes along the front and left side of superior mesenteric
artery (14p and 14d).
Distal Pancreatectomy withEn Bloc Celiac Axis Resection
In the case of advanced body/tail PDAC involving the CA or the CHA, the distal
pancreas can be resected “en-bloc” with the surrounding structures: CA (with CHA
and SA), the left adrenal gland, and the celiac plexus [49]. This can be achieved
through a right retroperitoneal, left retroperitoneal, ventral, or median approach [50].
Training andLearning Curve
With the rising popularity of LDP, the learning curve of LDP has been investigated.
The Dutch Pancreatic Cancer Group proposed a nationwide training program
(LEALAPS-1) [51] including following a detailed technique outline and video
training (2 hrs combined), followed by on-site or off-site proctoring by MIDP
experts. The surgeon could then start practicing MIDP independently after the proctor’s approval. Comparing results before and after training, improvement in conversion rate, estimated BL, and LOS were evident. According to different authors, a
single surgeon learning curve is achieved after 17 LDPs [52] and a reduction in
morbidity and LOS is achieved after 30 LDPs [53]. While surgeons should be
23 Laparoscopic Distal Pancreatectomy
415
familiar with different MIDP approaches, it is recommended to standardize their
proper technique [37].
Conclusion
In this chapter, the advantages and safety of LDP vs. ODP are detailed. Today, LDP
can be considered an appropriate approach for malignant disease by experienced
surgeons for selected patients and may improve morbidity and oncologic outcomes.
While the benets regarding morbidity include reduced operative time, BL, margins, and subsequently hospital costs, the oncologic benets may include faster
return to and fewer delays in initiating adjuvant chemotherapy.
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