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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_734_Библиотеки_им_академика_М_И_Перельмана.pdf
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visualization, improved precision in delicate vascular dissection, and the ability to
complete a ne pancreaticojejunostomy anastomosis allow a paradigm shift in the
decision making between distal pancreatectomy versus central pancreatectomy for
pancreatic body tumors. In this chapter, we describe indications, preoperative preparation, and surgical techniques of central pancreatectomy.
V. Butano et al.
Indications
Careful patient selection is essential to maximize derived benet. Risk and benet
must be carefully weighed for each individual patient since there are no absolute
indications for central pancreatectomy for the appropriate biology. Historically, distal pancreatectomy had been the standard treatment for pancreatic body malignant
tumors. Parenchymal-preserving central pancreatectomies then came as an alternative method for benign or low-risk malignant tumors (such as pancreatic neuroendocrine tumors, intraductal papillary mucinous neoplasms, mucinous cystic
neoplasms, and solid pseudopapillary neoplasm) conned to the neck or proximal
body of the pancreas [2]. The most classical indication for CP would be a central
pancreatic mass of a tumor type which would typically be amenable to enucleation;
however, due to its depth within the pancreatic parenchyma, or proximity to the
main duct, enucleation would be impossible or carry a signicant risk of pancreatic
duct leak with its subsequent morbidities. The inherent benet of pancreatic preservation and reduced risk of postoperative pancreatic insufciency must justify the
potential morbidity.
Preoperative Assessment
Patients diagnosed with suspicious lesions in the neck of the pancreas should
undergo a thorough preoperative evaluation before any surgical intervention is
offered. Many of these patients will be found to have metastatic disease or vascular
involvement, precluding surgical resection. A multi-disciplinary approach to these
central lesions is paramount to assess the patient’s comorbidities, preoperative risk,
the role of radiologic and endoscopic interventions, clinical staging, and potential
role for neoadjuvant or adjuvant therapies.
Serologic Testing
• All patients should have standard preoperative labs including CBC, chemistry,
hepatic panel, and PT/INR.
• Any patient with a suspicious pancreatic mass should have preoperative tumor
markers (CA19-9, Chromogranin A, metanephrines, catecholamines).
28 Minimally Invasive Central Pancreatectomy
473
Imaging andAdditional Diagnostic Studies
• The initial imaging modality of choice is triphasic CT abdomen pelvis with
1mm cuts. The CT is completed with intravenous contrast and timed for the arterial, venous, and portal venous phases. A non-contrast CT chest may be performed at the same time to rule out pulmonary lesions. This study is widely
available and can be used both for diagnosis and staging. The ability of the CT
scan to dene the tumor location, size, extension, biliary and pancreatic obstruction, and vascular involvement make this study the most valuable in terms of
information and efciency.
• MRI/MRCP can be obtained to provide additional information on the status of
biliary tree, proximity of lesion to the main pancreatic duct, and potential hepatic
metastasis should there be any concerns on the initial CT.The MRI is not as useful in gleaning information regarding vascular involvement, and this study is not
required prior to resection.
• Endoscopic ultrasound (EUS) has become routine in obtaining a tissue sample,
assessing the lymph nodes near the mass, and vascular involvement. This modality is especially useful for ruling out non-surgical masses such as lymphoma as
well as assessing the vasculature if the CT is equivocal. Should the tumor be
found unresectable, a denitive tissue diagnosis can be obtained by the EUS to
guide administration of systemic chemotherapy. This will allow the patient’s
therapy to be tailored to the specic tumor biology and potentially allow the
patient to be downstaged for a potentially later resection.
• PET/CT may be indicated in the setting of a mass that has a high likelihood of
metastasis; however, some tumors are not PET avid thus making this evaluation
somewhat controversial. It is generally our practice to obtain a PET/CT for the
majority of our preoperative patients, but this is not an absolute requirement.
DOTATATE contrasted PET/CT has become the gold standard for suspected or
conrmed pancreatic neuroendocrine tumors (pNET), and we recommend all
patients with neuroendocrine tumors undergo this study as pNET have a high
likelihood of regional and distant metastatic disease at presentation. Findings of
extrapancreatic metastasis do not necessarily preclude resection; however, it
helps identify other resectable lesions. DOTATATE also has an important role in
detecting multifocal disease in patients at increased risk due to genetic syndrome
(e.g., Multiple Endocrine Neoplasia type 1).
• Preoperative nutritional assessment is essential for all patients undergoing pan-
creatic resection. This is especially useful in those undergoing a central pancreatectomy as they are at higher risk for a pancreatic leak. A preoperative dietician
consult and dietary modication with appropriate protein supplementation
should be performed as indicated.
• In many patients with pancreatic masses, the preoperative glucose may be ele-
vated requiring control. Improved glycemic control has been shown to decrease
wound complications and other postoperative complications in many trials [3].
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V. Butano et al.
• Cardiology evaluation should be performed in patients with a history of cardiac
disease. It is our practice to request a cardiology evaluation for all patients over
the age of 50 to assess for any underlying cardiac abnormalities requiring intervention as well as preoperative risk stratication.
Surgical Management
In our institution, we undertake this operation using a robotic platform, which facilitates precise vascular dissection, stable platform, and increased manual dexterity for
suturing of pancreaticojejunostomy anastomosis [6–9].
Patient Preparation
• Patients are positioned supine, arms outstretched, secured to the operating table.
• A single shot of intra-thecal morphine sulfate is injected prior to induction.
• Following endotracheal intubation, a Foley catheter and a nasogastric tube is
inserted.
• Prophylactic antibiotics are given within 30min of incision and sequential com-
pression devices are applied to prevent deep vein thrombosis (DVT).
Diagnostic Laparoscopy
• Following an 8mm robotic trocar insertion at the umbilicus as a camera port
(arm #2), a diagnostic laparoscopy with the robotic laparoscope is performed to
exclude peritoneal carcinomatosis, liver metastasis, or other indicators of nonoperative disease.
• If the diagnostic laparoscopy shows localized disease without contraindications
for resection, further trocars are inserted (Fig.28.1):
– Arm #1: 8mm trocar lateral to the right midclavicular line at the level of the
umbilicus
– Arm #2: Robotic laparoscope
– Arm #3: 12mm at the left midclavicular line at the level of the umbilicus
– Arm #4: 8mm left anterior axillary line slightly cephalad to the level of the
umbilicus
– 5mm AirSeal
axillary line in the subcostal region for liver and stomach retraction
– An Advanced Access Gelport® (Applied Medical, Rancho Santa Margarita,
CA) is inserted between arms #1 and #2 caudal to the umbilicus
®
Access Port (ConMed Inc., Utica, NY) in the right anterior
28 Minimally Invasive Central Pancreatectomy
Fig. 28.1 Port placement
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Surgical Steps
Step 1: Gastric Mobilization
• Arms setup:
– Arm #1: Fenestrated bipolar
– Arm #2: Camera
– Arm #3: Monopolar scissors/hook cautery/vessel sealer
– Arm #4: Small grasping retractor
– Bedside assistant: Laparoscopic bowel grasper and suctioning device
• The lesser sac is entered by dividing the gastrocolic ligament using a combination of monopolar scissors, hook cautery, and the vessel sealer (Fig.28.2).
• Once the lesser sac is entered, the dissection is carried laterally in order to mobilize the stomach cephalad. Caution should be taken during this mobilization in
order to preserve the gastroepiploic vessels. The mobilization is complete once
the stomach can sufciently be retracted cephalad in order to view the neck and
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Fig. 28.2 Stomach
mobilization
Fig. 28.3 Stomach
retraction and exposure of
pancreas
V. Butano et al.
mid-body of the pancreas. This retraction can be obtained using a laparoscopic
liver retractor via the 5mm AirSeal® Port in the right upper quadrant subcostal
region. Both the stomach and the left lateral sector (segment 2 and 3) of the liver
can be both retracted together (Fig.28.3).
Step 2: Pancreatic Resection
• Arms setup:
– Arm #1: Fenestrated bipolar
– Arm #2: Camera
– Arm #3: Hook cautery/robotic stapling device
28 Minimally Invasive Central Pancreatectomy
Fig. 28.4 Ultrasonographic
examination of the pancreas
Fig. 28.5 Dissection of
inferior border of pancreas
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– Arm #4: Small grasping retractor
– Bedside assistant: Laparoscopic bowel grasper, suctioning device, intraopera-
tive ultrasound probe
• The lesion is assessed with ultrasound and the corresponding location can be
marked on the pancreatic parenchyma with the hook cautery (Fig.28.4). After
this, the resection lines can also be marked, and the dissection can begin.
• The dissection of the proximal pancreas is carried along the inferior edge of the
pancreatic neck. The superior mesenteric vein (SMV) is identied, and the dissection is carried under the pancreatic neck over the SMV and portal vein (PV)
(Fig.28.5). The assistant may use the laparoscopic suction device through the
Gelport
®
to retract and expose the SMV and PV to facilitate the dissection until
the retropancreatic tunnel is developed (Fig.28.6).
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Fig. 28.6 Dissection of
retropancreatic tunnel
Fig. 28.7 Proximal
pancreatic transection
V. Butano et al.
• The pancreatic neck may now be divided using a robotic stapling device. The
pancreatic duct and the underlying vessels dorsal to the pancreas must be identied during pancreatic resection to prevent injury to the SMV or PV (Fig.28.7).
• The pancreatic parenchyma should then be separated from the splenic artery and
vein for a sufcient length to reach the previously marked transection point distal
to the lesion (Fig.28.8).
• The distal transection should be performed with the hook cautery in order identify the pancreatic duct for reconstruction (Fig.28.9).
• At this point, the specimen should be placed into the EndoCatch™ (Medtronic,
Minneapolis, MN) bag and sent to pathology to ensure that the resection margins
are not involved by the disease before reconstruction can begin.
28 Minimally Invasive Central Pancreatectomy
Fig. 28.8 Lateral
retropancreatic dissection
Fig. 28.9 Distal pancreatic
transection
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Step 3: Reconstruction
• Arms setup:
– Arm #1: Needle driver
– Arm #2: Camera
– Arm #3: Needle driver/robotic stapling device/vessel sealer
– Arm #4: Small grasping retractor
– Bedside assistant: Laparoscopic bowel grasper and suctioning device
• Roughly 40 cm past the ligament of treitz the jejunum is transected with the
robotic stapler and the mesentery divided using the vessel sealer.
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V. Butano et al.
Jejunojejunostomy
• First, the proximal jejunum is anastomosed to the distal jejunum to create a sideto- side stapled jejunojejunostomy. Using the scissors, an enterotomy is made in
the proximal and distal jejunum. The enterotomies are enlarged to t the two
ends of the robotic 45mm blue load stapler. The robotic stapler is then inserted
into both ends and red (Fig.28.10).
• The staple line is checked for hemostasis and the common enterotomy is closed
with 3-0 non-absorbable V-Loc™ sutures in a running fashion (Fig.28.11).
Fig. 28.10 Side-to-side
stapled jejunojejunostomy
Fig. 28.11 Closure of
common enterotomy
28 Minimally Invasive Central Pancreatectomy
481
Pancreaticojejunostomy
• The distal jejunum is brought up to the distal pancreatic stump preferably in an
antecolic fashion. Should there be tension, the jejunum may need to be brought
to the distal pancreatic stump in a retrocolic fashion.
• The posterior-outer layer of the anastomosis is started with a running 3-0 nonabsorbable V-Loc™ suture between the pancreatic capsule and substance to the
seromuscular layer of the jejunum, with caution not to include or compress the
pancreatic duct (Fig.28.12).
• Using the scissors, a small enterotomy is made in the distal jejunal limb across
from the pancreatic duct. The inner layer of the anastomosis is constructed with
full-thickness, 3-0 or 4-0, interrupted absorbable V-Loc™ suture which are
placed between the pancreatic duct and the enterotomy so that the duct is continuous with the bowel in a duct-to-mucosa fashion (Fig.28.13).
Fig. 28.12 Outer layer of
pancreaticojejunostomy
Fig. 28.13 Inner layer of
pancreaticojejunostomy