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Spleen-preserving pancreatectomy of the body and tail 459
pancreas. With ventral traction on the pancreas, the
attachments to the retroperitoneum are divided.
At this step, we begin dissection of the origin of the
splenic artery. We now move to the superior border of the
pancreas to continue our dissection of the splenic artery.
Here you can see the bifurcation between the splenic
artery and hepatic artery. Now that the splenic artery is
completely dissected at its origin, it can be clipped and
divided.
The next step of the operation is pancreatic division at
its neck. Here we begin the parenchymal transection just
above the portal venous confluence. Here you can see the
portal vein appearing in the background.
The last step of the operation is division of the splenic
vein. The specimen is completely detached from the retroperitoneum. On this image, the splenic artery stump,
splenic vein stump, adrenal vein, renal vein, IMV, and
SMV can be seen (Figure v25.2). The specimenis placed in
the endoscopic retrieval bag for later removal. We are
planning on suture closing the transection surface of the
pancreas. We are suture closing the pancreatic remnant,
ensuring the pancreatic duct is well incooperated in the
runningsuture.At completionof the case,we place a drain.
IMPORTANT POINTS
• Take time for hemostasis in order to achieve excellent
working conditions.
• Avoid bleeding from the splenic vasculature, including
the hilum when controlling the splenic vessels more
proximally.
• Avoid injury to the retroperitoneal vessels such as the
renal vein or adrenal gland.
• When taking the splenic vessels, inspect the spleen at the
end of the case to ensure you have good perfusion.
• Should you have a splenic vein injury and need to take
the splenic vein, you should also clip the splenic artery.
This will avoid left-sided portal venous hypertension.
VIDEO 26
Pancreaticoduodenectomy
Video duration 20 minutes 9 seconds
In this video, we will show you a laparoscopic pancreaticoduodenectomy (Whipple procedure).
OUTLINE
The video is divided into the following parts:
• Port positioning
• Hepatic artery lymph node dissection
• Colonic mobilization
• Kocher maneuver
• Aortocaval lymph node dissection
• Portal venous confluence dissection
• Jejunal and gastric transection
• Gastroduodenal artery transection
• Pancreatic transection
• Retroperitoneal dissection
• Bile duct transection and indocyanine green (ICG) staining
• Important points.
Kocher maneuver, the operative surgeon stands at the left
side of the patient (Figure v26.1). The rest of the surgery is
performed from this position (Figure v26.2).
should not compromise the oncological soundness of the
operation. Therefore, an adequate lymph node dissection
should be performed. Several adhesions to the gallbladder
are lyzed. We are following the cystic duct on to the portal
structures and we will strip the porta of all lymphatic tissue.
Here lymph node stations 5, 12, and 8a are removed. A
hepatic artery injury should be avoided at this step. Here we
are following the hepatic artery towards lymph node stations 8p and 9. The dissection directly at the hepatic artery
should be performed using scissors. The cystic duct and
cystic artery are divided and the gallbladder removed.
deflected downwards. The deflection of the colon
For the colonic mobilization and the beginning of the
Performing the Whipple procedure laparoscopically
Before we can begin the Kocher maneuver, the colon is
Figure v26.1 For the colonic mobilization and the beginning of the Kocher maneuver, the operative surgeon stands at the left side of
the patient.
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
460
Pancreaticoduodenectomy 461
Figure v26.2 The remainder of the operation following colonic mobilization and Kocher maneuver is performed from this position.
downwards follows our operative approach for right
colectomy. We have to mobilize the colon just enough
in order to begin the kocherization comfortably. For the
Kocher maneuver, we ensure gentle traction on the
duodenum; as we see here, the IVC is exposed. It is
important to be gentle during duodenal retraction with
the laparoscopic instruments in order to avoid perforation. We recommend doing as much as possible of the
Kocher maneuver above the transverse mesocolon
because the exposure is easier.
We are performing an aortocaval lymph node dissection b efore transecting the intestine, stomach or pancreas. Only in very selective circumstances do we
complete a Whipple if the aortocaval lymph nodes
are positive. In order to avoid postoperative lymph
leak,weareapplyingacliptothelymphaticvessel.
The lymph nodes are sent for frozen section analysis. At
this step, we will terminate the procedure if the lymph
node(s) turn out to be positive.
This is the view along the IVC with the drainage of the
left renal vein (Figure v26.3). Here we are removing the
right celiac plexus which we are also sending for frozen
section. Watch out for the celiac trunk at this step of the
operation. We would discourage you from harvesting
both the celiac plexi as this can lead to diarrhea that is
difficult to manage (Figure v26.4).
We are now proceeding to the portal venous confluence dissection. As in open surgery, injury to the portal
venous confluence should be avoided at all costs. We are
beginning our dissection at the inferior border of the
pancreas and follow the jejunal branches towards the
portal venous confluence. Here the portal vein comes into
view. Here we are following the gastrocolic trunk to its
drainage into the portal vein. The gastrocolic trunk will be
Figure v26.3 This is the view along the IVC with the drainage
of the left renal vein.
462 Video 26
Figure v26.4 We would discourage you from harvesting both the celiac plexi as this can lead to diarrhea that is difficult to manage.
divided using the energy device. Now the portal venous
confluence has been dissected out.
The next stage is gastric and jejunal transection.
Here you can see the division of the ligament of Treitz.
In open surgery, creation of an anastomosis at the
level of the ligament of Treitz is diffi cult but it is much
easier in laparoscopic surgery. Creation of the
anastomoses at the level of the lig ament of Treitz
prevents having to mobilize a lot of the duodenum.
An additional port is now placed to accommodate the
stapler. Next we proceed to dividing the dista l stomach. The omentum and the gastroepiploic arca de are
divided. The stomach is staple divided. Before transecting the pancreas, we will control the gastroduodenal artery (Fig ure v26.5).
The gastroduodenal artery is dissected out using scissors. As in open surgery, the gastroduodenal artery
should be ligated with enough distance to the hepatic
artery. The gastroduodenal artery is divided using thermofusion. Now the portal vein is exposed at the superior
border of the pancreas.
We can now proceed to transect the pancreas. Pancreatic transection is performed with the energy device.
The inferior pancreaticoduodenal arcade is controlled
with stitches. Now the pancreas is completely transected. Next is the retroperitoneal dissection. The je junum is p ulled through from the ligament of Tr eitz. We
are now transecting the retroperitoneum along the
Figure v26.5 Before transecting the pancreas, we will control
the gastroduodenal artery.
Figure v26.6 This view demonstrates a replaced RHA.
Pancreaticoduodenectomy 463
SMA. Here, a replaced right hepatic artery come s into
view (Figure v26.6). With blunt dissection and the
bipolar forceps, the portal vein is detached from the
retroperitoneum. The poste rior pancreaticoduodenal
vein will be dissected out and divided. Here we are
dividing the retroperitoneal attachments along the
replaced right hepatic artery. Here the replaced right
hepatic artery, superior mesenteric artery, and portal
vein ca n be seen (Figure v26.7). The last ridge of
peritoneal attachments is divided.
Finally, we will divide the bile duct and determine
the perfusion of the pancreatic margin using ICG
staining.Herewearedividingthebileductusing
scissors. Prior to constructing a pancreaticoenteric
anastomosis, we are controlling the perfusion of the
pancreatic margin using systemic ICG administration
with the near infrared laparoscopic camera (Figure
v26.8). Using this technique, we are identifying an
area of hypoperfusion. We resect this pancreatic area
in the hope of reducing the pancreatic leak rate.
Finally, we are mobilizing the pancreatic remnant
stump for easier construction of the pancreaticoenteric
anastomosis.
We have had mixed experiences with l aparoscopically performed pancreaticogastrostomies and pancreaticojejunostomies. At the beginning of the
laparoscopic Whipple experien ce, we recom mend a
mini-laparotomy at this step and reconstructing vi a
an open technique.
Figure v26.7 Here we can see the replaced RHA, superior
mesenteric artery, and PV.
464 Video 26
Figure v26.8 Prior to constructing a pancreaticoenteric
anastomosis, we are controlling the perfusion of the pancreatic
margin using systemic ICG administration with the near
infrared laparoscopic camera. Using this technique, we are
identifying an area of hypoperfusion.
IMPORTANT POINTS
• Patient selection is the key.
• Even performing a laparoscopic kocherization can help
in reducing the incision size.
• There should be no compromise of the oncological
approach just because the procedure is performed
laparoscopically.
• A laparoscopic approach prevents adhesions; however,
adhesions might aid in containing a pancreatic fistula.
Therefore, be aware of a visceral artery bleed in the
postoperative period.
• Technical developments pertaining to the operative
techniques might make panc reaticoenteric anastomosis
safer in the future.
Afterword
Minimal invasive surgery has a firm place in many
surgical fields. Open cholecystectomy and appendectomy
have been almost completely replaced by laparoscopic
procedures and inguinal hernias are also commonly
performed through minimal invasive accesses. The low
mortality and reduced morbidity of today’s bariatric
surgery would not be possible with open surgery. Oncological procedures such as colectomies and rectal resections can be safely performed using minimal access
surgery with comparable outcomes to traditional surgery
in experienced centers. The benefits of laparoscopic surgery are the smaller abdominal incisions which result in
reduced postoperative pain and faster recovery time as
well as the lower rate of incisional hernias. Minimal
invasive procedures also have reduced blood loss and
therefore require fewer blood transfusions. All these
factors together result in reduced activation of the systemic inflammatory response as assessed by cytokines,
which may also contribute to the overall faster recovery.
For many patients, the better cosmetic results of laparoscopic surgery are also important.
These benefits of minimal invasive surgery have been
demonstrated in many large randomized controlled trials. However, they often come at the price of longer
operating times, more expensive equipment, and longer
learning curves because of the loss of three-dimensional
view, loss of tactile feedback, and the fulcrum effect.
These problems of laparoscopic surgery are paramount
for operations in complex anatomical areas such as the
hepatopancreatobiliary tract. It is noteworthy that the
widened indications for laparoscopic procedures usually
corresponded with advancements in instruments and
devices that made more complex minimal invasive procedures possible.
As the authors of the previous chapters have highlighted, pancreatic surgery poses special problems for the
adoption of minimal invasive procedures. The complex
anatomical position of the pancreas in the retroperitoneal
space, surrounded by vital organs and vessels, requires
highly experienced surgeons with detailed knowledge of
the anatomical situation to perform safe operations and
avoid potentially life-threatening complications. Besides
expertise in pancreatic surgery, surgeons performing
minimal invasive pancreatic procedures need profound
training in advanced laparoscopy. Aside from surgeon
factors, the technical setting must be appropriate. Laparoscopic devices, for example for the transection of the
pancreas, should be improved to avoid pancreatic fistulas
and other technical complications. Furthermore, laparoscopic intracorporeal suturing is a challenging and timeconsuming process, mainly responsible for the complications and long duration of minimal invasive pancreaticoduodenectomy. Thus, it is quite possible to perform
resection but not reconstruction.
These ramifications of minimal invasive surgery currently limit a wider application of laparoscopy to distal
pancreatectomy and maybe enucleation of small benign
lesions. However, before routine clinical implementation, well-designed and stringently conducted randomized controlled trials must be performed in experienced
centers to evaluate the safety and oncological outcome.
As Rutz and Kooby nicely demonstrate in Chapter 23, the
current evidence for minimal invasive distal pancreatectomy stems mainly from retrospective case series, with
significant differences regarding type of tumor, clearly
favoring benign and cystic lesions as well as smaller
tumor sizes in the case of laparoscopic procedures. Ductal
adenocarcinomas of the pancreas were only marginally
investigated in the currently available studies. In our
opinion, there is currently a limited role for minimal
invasive approaches in pancreaticoduodenectomy,
mainly owing to the difficulties of performing the pancreaticojejunostomy and biliodigestive anastomosis. The
long duration of this operation and the associated morbidity currently outweigh its potential benefits. The very
limited numbers of reports about these procedures in the
20 years since their first description indicate that there
are many obstacles to a wider application. If these challenges can be diminished and the duration of laparoscopic pancreaticoduodenectomy can be shortened, the
validity of this operation should be re-evaluated in randomized trials.
465
466 Afterword
In summary, the promises of minimal invasive surgery
make it likely that laparoscopic pancreatic surgery will
have benefits for patients. Laparoscopic pancreatic surgery should be evaluated in randomized controlled trials
to establish its true benefit. If the promises hold up, it will
be a viable alternative to open procedures in selected
patients.
Beat Müller-Stich, Adrian T. Billeter,
and Markus W. Büchler
Department of General, Visceral,
and Transplantation Surgery,
University of Heidelberg Hospital,
Heidelberg, Germany
Afterword
Since the establishment of laparoscopic cholecystectomy,
appendectomy or colorectal surgery, there has been
growing evidence that well-selected patients with liver
or pancreas tumors may have a greater benefit from
laparoscopic surgery compared to an open approach.
In particular, cirrhotic patients with well-preserved liver
function might have the greatest benefit from a laparoscopic approach. This new textbook on laparoscopic
hepatopancreatobiliary (HPB) surgery illustrates the
most current laparoscopic technologies used for resection
of liver and pancreas tumors. The chapters are authored
by well-known experts in HPB surgery and summarize
the rapid developments in this area. The 24 comprehensive chapters cover the presented topics in depth and are
illustrated by many color images. The book provides the
latest information not only on minimally invasive surgery but also on anatomical, imaging, and anesthesia
aspects. It also covers cutting-edge surgical approaches
such as robotic surgery and laparoscopic living donor
hepatectomy. This book should become one of the classic
references for those who are interested in laparoscopic
HPB surgery.
Prof. Dr. med. Pierre-Alain Clavien, PhD
UniversitätsSpital Zürich
Klinik für Viszeral- und Transplantationschirurgie
Zürich, Switzerland
467
Index
Page numbers in italics indicate figures; page numbers in bold indicate tables
abdominal entry and closure
trocars 35–37, 36
wound protection 36–37, 37
abdominal insufflation 172
aberrant hepatic arteries 289
ablative therapy
concepts and definitions 257
equipment 39
hepatocellular carcinoma 257, 262–264
interventional radiology 109–112, 110, 111
key points 271
laparoscopic tumor ablation 267–268, 267
noncolorectal liver metastases 217, 264–265
open tumor ablation 267
overview of modalities 257–262
pancreatic tumors 268–270
percutaneous tumor ablation 266–267, 266
postablation follow-up 265–266, 265
pre-RFA transarterial embolization 264
primary liver cancer 187
strategies for liver and pancreas tumors 257–272
transplantation 264
treatment approach 266–268
Abulcasis 3–4
acute cholecystitis 66, 67–68,79
acute pancreatitis 344
adenomyomatosis 79–80, 80
adjuvant therapies
biliary tract cancers 190–192
colorectal liver metastases 203, 206–207
hepatocellular carcinoma 187–188
solid tumors of the pancreas 303–305, 305, 309
advanced bipolar vessel sealing devices 38, 38
AIPDA see anterior–inferior pancreaticoduodenal artery
AIPDV see anterior–inferior
American Joint Committee on Cancer (AJCC) 308
ampullary adenocarcinoma 107
anastomosis 435, 454, 462–463
anesthesia
anesthetic techniques 174
blood loss and preventive strategies 175–177
central nervous system and ocular effects 172–173
coagulation 171
complications 177–178
concepts and definitions 169
effects on hepatic physiology 173
fluid management 175
pancreaticoduodenal vein
hemodynamic function 172, 172, 174–175
hepatic blood flow 169
induction of 174
intraoperative monitoring 175
key points 180
laparoscopic liver surgery 169–184
liver pathophysiology 169–171
low CVP anesthesia 176
maintenance of 174
management of anesthetic 174–175
nonpharmacological interventions for blood loss 176–177
organ response to hepatic dysfunction 170
pathology 171
patient positioning 171, 172–175, 178, 179
pharmacological changes to metabolism 170, 171
pharmacological interventions for blood loss 176
physiology of pneumoperitoneum 171–173, 177–178
postoperative recovery 178
preoperative assessment 173
surgical interventions for blood loss 177
animal models 20–23, 22
anterior–inferior pancreaticoduodenal artery (AIPDA) 288–289,
289
anterior–inferior pancreaticoduodenal vein (AIPDV) 291
anterior sectionectomy 276
anterior–superior pancreaticoduodenal artery (ASPDA) 290
anterior–superior pancreaticoduodenal vein (ASPDV) 291
anti-EGFR therapy 204–205
antifibrinolytics 176
Arantius’ ligament 157–158
Aranzi, Giulio Cesare 4
argon plasma coagulation 39
arterial injury 105, 107
arterial stimulation with hepatic venous sampling (ASVS) 101, 102
articulating triangular retractor 41
ascites 114–115
ASPDA see anterior–superior
ASPDV see anterior–superior pancreaticoduodenal vein
ASVS see arterial stimulation with hepatic venous sampling
augmented reality technology
achieving augmented reality 49–53
applications 53–58
challenges 58–59
concepts and definitions 47–49
console-integrated image overlay 57, 57
data alignment 50–52, 51,57
data visualization 59
pancreaticoduodenal artery
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
469
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