Laparoscopic pancreatic resection: Is it worthwhile?

Diagnostic and interventional laparoscopy and intraoperative ultrasonography in the management of pancreatic disease

The laparoscopic management of pancreatic disorders has evolved dramatically from its inception in 1911 and its rediscovery in the 1970s. Although investigators once proclaimed that "it seems unlikely that laparoscopy will have any more than an extremely limited use in the investigation of pancreatic disorders," laparoscopy and LUS now have a well-recognized role in the staging of pancreatic cancer and an increasing part in the management of benign pancreatic disease at many institutions. Although the appropriate role of LS and LUS is debatable, the development and refinement of laparoscopic techniques and instrumentation and the improvement of noninvasive diagnostic modalities will provide new data, increase the rate of resection at laparotomy, and allow surgeons to treat a broader range of pancreatic disease by minimally invasive methods. The value of LS and LUS for benign and malignant pancreatic disorders has been clearly demonstrated, but the inevitable issues of hospital resource, operative expertise, and surgical philosophy will ultimately determine the role of laparoscopy and LUS in clinical practice.

Laparoscopic approach to adrenal and endocrine pancreatic tumors

Laparoscopic adrenalectomy quickly has become the procedure of choice for benign adrenal lesions because it results in less pain, shorter hospital stay, comparable safety, and more patient satisfaction overall. The laparoscopic approach requires advanced laparoscopic surgical skills. Surgeons should be familiar with these techniques and the open approaches before attempting this procedure. When first learning the technique, small left-sided lesions are likely the easiest, and a more experienced surgeon should be present for the initial few cases; however, at this point, the laparoscopic approach to pancreatic endocrine tumors does not have a clear benefit, and it should be considered primarily investigational without clearly established benefits.

Hand-assisted laparoscopic surgery (HALS) with the HandPort system: initial experience with 68 patients

OBJECTIVE

To evaluate the feasibility and potential benefits of hand-assisted laparoscopic surgery with the HandPort System, a new device.

SUMMARY BACKGROUND DATA

In hand-assisted laparoscopic surgery, the surgeon inserts a hand into the abdomen while pneumoperitoneum is maintained. The hand assists laparoscopic instruments and is helpful in complex laparoscopic cases.

METHODS

A prospective nonrandomized study was initiated with the participation of 10 laparoscopic surgical centers. Surgeons were free to test the device in any situation where they expected a potential advantage over conventional laparoscopy.

RESULTS

Sixty-eight patients were entered in the study. Operations included colorectal procedures (sigmoidectomy, right colectomy, resection rectopexy), splenectomy for splenomegaly, living-related donor nephrectomy, gastric banding for morbid obesity, partial gastrectomy, and various other procedures. Mean incision size for the HandPort was 7.4 cm. Most surgeons (78%) preferred to insert their nondominant hand into the abdomen. Pneumoperitoneum was generally maintained at 14 mmHg, and only one patient required conversion to open surgery as a result of an unmanageable air leak. Hand fatigue during surgery was noted in 20.6%.

CONCLUSIONS

The hand-assisted technique appeared to be useful in minimally invasive colorectal surgery, splenectomy for splenomegaly, living-related donor nephrectomy, and procedures considered too complex for a laparoscopic approach. This approach provides excellent means to explore, to retract safely, and to apply immediate hemostasis when needed. Although the data presented here reflect the authors' initial experience, they compare favorably with series of similar procedures performed purely laparoscopically.

Anterior-Retroperitoneal Living Donor Nephrectomy: Technique and Outcomes

Of 133 consecutive renal transplants, 61 (46%) were living donor grafts recovered in an anterior-retroperitoneal approach. Donor demographics, operative-anesthetic care, length of stay (LOS), hospital charges, and complications were reviewed with donor and recipient follow-up of 4 to 40 months. Donors included 35 women and 26 men, ages 22 to 61 years (mean, 42.2); thirty-nine were living related and 22 were living unrelated donors. Pretransplant evaluation defined renal anatomy and function (minimal creatinine clearance, 75 cc/minute). Hospital admission occurred the morning of donation. Nephrectomy by the anterior-retroperitoneal approach (no rib resection) was followed by postoperative epidural pain control, early resumption of diet, progressive ambulation, and aggressive pulmonary care. Operating room time door-to-door averaged 2 hours, 43 minutes (range, 1 hour, 45 minutes-3 hours, 55 minutes). Donors were hospitalized for 2 (n = 7), 3 (n = 24), 4 (n = 19), and 5 to 8 (n = 11) days (mean LOS, 3.75; range, 2–8 days). The mean charge for donor hospitalization was $15,329 (range, $10,808–$29,579). One donor required transfusion; another was readmitted for wound drainage and pneumonia treated medically. All donors remain well with normal renal function. One early graft loss (3 days) occurred from arterial intimal dissection; all others gained life-sustaining function. Recipient (98%) and graft (92%) survival was excellent at 4 to 40 months. Anterior-retroperitoneal living donor nephrectomy is safe and effective, permitting hospital LOS of usually <4 days, early recovery, and no lasting complications. Excellent donor and recipient results from this procedure should compel critical assessment of techniques requiring more extensive operative exposure or more costly operating room and hospital approaches to donor surgical management.

Laparoscopic pancreatic surgery

BACKGROUND

Potential applications for laparoscopic surgery in pancreatic disease include (1) staging of pancreatic malignancies; (2) palliation of pancreatic malignancies; (3) pancreatic resections for benign and malignant disease; and (4) pancreatic drainage procedures.

METHODS

A review of the literature is presented. In addition, original data on a series of 5 laparoscopic pancreatic distal resections and 10 laparoscopic cystogastrostomies are presented.

RESULTS AND CONCLUSIONS

Laparoscopy may have a role in the staging of patients with pancreatic malignancies; however, with high-quality preoperative imaging, the percentage of patients who will benefit from laparoscopy may be as low as 5%. For palliation, both cholecystoenterostomy and choledochoenterostomy can be performed laparoscopically. The former is technically straightforward but has a higher failure rate; the latter is technically difficult and currently not suitable for widespread adoption. Laparoscopic gastroenterostomy is a straightforward means of palliating gastrointestinal obstruction. Patients appear to benefit from laparoscopic distal pancreatic resection but not from laparoscopic pancreaticoduodenectomy. Patients appear to benefit from laparoscopic pseudocyst decompression.

Hand-assisted laparoscopic distal pancreatectomy for pancreatic cystadenoma

A cystic lesion in the body of the pancreas was detected during staging workup of a 59-year-old woman with T-cell lymphoma of the tongue. After six cycles of chemotherapy the pancreatic lesion was unchanged. Suggestive ulceration of the vulva with edema appeared at the end of chemotherapy. After right vulvar excision, distal pancreatic resection with splenectomy was carried out by a hand-assisted laparoscopic technique utilizing a small muscle-splitting right lower quadrant incision. This allowed for palpation of the peritoneal cavity for evidence of tumor and allowed for safe and expeditious pancreatectomy. The pancreatic tumor was found to be a serous cystadenoma without evidence of malignancy. T-cell lymphoma was identified in the spleen and the vulva. The patient was discharged home on the fifth postoperative day and returned to normal activity within 2 weeks after operation. Two months after the surgery, computed tomography demonstrated a 3-cm pseudocyst in the region of the tail of the pancreas. As the patient was asymptomatic, this required no further therapy. Minimally invasive surgery together with hand assistance combines the advantages of both laparotomy and laparoscopy in the surgical management of selected lesions in the pancreas.