Successful laparoscopic pancreaticoduodenectomy for intraductal papillary mucinous neoplasm: a case report and a reliable technique for pancreaticojejunostomy

Robotic pancreaticoduodenectomy for pancreatic adenocarcinoma: role in 2014 and beyond

Minimally invasive surgery (MIS) for pancreatic adenocarcinoma has found new avenues for performing pancreaticoduodenectomy (PD) procedures, a historically technically challenging operation. Multiple studies have found laparoscopic PD to be safe, with equivalent oncologic outcomes as compared to open PD. In addition, several series have described potential benefits to minimally invasive PD including fewer postoperative complications, shorter hospital length of stay, and decreased postoperative pain. Yet, despite these promising initial results, laparoscopic PDs have not become widely adopted by the surgical community. In fact, the vast majority of pancreatic resections performed in the United States are still performed in an open fashion, and there are only a handful of surgeons who actually perform purely laparoscopic PDs. On the other hand, robotic assisted surgery offers many technical advantages over laparoscopic surgery including high-definition, 3-D optics, enhanced suturing ability, and more degrees of freedom of movement by means of fully-wristed instruments. Similar to laparoscopic PD, there are now several case series that have demonstrated the feasibility and safety of robotic PD with seemingly equivalent short-term oncologic outcomes as compared to open technique. In addition, having the surgeon seated for the procedure with padded arm-rests, there is an ergonomic advantage of robotics over both open and laparoscopic approaches, where one has to stand up for prolonged periods of time. Future technologic innovations will likely focus on enhanced robotic capabilities to improve ease of use in the operating room. Last but not least, robotic assisted surgery training will continue to be a part of surgical education curriculum ensuring the increased use of this technology by future generations of surgeons.

Laparoscopic resection of choledochal cyst: report of a case

We report a choledochal cyst that was successfully treated with laparoscopic surgery. A 32-year-old Japanese woman was referred to our hospital with a suspected choledochal cyst. Magnetic resonance cholangiopancreatography and computed tomography showed the common bile duct to be grossly dilated to the hepatic confluence. A diagnosis of type-Ia choledochal cyst in the Todani classification was made, and laparoscopic resection was performed. The patient was placed in the lithotomy position under general anesthesia, and 4 ports were inserted. After the cystic duct was dissected, the hepatoduodenal ligament was incised and a choledochal cyst was identified. Next, the common bile duct was mobilized and dissected away from the surrounding vessels and tissues. Taping of the common bile duct allowed better exposure and dissection of the surrounding tissues. Mobilization of the bile duct and dissection of the surrounding tissue was performed to the bifurcation of the common hepatic duct. Then the common hepatic duct was transected just distal to the choledochal cyst. The inferior common bile duct was dissected from the pancreas to identify the distal end of the choledochal cyst and the pancreaticobiliary junction behind the duodenum. The narrow segment of the choledochal cyst was identified and divided after distal closure with clips. After the gall bladder was dissected from the liver bed, the choledochal cyst and gallbladder were removed. A Roux limb was created extracorporeally via the umbilical incision. The jejunum 30 cm distal to the ligament of Treitz was removed through the transumbilical incision and transected. To create the Roux limb, the mesentery of the jejunum was also extracorporeally separated. A 50-cm Roux limb was made by means of side-to-side anastomosis with an endostapler. After a jejunostomy for hepaticojejunostomy anastomosis was created, the Roux limb was returned to the abdominal cavity. Then, pneumoperitoneum was started again, and the Roux limb was brought up laparoscopically in a retrocolic fashion. An end-to-side hepaticojejunostomy was intracorporeally established with a continuous, single-layer full-thickness 4-0 vicryl suture. Total operation time was 715 minutes. Intraoperative body fluid loss was 250 mL, and the postoperative course was uneventful with no major complications. The patient was discharged from hospital on the 12th postoperative day. She remains asymptomatic with normal liver function after 24 months of follow-up.

Adenocarcinoma of the minor duodenal papilla: report of a case

We report a rare case of adenocarcinoma of the minor papilla of the duodenum treated with transduodenal minor papillectomy. A 64-year-old woman was treated for an asymptomatic duodenal tumor detected on gastroduodenoscopy. Endoscopy showed a 15-mm sessile mass in the descending duodenum proximal to the major papilla. The major papilla was a villous 24-mm-diameter polypoid tumor. Histopathologic examination of the biopsy specimen showed tubular adenoma with moderate epithelial atypia. Transduodenal major and minor papillectomies were performed. The orifice of the duct of Santorini and the pancreatic duct were re-approximated to the duodenal wall to prevent acute pancreatitis caused by scarring and stenosis of the duct orifice. Histological findings were consistent with well-differentiated adenocarcinoma limited to the minor duodenal papilla, without infiltration of the duodenal wall submucosa, and confirmed complete resection. The patient had an uneventful postoperative course and has remained asymptomatic, without evidence of tumor recurrence or stenosis of the pancreatic duct orifice, for 4 years.