Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions
Summary
This article provides a whole technical process of laparoscopic duodenum-preserving pancreatic head resection via an inferior infracolic approach. This is a surgical approach for benign tumors without intraoperative fluorescence image guidance.
Abstract
Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct.
This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms.
LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.
Introduction
In 1972, Prof. Berger first proposed the duodenum-preserving pancreatic head resection (DPPHR) and Roux-en-Y pancreatic-enteral reconstruction as a treatment for chronic pancreatitis1. DPPHR has become the primary surgical treatment for benign lesions of the pancreatic head due to its low incidence of postoperative complications and mortality, as well as its ability to maintain the endocrine and exocrine functions of the pancreas and high remission rate of abdominal pain2,3,4. DPPHR only removes the diseased pancreatic head while preserving the duodenum, stomach, jejunum, common bile duct, and gallbladder that need to be removed in Whipple surgery, resulting in minimal damage and high postoperative quality of life3,5.
Laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has made significant progress in the last decade and is gradually replacing duodenum-preserving pancreatic head resection (DPPHR)6,7. The key to this surgical procedure is to ensure the blood supply of the duodenum and bile duct in order to avoid damage to the duodenum and bile duct, as well as duodenal necrosis and stenosis or atresia of the bile duct caused by ischemia7,8. A few experienced medical centers have reported LDPPHR9,10,11. As maintaining the integrity of the duodenum and biliary system and preserving complex blood supplies are necessary, the surgical procedure is challenging. It is essential to be very familiar with the special anatomical relationship between the pancreatic head and the duodenum while implementing LDPPHR, which is a difficult surgery that requires stronger surgical skills and psychological qualities.
Previous studies have proved that preserving the integrity of both anterior and posterior pancreaticoduodenal arterial arcades, as well as only preserving the posterior collateral branches of the arteries, will not cause duodenal ischemic necrosis11,12. Some surgeons preserve a thin layer of pancreatic tissue adhering to the common bile duct to avoid ischemia of the bile duct and duodenum but increase the incidence of pancreatic fistula13. In this study, the inferior infracolic approach was chosen for LDPPHR due to the patient with a thin mesenteric fat layer. By taking advantage of the amplification of the 3D laparoscopy, we successfully removed the pancreas from the lateral wall of the common bile duct (CBD) and the medial side of the duodenal ring without intraoperative fluorescence image guidance. This approach ensured the integrity of the vascular arch and reduced intraoperative blood loss, thereby minimizing the risk of pancreatic fistula.
Protocol
Representative Results
Discussion
LDPPHR only removes the diseased pancreatic head while preserving the duodenum, stomach, jejunum, common bile duct, and gallbladder that need to be removed in Whipple surgery. Compared to pancreaticoduodenectomy (PD) and pylorus-preserving pancreaticoduodenectomy (PPPD), LDPPHR showed enhancements in mid- and long-term results encompassing hospital stay duration, quality of life, post-surgery recovery, and maintenance of exocrine function5,14. DPPHR only removes …
Disclosures
The authors have nothing to disclose.
Acknowledgements
We thank the anaesthesiologists and operating room nurses who assisted with the operation.
Materials
| 3D Laparoscope | STORZ | TC200,TC302 | |
| Cisatracurium Besylate Injection | Hengrui Pharma | H20183042 | |
| Drainage catheters | Jiangsu YUBANG MED-DEVICE | YB-B-III | |
| Harmonic ACE Ultrasonic Surgical Devices | Ethicon Endo-Surgery | HAR36 | |
| Ligating Clips | Teleflex Medical | ||
| Nacrotrend anaesthesia monitoring system | Monitor Technik | Bad Bramsted | |
| Trocar | Ethicon Endo-Surgery | 10 mm |
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