Oncologically safe left pancreatectomy requires radical resection (R0), Gerota’s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.
Radical resection margins, resection of Gerota’s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota's fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota’s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (>1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.
Surgical resection combined with systemic chemotherapy is the most effective treatment for resectable pancreatic cancer. Several meta-analyses have shown comparable results for minimally invasive and open distal pancreatectomy for benign and premalignant disease1,2,3,4,5,6. Recently, the first multicenter randomized trial demonstrated a shorter time to functional recovery using laparoscopic distal pancreatectomy (LDP) as compared to open distal pancreatectomy (ODP)7. Although minimally invasive techniques have been shown to be safe and feasible for left pancreatectomy when performed by experienced surgeons8,9,10,11,12,13, the non-inferiority of minimally invasive surgery compared to the open surgical approach for the treatment of pancreatic cancer is still debated14,15,16,17. A pan-European survey showed that 31% of pancreatic surgeons considered ODP superior to minimally invasive distal pancreatectomy (MIDP) in terms of oncological margins and lymphadenectomy in pancreatic cancer18. On both a European and global level, 19–20% of participating surgeons considered malignancy a contraindication for a minimally invasive approach18,19.
Given the current lack of randomized controlled trials on the effectiveness of MIDP, the only available data to compare the procedures are limited to retrospective and prospective cohort studies. In a recent systematic review and meta-analysis on oncological safety in MIDP versus ODP for pancreatic cancer, no differences between the two groups regarding oncologic outcomes (OR = 0.49, p = 0.12) and overall survival (OS = 3 years, HR = 1.03, p = 0.66; OS = 5 years, HR = 0.91, p = 0.59) were seen20. Another systematic review showed comparable outcomes for MIDP versus ODP in overall survival and a somewhat surprising higher margin-negative (R0) resection rate but at the cost of a lower lymph node dissection in MIDP21.
The radical antegrade modular pancreatosplenectomy (RAMPS) technique, as described by Strasberg in 2003, aims to perform a better, radical resection of pancreatic ductal adenocarcinoma (PDAC) in the body or the tail of the pancreas including resection of Gerota’s fascia15. The laparoscopic radical left pancreatectomy (LRLP) technique, as described by Abu Hilal et al.16, aims to obtain the same results but during minimally invasive surgery by combining a formal lymphadenectomy with the no-touch technique. Hereby, a radical oncological resection can be obtained with a minimized risk of tumor dissemination and seeding15,22. The standardization of this technique allows for reproducibility and adoption in different health care centers. This paper describes LRLP, because this technique is currently used in the international, multicenter randomized DIPLOMA trial16,23.
1. Patient Selection
- Select patients with an upfront resectable pancreatic cancer in the pancreas body or tail visible on a recent contrast enhanced CT scan (maximum of 4 weeks old) without downstaging neoadjuvant therapy.
- Exclude patients with metastatic disease or vascular involvement of vessels other than the splenic vein or artery24.
- During training, it is best to exclude patients with a body max index (BMI) > 35 kg/m2, recurrent acute or chronic pancreatitis, previous major upper abdominal surgery, or pancreas targeted radiotherapy.
2. Surgical Technique
- Operative setting
- Place the anesthetized patient in the French position on a bean bag. Place both arms in 90° abduction.
- Place sterile drapes so that the suprapubic region is exposed for the Pfannenstiel incision.
- Create pneumoperitoneum via a Veress needle at Palmer’s point.
- Perform a routine diagnostic laparoscopy to exclude peritoneal and liver metastases.
- The procedure is performed using a 5-port technique. Place additional trocars a shown in Figure 1.
NOTE: Use of laparoscopic ultrasound is advisable for staging and localizing the lesion, thereby determining the extent of the resection.
- Exploration Phase
- Divide the gastrocolic ligament approximately 2 cm distal from the gastroepiploic artery and vein, thus opening the lesser sac.
- Dissect and ligate the short gastric vessels in preparation of splenectomy. The most superior short gastric vessels may also be spared at this stage to avoid early bleeding without adequate exposure.
- Mobilize the stomach from the pancreas and retract upwards. The stomach may be retracted in various ways. Use of umbilical tape around the stomach, after it has been rolled backwards and secured in this position with surgical gauze between the top of the stomach and the surgical tape is recommended.
- Extract this tape next to the subxiphoidal trocar and grip using a surgical clamp.
NOTE: A second piece of tape may pull the pyloric region to the right upper quadrant using a stab incision to extract it25. This second tape is especially useful to obtain maximal exposure of the pancreatic neck and hepatic artery region.
- Divide the splenocolic ligament in order to mobilize the splenic flexure and visualize the pancreatic tail. If needed, the lesion is located using laparoscopic ultrasonography. The transection plane of the pancreas in case of pancreatic cancer is at the portal confluence.
- Mobilize the lower margin of the pancreas from medial to lateral including the splenic inferior border. At this stage, both the superior and inferior mesenteric vein may be visualized. Incise Gerota’s fascia.
NOTE: Care should be taken to avoid venous bleeding. Optionally, the splenic flexure of the colon can be mobilized separately using a lateral to medial approach but often this is not required.
- Identify the splenic vein at the inferior border of the pancreas.
NOTE: The inferior mesenteric vein could drain directly into the splenic vein.
- Identify the splenic artery at the superior border of the pancreas.
- Pancreatic hanging and dissection of Gerota’s fascia dissection.
- During the dissection of the posterior plane, mobilize and lift the Gerota’s fascia (i.e., anterior renal fascia).
- Create the posterior plane underneath the Gerota’s fascia superior to the adrenal gland toward the superior border of the pancreas. This is an avascular plane. If needed, the adrenal gland can be included (i.e., posterior RAMPS).
- Create a tunnel by dissecting the superior pancreatic margin.
- Pass a quarter length vessel loop through the tunnel and secure with a nonabsorbable locking clip. Use this to hang the pancreas including Gerota’s fascia.
- Identify the splenic artery at the superior border of the pancreas.
- Mobilize the splenic artery using blunt and sharp dissection and a pass quarter length vessel loop.
- Transect the artery using 3–4 nonabsorbable locking clips. Alternatively, a vascular endostapler may be used.
NOTE: The splenic artery must not be transected until the entire anatomy, especially the hepatic artery, is visualized and confirmed. If the splenic artery cannot be visualized from the pancreatic superior margin, it may identified from beneath the pancreas or by following the hepatic artery towards the celiac artery.
- Perform the same tunneling procedure at the pancreatic neck, on the right side of the pancreatic lesion, mostly above the confluence/portal vein.
- The two vessel loops can be held by an assistant to literally hang the pancreas and expose the posterior margin during the retroperitoneal dissection.
- Determine the transection plane at the inferior border of the pancreas.
- Mobilize the remaining part of the pancreas, including Gerota’s fascia, exposing the anterior aspect of the kidney.
- Pancreatic transection
- Pull the pancreas ventrally using the vessel loops.
- Transect the pancreas at the neck using a stapler with a graded compression technique (vascular or thicker cartridge, based on the pancreatic thickness and texture at the transection level)26.
NOTE: With this technique, the stapler is closed very slowly, in steps, until resistance is felt. Before continuing with the compression, the surgeon should wait for 20–30 s until the resistance decreases. The entire process typically requires 4–5 min before the stapler is completely closed. Faster closure often leads to rupture of the pancreatic capsule27. If needed, sutures can be applied to the pancreatic stump in case of rupture or bleeding.
- Identify the left gastric vein and the splenic vein. Clip and transect the left gastric vein.
- Mobilize the splenic vein, pass and secure a vessel loop.
- Hereafter, place 3–4 locking clips on the splenic vein: two on the patient site and at least one on the specimen site. In case of lack of space, an additional metal clip may be placed on the specimen site.
NOTE: The standard order of transection is splenic artery, pancreas, splenic vein. This order may be varied based on local anatomy (e.g., by transecting the pancreas first). However, if the splenic vein is transected before the splenic artery, there will be venous congestion with increased risk of conversion due to bleeding.
- Lymph node dissection
- Dissect the lymph nodes in a clockwise fashion, according to the description of Strasberg’s RAMPS procedure15.
- Start with lymph node station 8A at the hepatic artery and station 9 at the celiac trunk.
NOTE: If possible, the left gastric artery should be preserved while performing lymphadenectomy. If needed, it can be resected.
- Extend the lymphadenectomy to the left border of the aorta and the left side of the superior mesenteric artery.
- Proceed with the dissection laterally towards the spleen, where any further attached tissue is taken, including the Gerota’s fascia.
- Detach the spleen by transecting the gastrosplenic ligament, splenorenal ligament, and retroperitoneal adhesion.
- Extraction and drain placement
- Once the spleen is detached, remove the specimen using an endo-bag through a Pfannenstiel incision. Turn the camera 180° to the inferior part of the abdomen to visualize the extraction of the specimen.
- The Pfannenstiel incision should be an approximately 6 cm transverse skin incision and 8 cm transverse fascia incision where the midline is divided between both rectus muscles.
- Take caution during the extraction to avoid small bowel injury and compromising of the specimen for pathological assessment.
- Place one surgical drain. This drain enters through the left most trocar site, loops with 2–3 additional holes through the splenic bed, runs under the stomach, and ends next to the pancreatic stump.
NOTE: Care must be taken to avoid direct contact with the pancreas, artery, and vein stump.
- Close the peritoneum using an absorbable braided suture and the fascia with a monofilament absorbable suture.
- Re-insufflate the abdomen.
- Confirm hemostasis at the transection planes.
- Revert all loops and the gastric hanging.
- Inspect the stomach for any injuries.
- Close any fascia defect larger than 5 mm using an absorbable multifilament suture.
- Close the skin intracutaneously using an absorbable monofilament suture.
A 61-year-old woman presented with mild liver dysfunction at the surgical outpatient clinic. On both CT and MRI scans, an incidental finding of a 3 cm mass in the pancreatic tail suspect for malignancy was seen with potential involvement of the left adrenal gland (See Figure 2). No distant metastasis or lymph node involvement was seen on the preoperative contrast-enhanced CT scan. Therefore, the patient was deemed suitable for a minimally invasive approach.
The total operation time was 210 min with 250 mL blood loss. Intraoperatively the adrenal gland was not involved, and LRLP was performed, leaving the adrenal gland in situ. The postoperative course was uncomplicated. The postoperative day (POD) 3 amylase level in the drain was 1,316 U/L. The drain was removed in POD 5 when the amylase level was 158 U/L, and the patient was discharged on the same day in good health. The pathology assessment revealed a 31 mm well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. The resection margins were microscopically radical (R0), and none of the 15 lymph nodes were involved.
Figure 1: Trocar placement. The right-most trocar may also be a 12 mm trocar. The distance between trocars should be at least one hand's width. The figure is reproduced from T. De Rooij et al.35. and is licensed under CC BY 3.0 copyright mark was removed from original figure. Please click here to view a larger version of this figure.
Figure 2: Preoperative CT-scan. Mass in the pancreatic tail suspect for malignancy. Please click here to view a larger version of this figure.
Advantages of the technique
LRLP is a standardized, reproducible, and safe procedure if performed by experienced surgeons. Moreover, this minimally invasive procedure offers low intraoperative blood loss, early mobilization, and short hospital stays as confirmed by the LEOPARD trial7. Surgery for pancreatic cancer must aim for a radical resection, adequate lymphadenectomy, and a no-touch dissection to prevent seeding and dissemination of tumor cells16,28. Laparoscopy can offer high quality visualization, enlarge the details within the surgical field, and minimize tissue manipulation16. In a recent study on MIDP for PDAC over an 8-year period, the laparoscopic approach seemed to have a similar survival as compared to ODP29. Current surgical series show no difference between laparoscopic and open technique for radicality (R0) of the resection30,31. However, fewer lymph nodes were retrieved with laparoscopy, therefore the non-inferiority of lymphadenectomy with minimally invasive distal pancreatectomy is still debated30,31,32,33.
Intraoperative ultrasound is useful to locate the neoplasm and better understand the anatomy of the pancreatic body and tail also in relation to major vasculature. The described LRLP technique using the double hanging of the pancreas (both to the left and right side of the neoplasm), allows for a no-touch dissection of the retroperitoneal plane16. Furthermore, the vessel mobilization and slinging give a better understanding of the anatomy and is useful during the lymph node dissection. Finally, early mobilization and transection of the splenic artery reduces the perfusion of the pancreatic body, tail, and spleen in order to minimize the blood loss during the dissection phases. Splenic vessels should only be cut once the anatomy is clear and the resectability of the primary tumor has been confirmed.
LRLP needs specialized training. The difficulty of the operation is related to the tumor extension beyond the pancreatic parenchyma, requiring reaching a deeper plane in relation to the Gerota’s fascia or need for an extended resection.
LRLP is a feasible, safe, oncologically efficient, and reproducible technique and should be taught in order to ensure its validity and acceptance16. Due to the possible complications of this laparoscopic procedure, it should be performed in high-volume centers by surgeons with extensive experience in both open and minimally invasive surgery, where failure to rescue is low34. Future studies should identify the minimum annual volume required to obtain adequate results.
LRLP is also highly suitable for a robotic approach to left-sided pancreatic cancer. Further pragmatic multicenter randomized controlled trials are needed to assess the long-term outcomes of MIDP specifically for PDAC. The DIPLOMA trial is currently being performed in centers across Europe and in the United States.
The authors have nothing to disclose.
This technique was originally described by Abu Hilal et al.16.
|Arietta Ultrasound||Hitachi||Intraoperative laparoscopic ultrasonography|
|Autosuture Endo Clip applier 5 mm||Covidien||176620||Sling use clip applier, 5 mm|
|Blue reload for Echelon 60||Ethicon||GST60B||Regular tissue thickness, open staple height 3.6 mm, closed staple height 1.5 mm|
|ECHELON FLEX ENDOPATH 60mm Stapler||Ethicon||GST60T||Powered surgical stapler with gripping surface technology|
|Endo Catch II Pouch 15 mm||Covidien||173049||For single lymph node extractions a cut off finger surgical glove can be used.|
|Green reload for Echelon 60||Ethicon||GST60G||Thick tissue thickness, open staple height 4.1 mm, closed staple height 2.0 mm|
|Harmonic Advanced Hemostasis 36 cm||Ethicon||HARH36||Curved tip, energy sealing and dissecting, diameter 5 mm, length 36 cm|
|Hem-o-lok Clips MLX||Weck Surgical Instruments, Teleflex Medical, Durham, NC||544230||Vascular clip 3 mm – 10 mm Size Range|
|Hem-o-lok clips Xl||Weck Surgical Instruments, Teleflex Medical, Durham, NC||544250||Vascular clip 7 mm – 16 mm Size Range|
|Hem-o-Lok Polymer Ligation System||Weck Surgical Instruments, Teleflex Medical, Durham, NC||544965|
|LigaSure Dolphin Tip Laparoscopic Sealer/Divider||Medtronic||LS1500||Dolphin-nose tip sealer and divider, 37 cm shaft|
|White reload for Echelon 60||Ethicon||GST60W||Mesentery/thin tissue thickness, open staple height 2.6 mm, closed staple height 1.0 mm|
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