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
2. Surgical Technique
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.
Recommendations
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.
Limitations
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.
Future applications
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 |