Application of Laparoscopic Programmatic Neurolymphatic Radical Pancreaticoduodenectomy in Pancreatic Head Cancer

Summary

This protocol introduces Laparoscopic Programmatic Neurolymphatic Radical Pancreaticoduodenectomy (LPNRPD), a standardized surgical approach for pancreatic head cancer, emphasizing safety, reproducibility, and effective R0 resection through modular techniques and radical neurolymphatic dissection.

Abstract

Laparoscopic pancreaticoduodenectomy (LPD) has become a widely adopted surgical approach for treating pancreatic head cancer. Traditional open pancreaticoduodenectomy (OPD) is associated with significant surgical trauma, with postoperative hospital stays often exceeding 2 weeks. In contrast, LPD presents higher surgical risks due to the lack of standardized protocols, particularly posing challenges in minimally invasive resection and anastomosis. In addition, the optimal extent of lymphatic and neural dissection in pancreatic head cancer remains controversial and continues to be actively debated. To address these challenges in traditional pancreatic cancer treatment, we developed a modular surgical approach and a dual-surgeon model to systematize laparoscopic pancreatic surgery. Our novel Laparoscopic Programmatic Neurolymphatic Radical Pancreaticoduodenectomy (LPNRPD) technique not only ensures surgical safety but is also user-friendly, making it particularly suitable for laparoscopic surgery beginners. For radical resection of pancreatic head cancer, we propose that complete dissection of the peripancreatic neural plexus is critical for achieving R0 resection. Through multicenter RCT studies, we established standardized protocols for radical neurolymphatic dissection tailored to different subtypes of pancreatic cancer. For patients with resectable pancreatic head cancer (preoperative CA19-9 < 200 U/mL, no vascular invasion), we recommend the LPNRPD strategy. However, the successful implementation of LPNRPD heavily relies on the surgeon's skill and expertise. This article provides a comprehensive overview of the techniques for performing LPNRPD, emphasizing its safety, reproducibility, and applicability in the context of pancreatic head cancer treatment.

Introduction

Pancreatic cancer, known as the king of cancer, is marked by late detection, low resectability, and poor prognosis. Surgical resection remains the only potentially curative treatment and a critical first step. Despite advancements in multidisciplinary strategies, the 5-year survival rate after R0 resection remains unsatisfactory, highlighting the need for improved therapies¹.

Perineural invasion (PNI), marked by tumor infiltration and spread along nerves, is a key driver of early progression, recurrence, and poor prognosis in cancer patients^2,3. With an incid....

Protocol

This study included 76 patients who underwent LPNRPD between August 2019 and January 2022. The protocol received approval from the Institutional Review Board of Guangdong Provincial People's Hospital, and all participants provided written informed consent. The Table of Materials provides details of the consumables and equipment used.

1. Inclusion criteria

1. Include patients with pancreatic head carcinoma, including ductal adenocarcinoma (64 cases), adenosquamous carcinoma (11 cases), and colloid carcinoma (1 case).
2. Include patients with tumor involvement of the CA, SMA, or abdominal ....

Results

Baseline and intraoperative data (Table 1)
From January 2018 to January 2022, a total of 76 cases of LPNRPD were performed. The conversion rate to open surgery was 10.5%, and the rate of laparoscopic venous reconstruction was 5.3%. The proportion of preoperative biliary drainage was 39.4%. The median operative time was 250 min (135-425 min), median intraoperative blood loss was 50 mL (20-1500 mL), and the rate of intraoperative red blood cell transfusion was 13.2%.

Discussion

Current expert consensus, both domestically and internationally, recommends performing LPD in high-volume pancreatic minimally invasive surgery centers²⁰. As surgical experience accumulates, the learning curve for LPD has progressively shortened. An analysis by Adam's team at Duke University, based on 865 LPD cases in the United States from 2000 to 2012, showed that performing more than 22 LPDs annually significantly reduces postoperative complications¹⁸. Updated data f.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
4-0 Prolene *5 strands		8521	None
4-0 Prolene *5 strands		W8557	None
5-0 PDS suture *2 strands		PDP148	None
5-0 Prolene *5 strands		W8310/EPH8710	None
0 Absorbable suture *1 strand		VCP752D	None
3-0 (15 cm) V-LOC suture *1 strand		LOCL0614	None
4-0 (7x7 cm) Absorbable suture *1 strand		VCP771D	None
5-0 Prolene *5 strands		EPH8710?W8310/W8710	None
5-0 *3 strands		PDP148	None
4-0 Prolene *2 strands		HS6855	None
Titanium clips *3 packages			None
Trocars (12mm) *5			None
Ultracision Harmonic Curved Scissors *1		HAR36CN	None
Straight cut closure *1		PSEE60A	None
60mm blue and white nails for cutting closure device *2 (each)		ECR60B	None
Multifunctional Abdominal Drainage Tubes *1 (each)		M8A/M10A	None
Hem-o-lok Green Clips *20 packages			None
Hem-o-lok Purple Clips *10 packages			None
Hem-o-lok Brown Clips *5 packages			None
4K3D Fluoroscopy			None
Bipolar Electrocoagulation Clamp			None
Ultrasonic Scalpel Handle			None