Treatment of Middle-segment Pancreatic Benign Tumor Using Laparoscopic Central Pancreatectomy with End-to-end Pancreatic Duct Reconstruction

Summary

This article presents laparoscopic central pancreatectomy with pancreatic duct end-to-end anastomosis as an important surgical approach for middle-segment pancreatic benign and low-grade malignant tumors.

Abstract

Benign and low-grade malignant tumors of the middle-segment pancreatic body represent a prognostically favorable subset of pancreatic neoplasms. For such tumors, the surgical approaches historically employed in clinical practice include distal pancreatectomy, middle-segment pancreatectomy followed by closure of the proximal pancreatic stump and pancreaticojejunostomy or pancreaticogastrostomy for the distal stump, local enucleation of the pancreatic tumor, or upfront pancreaticoduodenectomy. However, these historical approaches may remove excessive pancreatic tissue, alter the native pancreatic and intestinal anatomy, cause significant surgical trauma, lead to postoperative complications such as anastomotic leakage, and risk injuring the main pancreatic duct (particularly with local enucleation). This study introduces a novel surgical approach: laparoscopic central pancreatectomy (LCP) with end-to-end pancreatic duct reconstruction for mid-pancreatic tumors. This technique preserves the physiological pancreatic anatomy and restores the main pancreatic ductal continuity. Our findings demonstrate that laparoscopic central pancreatectomy with end-to-end pancreatic duct reconstruction is a safe and feasible procedure. We propose that this approach represents a promising alternative approach for middle-segment pancreatic tumor resection.

Introduction

Benign tumors of the middle-segment pancreas primarily include serous cystadenoma, mucinous cystadenoma, and intraductal papillary mucinous neoplasm (IPMN), along with low-grade malignant tumors such as solid pseudopapillary neoplasm (SPN); these lesions generally carry an excellent prognosis, with complete resection achieving 5-year survival rates exceeding 95%^1,2. For these pancreatic tumors, performing distal pancreatectomy may remove excessive normal pancreatic tissue and cause postoperative impairment of pancreatic endocrine and exocrine functions^3,4; performing middle-segment pancreatectomy followed by closure of the proximal stump and pancreaticojejunostomy or pancreaticogastrostomy alters the native anatomy of the pancreas and intestine⁵; performing local enucleation of the pancreatic tumor risks injuring the main pancreatic duct during the procedure and, for potentially low-grade malignant mid-pancreatic tumors, poses a hidden risk of incomplete resection⁶; performing pancreaticoduodenectomy directly involves a complex procedure with high risks, significant trauma, and potential complications such as delayed gastric emptying, pancreatic fistula, bile leak, and gastrojejunal anastomotic leakage^7,8.

Laparoscopic central pancreatectomy (LCP) with end-to-end pancreatic duct reconstruction is an innovative, function-preserving surgical procedure designed for benign or low-grade malignant tumors located in the neck/body of the pancreas^9,10. Its core advantage lies in the precise removal of the lesion while simultaneously restoring the physiological continuity of the main pancreatic duct through meticulous duct-to-duct anastomotic reconstruction. This technique maximally preserves the normal pancreatic anatomy¹¹.

Compared to distal pancreatectomy, middle-segment pancreatectomy followed by closure of the proximal pancreatic stump and pancreaticojejunostomy or pancreaticogastrostomy for the distal stump and pancreaticoduodenectomy, this procedure significantly reduces the incidence of postoperative pancreatic fistula¹². Crucially, it effectively preserves the endocrine and exocrine function of the remnant pancreas¹³, substantially mitigating the long-term risks of metabolic complications such as new-onset diabetes mellitus and steatorrhea^14,15. It thus achieves a high degree of integration between minimally invasive surgery, precision, and functional preservation.

Laparoscopic central pancreatectomy with end-to-end pancreatic duct reconstruction primarily employs Professor Liu Rong's "Bridge-Closing Theory." The following section details the surgical technique through a specific case presentation¹³.

The indications for LCP with end-to-end pancreatic duct anastomosis primarily include: (1) benign or low-grade malignant tumors (such as serous cystadenoma, mucinous cystadenoma, IPMN, SPN) confined to the pancreatic neck/body; optimal tumor diameter should be less than 5 cm; (2) lesions not invading major vessels (such as portal vein, superior mesenteric vein) with ensured negative resection margins; (3) preoperative imaging confirming an intact and patent main pancreatic duct on both the cephalic and tail sides, suitable for end-to-end anastomosis, and intraoperative assessment indicating a distance between the two pancreatic stumps of less than 5 cm.

The contraindications mainly include: (1) definite or highly suspected invasive pancreatic cancer; (2) tumor invasion into surrounding critical vessels; (3) poor condition of the remnant pancreatic duct (e.g., severe stenosis, obstruction, significant diameter discrepancy, or a distance between the two pancreatic stumps of less than 5 cm) or poor pancreatic texture precluding a reliable anastomosis.

Protocol

The surgical procedure was approved by the Ethics Committee at Qingyuan People's Hospital, Guangzhou Medical University. Written informed consent was obtained from the patient and her family, approved by the hospital ethics committee.

1. General information

NOTE: The patient is a 68-year-old woman who presented with a one-month history of vague upper abdominal pain.

1. During the evaluation, identify an occupying lesion in the pancreatic body. Upon admission, perform contrast-enhanced abdominal CT (Figure 1 and Supplementary video 1), which reveals an occupying lesion in the pancreatic body, suspicious for cystadenocarcinoma, measuring approximately 48 mm × 28 mm. Conduct abdominal MRI (Figure 2 and Supplementary video 2), which demonstrates a mass in the pancreatic body most consistent with a Serous Cystic Neoplasm (SCN); however, do not exclude the possibility of malignant transformation and include solid pseudopapillary neoplasm in the differential diagnosis.
2. Note the patient's symptomatic abdominal discomfort and imaging findings suggesting a high probability of a benign lesion, yet cannot completely rule out malignancy. Establish surgical indications. Discuss the condition with the patient and her family, and proceed with their choice for surgical treatment.

2. Surgical technique

1. Anesthesia and access
   1. Ensure that the patient fasts for at least 8 h and refrains from fluids for at least 4 h preoperatively. Under general anesthesia, perform endotracheal intubation. Administer muscle relaxants to achieve abdominal relaxation. Initiate the surgery after confirming stable vital signs following anesthesia. After successfully inducing anesthesia, place the patient in the supine position with the legs abducted (lithotomy position). Perform standard skin disinfection and apply sterile draping.
   2. Make a 1 cm vertical incision approximately 5 cm below the umbilicus. Establish pneumoperitoneum and insert a 10 mm trocar under direct vision. Under laparoscopic guidance, place a 5 mm trocar 2 cm below the right anterior axillary line at the costal margin, a 10 mm trocar at the mirror-image site on the left, a 12 mm trocar along the right mid-clavicular line at the level of the umbilicus, and a 5 mm trocar at the symmetrical site on the left (Figure 3).
2. Exploration
   1. We initially explored abdominal organs to assess the intra-abdominal condition and to ensure no obvious ascites was present.
   2. Observe a distended gallbladder with no significant wall thickening. Identify no markedly enlarged lymph nodes within the abdominal cavity. Confirm that the gastrointestinal tract appears grossly normal.
3. Exposure and exploration of the pancreas
   1. Open the gastrocolic ligament using an ultrasonic dissector. Divide the left half of the ligament segmentally up to the avascular plane and continue the dissection to the right as far as the pancreatic head (Figure 4).
   2. Fully expose the pancreas, noting its non-edematous and soft appearance. Identify a mass located at the pancreatic neck and body. Observe multiple cysts, each approximately 0.3 × 0.3 cm, to the right of the mass, and a single cyst measuring about 3.5 cm × 3.0 cm × 3.0 cm superior and to the left. Note that all cysts are soft and well-circumscribed, suggesting a benign nature (Figure 5).
   3. Now, plan for the mid-segment pancreatic resection. Adjust the definitive surgical procedure according to the intraoperative frozen-section pathology results.
4. Mid-segment pancreatic resection
   1. Open the lesser omentum. Retract the stomach and liver to fully expose the pancreas. Mobilize the inferior border of the mid-pancreas (Figure 6).
   2. Identify the superior mesenteric vein and the root of the splenic vein. Proceed with dissection leftward along the posterior-inferior aspect of the pancreas toward the left margin of the lesion.
   3. Dissect the superior border to expose the common hepatic artery. Transect the pancreatic neck just to the right of the mass using the ultrasonic dissector. Sharply divide the pancreatic duct (approximately 0.2 cm in diameter) with scissors, noting the clear pancreatic fluid (Figure 7). Complete the transection of the remaining pancreatic tissue and achieve hemostasis by coagulating the cut surface.
   4. Free the superior pancreatic vessels. Isolate the splenic artery and carefully dissect the posterior aspect of the pancreatic body and the superior border along the splenic artery and vein (Figure 8). Clip and divide all vessels entering the pancreas. Continue the dissection to the left margin of the lesion (Figure 9).
   5. Transect the pancreas to the left of the mass using the ultrasonic dissector. Sharply divide the pancreatic duct (approximately 0.3 cm in diameter), again observing clear pancreatic fluid. Divide the remaining pancreatic tissue and coagulate the cut surface for final hemostasis.
5. Specimen retrieval and pathological examination
   1. Place the resected mid-segment of the pancreas into a specimen retrieval bag. Extend the umbilical incision approximately 3 cm toward the umbilicus to deliver the specimen.
   2. Send the specimen for immediate frozen-section analysis. Upon receiving the pathology report stating "Pancreatic lesion, favor benign tumor," proceed with the planned LCP and end-to-end pancreatic duct reconstruction (Figure 10).
6. End-to-end pancreatic duct reconstruction
   1. Approximate the superior pancreatic margins with 3-0 Prolene figure-of-eight sutures (Figure 11). Trim a 24-gauge scalp-needle sheath to an 11 cm stent and insert it into the pancreatic duct. Secure the duct at the 6, 9, 12, and 3 o'clock positions using 4-0 Prolene figure-of-eight stitches (Figure 12 and Figure 13).
   2. Place three additional 3-0 Prolene figure-of-eight sutures to complete the end-to-end pancreatic anastomosis.
7. Final inspection and drain placement
   1. Flush the peritoneal cavity with normal saline and aspirate until dry. Confirm the absence of active bleeding or pancreatic leakage.
   2. Introduce a 24-French silicone drain through the left abdominal wall and position it above the pancreas. Place another identical drain through the right port, positioning it below the pancreatic remnant. Verify correct instrument and sponge counts, and close all incisions.
8. Operation conclusion
   1. Note that the procedure was uneventful and anesthesia was satisfactory. Record an estimated blood loss of 20 mL. Confirm that the patient remained hemodynamically stable throughout the operation. Transfer the patient to the ward in good condition.
   2. The total operative time was 155 min, which included approximately 60 min awaiting intraoperative frozen section analysis. Estimate the intraoperative blood loss at 20 mL. Confirm that the frozen section analysis indicated a benign pancreatic lesion.
   3. Implement postoperative management, including Nil Per Os (NPO) status, antibiotics, parenteral nutrition, somatostatin analogues, and proton pump inhibitors. On postoperative day (POD) 1, record an ascitic fluid amylase level of 44,323 U/L, interpret this as a B-grade postoperative pancreatic fistula, and manage it with continuous drainage. Recheck the ascitic fluid amylase on POD 4, noting a decrease to 1,277 U/L. Simultaneously on POD 1, note a serum amylase level of 513 U/L, diagnosing concurrent pancreatitis. After confirming the normalization of serum amylase levels on POD 4, initiate a full liquid diet.
   4. Document the absence of preoperative diabetes. Monitor postoperative fasting blood glucose levels fluctuating between 6.2-7.7 mmol/L. Remove the right abdominal drain on POD 17 and discharge the patient on POD 21. Remove the left abdominal drain in the outpatient clinic one week after discharge. During the hospitalization, address concurrent gynecological issues and a lower leg mass, recognizing these as contributors to the prolonged stay.

Results

Confirm the final pathological diagnosis as serous cystadenoma (microcystic variant) (Figure 14). Review the postoperative CT scan, which demonstrates uniform pancreatic parenchymal density without surrounding exudative changes and confirms the satisfactory position of the pancreatic duct stent (Figure 15). At the one-month postoperative follow-up, perform an abdominal ultrasound showing postoperative pancreatic changes with minimal peri-pancreatic fluid collect...

Discussion

Currently, for benign or low-grade malignant tumors in the middle-segment pancreas, the following surgical options should be recognized: local enucleation of the pancreatic tumor, distal pancreatectomy, middle-segment pancreatectomy with closure of the proximal stump and pancreaticojejunostomy or pancreaticogastrostomy for the distal stump, central pancreatectomy with end-to-end anastomosis, and pancreaticoduodenectomy^3,4,5...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
3-0 Polypropylene Suture (Prolene)	Johnson & Johnson	W8522	Used for the superior pancreatic margin and end-to-end reconstruction
4-0 Polypropylene Suture (Prolene)	Johnson & Johnson	8551H	Used for figure-of-eight suture of the pancreatic duct
5/10/12 mm  Laparoscopic Port / Trocar	Johnson & Johnson	TB5ST/TB10ST/TB12ST	Used for laparoscopic operative access during surgery
Harmonic Scalpel (Ultrasonic Dissector)	Johnson & Johnson	HARHD36	Used for tissue division and hemostasis
Hemoclips / Clip Applier	Weck	544230	Used for clipping and dividing vessels entering the pancreas
Laparoscope	Olympus	WA50002L	Used for laparoscopic visualization
Scalp Vein Needle Tubing (trimmed to ~11 cm)	Jiangxi Hongda Medical	https://item.jd.com/49417785121.html	Trimmed segment used as a pancreatic duct stent