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Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video
Summary June 6th, 2020
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.
Transcript
Laparoscopic radical left pancreatectomy for malignancy. Adequate lymph node dissection and radical resection margins are crucial in obtaining safe oncological dissection of tumors in distal pancreatectomy. We demonstrate all steps of the laparoscopic radical left pancreatectomy as described by Abu Hilal, et al.
A 61-year-old woman presented with an incidental finding of a three centimeter mass, suspect for malignancy, in the pancreatic tail. No distant metastasis, nor lymph node involvement was present on the preoperative CT scan. The patient was suitable for minimally invasive approach.
The operative steps comprised trocar placement, five distinct surgical phases, and closure of the trocar sites. The pneumoperitoneum is created by a Veress needle in the left hypochondrium. First, a diagnostic laparoscopy is performed to exclude peritoneal and liver metastasis.
Hereafter, the additional trocars are placed as shown. The exposure phase enables adequate handling of the pancreatic tail and identification of major vessels and planes. After opening the gastrocolic ligament, the short gastric vessels are dissected and ligated in preparation of spleen resection.
The stomach is detached from the pancreas and retracted anteriorly. To do so, an umbilical tape is placed around the stomach as described by The anterior plane of the pancreas is now exposed. This enables identification of the splenic vein at the inferior border of the pancreas and incision of Gerota's fascia that remains with the pancreatic specimen.
Remember, the inferior mesenteric vein could be inserted into the splenic vein at this position. Therefore, it is wise to consult imaging of this area. The splenic artery is localized at the superior margin of the pancreas.
The next step is pancreatic hanging and dissection of Gerota's fascia. First, the pancreatocolic ligament and the splenocolic ligament can be transected. Especially, Gerota's fascia can be transected to expose the anterior aspect of the kidney.
Now the pancreas is tunneled at the lateral position. Then it is lifted with the hanging technique. This includes Gerota's fascia that remains with the pancreatic specimen.
The splenic and hepatic artery are clearly identified. The splenic artery is either occluded using a bulldog clamp or transected using Hem-o-lok clips or a stapler. Special care should be taken not to mistake the hepatic artery for the splenic artery.
The now limited splenic perfusion reduces blood loss during dissection. Secondly in this phase, the pancreatic neck is tunneled and lifted using the same hanging technique. Additional posterior exposure is created anteriorly of the splenic vein.
At this area, the stapler will be inserted. The next step is the pancreatic transection. The stapler is closed gently until a resistance is felt.
At this point, the surgeon should wait until the resistance is decreased before continuing with compression. This creative compression technique as described by takes four to five minutes and is crucial to avoid rupture of the pancreatic capsule. If needed, sutures for further closure can be applied to the pancreatic stump.
From here, the first point of tension will be transection of the splenic vein. After lifting the splenic vein, it is transected either with Hem-o-lok clips or a vascular stapler. The next operative step is the lymph node dissection.
Carefully and meticulously, the arteries are freed of lymphatics. Lymphadenectomy should be extended to the left border of the aorta and the left side of the superior mesenteric artery. The left gastric artery should be preserved while performing lymphadenectomy around it.
Finally, the dissection is proceeded laterally towards the spleen where any further attachment tissue is taken. Attention should be directed to the dissection of the spleen starting with the gastrosplenic ligament. The spleen is detached from the retroperitoneal adhesions.
The last phase is the extraction of the specimen and drain placement. Once free, the specimen is removed with an endobag through a Pfannenstiel incision. The camera should be turned 180 degrees downward to the inferior part of the abdomen.
Once surgical drain is placed, this drain enters through the most left-side trocar site and has two extra side holes cut at the location of the splenic fossa for better drainage. Care is taken to avoid direct contact with the pancreas, artery, and vein stump. The fascia of the 12 millimeter port is closed using Vicryl sutures and skin intracutaneously.
The total duration of the procedure was 210 minutes with an estimated blood loss of 250 milliliters. Histopathology revealed an R0 resection of a good to moderately differentiated adenocarcinoma. It originated from an intraductal papillary mucinous neoplasm.
A total of 15 tumor negative lymph nodes were resected. This is a detailed description of a laparoscopic radical left pancreatectomy for cancer as performed within the DIPLOMA trial.
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