Name: Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions (Video) | JoVE Journal
Uploaded: 2024-02-09T14:10:00.000+00:00
Duration: 3 min 34 s
Description: Learn laparoscopic duodenum-preserving pancreatic head resection via the inferior infracolic approach for benign lesions. This technique uses ultrasonic scalpels and clips to safely expose and transect vessels while preserving the duodenum.

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5 minutes

We thank the anaesthesiologists and operating room nurses who assisted with the operation.

This protocol follows the guidelines of the human research ethics committee of the Sixth Affiliated Hospital, Sun Yat-sen University. Written informed consent was obtained from the patients for performing this study.
NOTE: A 48-year-old female patient presented with an incidental finding of a 3.0 cm x 2.5 cm asymptomatic mass in the head of the pancreas. The patient&#39;s clinical history showed a healthy status. Endoscopic ultrasound (EUS) showed a cystic lesion of the pancreatic head.
1. Preoperative workup
<ol>
	<li>Determine the surgical approach based on the computed tomography (CT) scan to determine the extent of the tumor and any abnormal vasculature, see Figure 1.</li>
	<li>Check for contraindications carefully. 
	NOTE: There are relative contraindications to LDPPHR, including tumors in the portal vein or superior mesenteric vein that need vascular reconstruction, as well as previous major abdominal surgery with possible complications. It depends on preoperative imaging diagnosis and intraoperative diagnosis of vascular invasion. The preoperative enhanced CT and MR imaging are valuable.</li>
</ol>
2. Anesthesia
<ol>
	<li>Apply the antibiotic (2 g of Ceftriaxone sodium) 30 min before the surgery to prevent infection. Puncture and catheterize the radial artery (catheter size, 20 G) and a central venous (catheter size, 8 Fr) under ultrasound guidance. 
	NOTE: The amount of anesthesia administered differs greatly among patients, primarily dependent on individual characteristics such as age and other medical factors.</li>
</ol>
3. Surgical technique
<ol>
	<li>Operation setting
	<ol>
		<li>Position the patient in a reverse Trendelenburg position with the head elevated 30&#176; and legs split apart, see Figure 2.</li>
		<li>Set the standing position as depicted in Figure 2. Use a 5-port technique to perform the procedure. 
		NOTE: The first surgeon is on the right side, the second surgeon is on the left side, and the first assistant stands between the patient&#39;s legs, respectively.</li>
		<li>Place the sub-umbilical 10 mm trocar and then four trocars along a semi-circular plane after creating the pneumoperitoneum. Place two 10 mm trocars to the left and right of the umbilicus and two 10 mm trocars four fingers subcostal to the left and right in the anterior axillary line, see Figure 2.</li>
	</ol>
	</li>
	<li>Exploration phase
	<ol>
		<li>Exclude peritoneal and liver metastases using diagnostic laparoscopy as a routine step. Explore the anterior abdominal wall, the surface of abdominal viscera, pelvic cavity, and the surface of abdominal viscera, the mesentery and the small intestine and stomach and adjacent structures, and the omental bursa in order.
		<ol>
			<li>Ensure that the exploration follows a specific sequence, usually from top to bottom, first examining solid organs before hollow ones, starting with the abdominal cavity followed by the pelvic cavity.</li>
			<li>Conduct a comprehensive examination of all abdominal organs, such as the liver, spleen, stomach, intestines, mesentery, peritoneum, uterus, and adnexa. Simultaneously, perform a focused examination on suspicious areas of pathology.</li>
			<li>Utilize non-traumatic graspers to gradually inspect the intestinal tract, progressing in approximately 5 cm segments per examination from the duodenal suspensory ligament to the ileocecal region and repeating the process in the opposite direction. Ensure that the examination encompasses both the intestinal tract and mesentery.</li>
		</ol>
		</li>
		<li>Retract the ligament to the ventral abdominal wall by placing a straight needle transcutaneously in the epigastric region around the Teres ligament.</li>
	</ol>
	</li>
	<li>Dissection phase
	<ol>
		<li>Suspend the transverse colon enteric fat over the liver falciform ligament to expose the infracolic compartment (see Figure 3A).</li>
		<li>Make an incision in front of the duodenum&#39;s transverse mesocolon to expose the pancreatic head using an ultrasonic scalpel (see Figure 3B).</li>
		<li>Expose the infracolic compartment between the transverse colon and the pancreatic head, fully free the superior mesenteric vein (SMV) from the uncinate process of the pancreas, and transect its tributary using clips (see Figure 3C).</li>
		<li>Dissect the inferior margin of the uncinate process of the pancreas using an ultrasonic scalpel, and pull up the margin of the uncinate process of the pancreas to expose the sub pancreaticoduodenal vessels branch into the uncinate process of the pancreas and transect them using clips (see Figure 3D).</li>
		<li>Restore the transverse colon position and section the gastrocolic ligament to expose the pancreas behind the stomach. Position the patient&#39;s head low and right upside. Suspend the stomach body over the liver falciform ligament to set free it from the pancreas using a red urine catheter and a clip (see Figure 3E).</li>
		<li>Expose the common hepatic artery (CHA) and gastroduodenal artery (GDA) (see Figure 3F). Removed the pancreas from the medial side of the duodenal ring and anterior superior pancreaticoduodenal artery (ASPDA), and ligate and detach the branches of ASPDA into the uncinate process of the pancreas using a clip.</li>
		<li>Cut off the peritoneum at the lower margin of the pancreatic head, ligate, and detach the right gastroepiploic vein. Flip the uncinate process of the pancreas to the head side to expose the SMV to transect the pancreatic neck with Harmonic scissors in front of the SMV. 
		NOTE: The cystic tumor was found behind the uncinate process of the pancreas (see Figure 3G).</li>
		<li>Detach the pancreatic head from the right and dorsal edges of the SMV. Then, detach the upper part to expose the distal CBD.</li>
		<li>Perform dissection along the left and dorsal margins of the common bile duct (CBD) to expose and safeguard the posterior superior pancreatic duodenal artery (PSPDA) (see Figure 3H). This artery originates from the GDA and extends its branches into the distal CBD and the ampulla of Vater. Severe the anterior superior pancreatic duodenal artery (ASPDA) to facilitate deeper dissection.</li>
		<li>Dissect, ligate, and cut off the main pancreatic duct to the ampulla finally using an ultrasonic scalpel (see Figure 3I).</li>
	</ol>
	</li>
	<li>Reconstruction phase
	<ol>
		<li>Transect the jejunum at a distance of 20 cm from the distal Treinz ligament for pancreatojejunal anastomosis and jejunal anastomosis.</li>
		<li>Insert an external ventricular drainage catheter after identifying the main pancreatic duct. Perform an end-to-side pancreaticojejunostomy (duct-to-mucosa) (see Figure 3J) and side-to-side jejunojejunostomy.</li>
		<li>Place the specimen inside a bag and remove it through a 5 cm incision on the lower abdomen. Place two drainage catheters near the pancreaticojejunostomy and the CBD and bring them out through two trocar port sites. 
		NOTE: The texture at the pancreatic stump is quite tough, so we perform an end-to-side pancreaticojejunostomy to reduce the risk of pancreatic fistula. The diameter of drainage catheters with side holes is 1.5 cm.</li>
	</ol>
	</li>
</ol>

<ol><li>Mihaljevic, A. L., Kleeff, J., Friess, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Beger%27s+operation+and+the+Berne+modification%3A+Origin+and+current+results%5BTitle%5D)+AND+%22J+Hepatobiliary+Pancreat+Sci%22%5BJournal%5D)">Beger's operation and the Berne modification: Origin and current results.</a> J Hepatobiliary Pancreat Sci. 17 (6), 735-744 (2010).</li>
<li>Beger, H. G., Schlosser, W., Friess, H. M., Büchler, M. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Duodenum-preserving+head+resection+in+chronic+pancreatitis+changes+the+natural+course+of+the+disease%3A+A+single-center+26-year+experience%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">Duodenum-preserving head resection in chronic pancreatitis changes the natural course of the disease: A single-center 26-year experience.</a> Ann Surg. 230 (4), 512-519 (1999).</li>
<li>D'haese, J. G., Ceyhan, G. O., Demir, I. E., Tieftrunk, E., Friess, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Treatment+options+in+painful+chronic+pancreatitis%3A+A+systematic+review%5BTitle%5D)+AND+%22HPB+%28Oxford%29%22%5BJournal%5D)">Treatment options in painful chronic pancreatitis: A systematic review.</a> HPB (Oxford). 16 (6), 512-521 (2014).</li>
<li>Beger, H. G., Rau, B. M., Gansauge, F., Poch, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Duodenum-preserving+subtotal+and+total+pancreatic+head+resections+for+inflammatory+and+cystic+neoplastic+lesions+of+the+pancreas%29%5BTitle%5D)+AND+%22J+Gastrointest+Surg%22%5BJournal%5D)">Duodenum-preserving subtotal and total pancreatic head resections for inflammatory and cystic neoplastic lesions of the pancreas).</a> J Gastrointest Surg. 12 (6), 1127-1132 (2008).</li>
<li>Beger, H. G., Büchler, M., Bittner, R. R., Oettinger, W., Roscher, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Duodenum-preserving+resection+of+the+head+of+the+pancreas+in+severe+chronic+pancreatitis.+Early+and+late+results%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">Duodenum-preserving resection of the head of the pancreas in severe chronic pancreatitis. Early and late results.</a> Ann Surg. 209 (3), 273-278 (1989).</li>
<li>Beger, H. G., Nakao, A., Mayer, B., Poch, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Duodenum-preserving+total+and+partial+pancreatic+head+resection+for+benign+tumors--systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Pancreatology%22%5BJournal%5D)">Duodenum-preserving total and partial pancreatic head resection for benign tumors--systematic review and meta-analysis.</a> Pancreatology. 15 (2), 167-178 (2015).</li>
<li>Cao, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+duodenum-preserving+total+pancreatic+head+resection%3A+A+novel+surgical+approach+for+benign+or+low-grade+malignant+tumors%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Laparoscopic duodenum-preserving total pancreatic head resection: A novel surgical approach for benign or low-grade malignant tumors.</a> Surg Endosc. 33 (2), 633-638 (2019).</li>
<li>Loomba, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Randomized%2C+controlled+trial+of+the+fgf21+analogue+pegozafermin+in+nash%5BTitle%5D)+AND+%22N+Engl+J+Med%22%5BJournal%5D)">Randomized, controlled trial of the fgf21 analogue pegozafermin in nash.</a> N Engl J Med. 389 (11), 998-1008 (2023).</li>
<li>Lu, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+duodenum-preserving+pancreatic+head+resection+with+real-time+indocyanine+green+guidance+of+different+dosage+and+timing%3A+Enhanced+safety+with+visualized+biliary+duct+and+its+long-term+metabolic+morbidity%5BTitle%5D)+AND+%22Langenbecks+Arch+Surg%22%5BJournal%5D)">Laparoscopic duodenum-preserving pancreatic head resection with real-time indocyanine green guidance of different dosage and timing: Enhanced safety with visualized biliary duct and its long-term metabolic morbidity.</a> Langenbecks Arch Surg. 407 (7), 2823-2832 (2022).</li>
<li>Huang, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Real-time+fluorescence+imaging+with+indocyanine+green+during+laparoscopic+duodenum-preserving+pancreatic+head+resection%5BTitle%5D)+AND+%22Pancreatology%22%5BJournal%5D)">Real-time fluorescence imaging with indocyanine green during laparoscopic duodenum-preserving pancreatic head resection.</a> Pancreatology. , (2023).</li>
<li>Hong, D., Cheng, J., Wu, W., Liu, X., Zheng, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((How+to+perform+total+laparoscopic+duodenum-preserving+pancreatic+head+resection+safely+and+efficiently+with+innovative+techniques%5BTitle%5D)+AND+%22Ann+Surg+Oncol%22%5BJournal%5D)">How to perform total laparoscopic duodenum-preserving pancreatic head resection safely and efficiently with innovative techniques.</a> Ann Surg Oncol. 28 (6), 3209-3216 (2021).</li>
<li>Zhou, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+duodenum-preserving+pancreatic+head+resection%3A+A+case+report%5BTitle%5D)+AND+%22Medicine+%28Baltimore%29%22%5BJournal%5D)">Laparoscopic duodenum-preserving pancreatic head resection: A case report.</a> Medicine (Baltimore). 95 (32), 4442(2016).</li>
<li>Alvarado-Bachmann, R., Choi, J., Gananadha, S., Hugh, T. J., Samra, J. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+infracolic+approach+to+pancreatoduodenectomy+for+large+pancreatic+head+tumours+invading+the+colon%5BTitle%5D)+AND+%22Eur+J+Surg+Oncol%22%5BJournal%5D)">The infracolic approach to pancreatoduodenectomy for large pancreatic head tumours invading the colon.</a> Eur J Surg Oncol. 36 (12), 1220-1224 (2010).</li>
<li>Diener, M. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Duodenum-preserving+pancreatic+head+resection+versus+pancreatoduodenectomy+for+surgical+treatment+of+chronic+pancreatitis%3A+A+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">Duodenum-preserving pancreatic head resection versus pancreatoduodenectomy for surgical treatment of chronic pancreatitis: A systematic review and meta-analysis.</a> Ann Surg. 247 (6), 950-961 (2008).</li>
<li>Beger, H. G., Mayer, B., Poch, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Duodenum-preserving+pancreatic+head+resection+for+benign+and+premalignant+tumors-a+systematic+review+and+meta-analysis+of+surgery-associated+morbidity%5BTitle%5D)+AND+%22J+Gastrointest+Surg%22%5BJournal%5D)">Duodenum-preserving pancreatic head resection for benign and premalignant tumors-a systematic review and meta-analysis of surgery-associated morbidity.</a> J Gastrointest Surg. 27 (11), 2611-2627 (2023).</li>
<li>Chen, X., Chen, W., Zhang, Y., An, Y., Zhang, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Short-term+outcomes+of+laparoscopic+duodenum-preserving+total+pancreatic+head+resection+compared+with+laparoscopic+pancreaticoduodenectomy+for+the+management+of+pancreatic-head+benign+or+low-grade+malignant+lesions%5BTitle%5D)+AND+%22Med+Sci+Monit%22%5BJournal%5D)">Short-term outcomes of laparoscopic duodenum-preserving total pancreatic head resection compared with laparoscopic pancreaticoduodenectomy for the management of pancreatic-head benign or low-grade malignant lesions.</a> Med Sci Monit. 26, e927248(2020).</li>
<li>Takada, T., Yasuda, H., Amano, H., Yoshida, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+duodenum-preserving+and+bile+duct-preserving+total+pancreatic+head+resection+with+associated+pancreatic+duct-to-duct+anastomosis%5BTitle%5D)+AND+%22J+Gastrointest+Surg%22%5BJournal%5D)">A duodenum-preserving and bile duct-preserving total pancreatic head resection with associated pancreatic duct-to-duct anastomosis.</a> J Gastrointest Surg. 8 (2), 220-224 (2004).</li>
<li>Li, X. L., Gong, L. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Preoperative+3d+reconstruction+and+fluorescent+indocyanine+green+for+laparoscopic+duodenum+preserving+pancreatic+head+resection%3A+A+case+report%5BTitle%5D)+AND+%22World+J+Clin+Cases%22%5BJournal%5D)">Preoperative 3d reconstruction and fluorescent indocyanine green for laparoscopic duodenum preserving pancreatic head resection: A case report.</a> World J Clin Cases. 11 (4), 903-908 (2023).</li>
<li>Vlek, S. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Biliary+tract+visualization+using+near-infrared+imaging+with+indocyanine+green+during+laparoscopic+cholecystectomy%3A+Results+of+a+systematic+review%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Biliary tract visualization using near-infrared imaging with indocyanine green during laparoscopic cholecystectomy: Results of a systematic review.</a> Surg Endosc. 31 (7), 2731-2742 (2017).</li>
<li>Cai, Y., Zheng, Z., Gao, P., Li, Y., Peng, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+duodenum-preserving+total+pancreatic+head+resection+using+real-time+indocyanine+green+fluorescence+imaging%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Laparoscopic duodenum-preserving total pancreatic head resection using real-time indocyanine green fluorescence imaging.</a> Surg Endosc. 35 (3), 1355-1361 (2021).</li>
</ol>

The authors report no conflict of interest.

LDPPHR only removes the diseased pancreatic head while preserving the duodenum, stomach, jejunum, common bile duct, and gallbladder that need to be removed in Whipple surgery. Compared to pancreaticoduodenectomy (PD) and pylorus-preserving pancreaticoduodenectomy (PPPD), LDPPHR showed enhancements in mid- and long-term results encompassing hospital stay duration, quality of life, post-surgery recovery, and maintenance of exocrine function5,14. DPPHR only removes the diseased pancreatic head, which reduces the extent of pancreatic resection and protects the physiological and anatomical integrity. This may explain why DPPHR has a better preservation of the exocrine function compared to PD15. It is still a challenging surgery due to the need to maintain the integrity of the duodenum and biliary system and preserve the complex blood supply. Classically, some pancreatic tissues are left on the duodenum side and in the distal CBD in Beger&#39;s procedure to preserve the pancreatic duodenal arterial arcade. It can provide adequate blood supply to the duodenum, distal CBD, and ampulla of Vater16.
By taking advantage of the amplification of the enhanced 3D laparoscopy, the pancreatic duodenal arterial arcade to the duodenum, distal CBD, and ampulla of Vater will be better preserved due to the clearer 3D vision. In addition, under clearer 3D vision, it is feasible that pancreas tissue would be removed from the lateral wall of the CBD and the medial side of the duodenal ring.
Just the same with open abdominal surgery, the key surgical points of LDPPHR are to ensure the blood supply in the duodenum and bile duct. It is reported that an important factor in avoiding ischemia is the preservation of the posterosuperior pancreatoduodenal artery17. In this case, we preserved the retropancreatic fascia along the CBD to ensure the blood supply and avoid injury to the CBD. Reliable pancreaticojejunostomy is an important factor in decreasing the pancreatic fistula rate.
To enhance the procedure of LDPPHR, the utilization of intravenous indocyanine green fluorescent can be implemented. This approach enables real-time navigation with fluorescent display, facilitating the guidance of surgical dissection and mitigating the risk of injury to the biliary tract9,11,18,19,20. However, in cases of swelling of the pancreatic head, the fluorescence laparoscope remains less than satisfactory in protecting the lower segment of the common bile duct. By contrast, with a 3D laparoscopic imaging system, important structures can be preserved more easily, resulting in a faster continence recovery. There is no standardized approach for LDPPHR. LDPPHR is demanding with respect to surgical experience, proficiency in anatomy, and suturing skills. Also, it requires precise planning that relies on preoperative imaging. Due to the two limitations, it is not possible to perform this procedure at relatively low-level centers. Which approach will be chosen for LDPPHR likely depends on the local anatomy of the lesions of the pancreatic head. In our opinion, the inferior infracolic approach is more suitable for patients with a thin mesenteric fat layer since it is more convenient to dissect the inferior pancreaticoduodenal artery via the inferior infracolic approach.
The LDPPHR method is both safe and feasible for the treatment of benign lesions of the pancreatic head. However, further studies are needed in surgical methods, minimally invasive surgery, and preoperative patient selection to improve long-term outcomes.

In 1972, Prof. Berger first proposed the duodenum-preserving pancreatic head resection (DPPHR) and Roux-en-Y pancreatic-enteral reconstruction as a treatment for chronic pancreatitis1. DPPHR has become the primary surgical treatment for benign lesions of the pancreatic head due to its low incidence of postoperative complications and mortality, as well as its ability to maintain the endocrine and exocrine functions of the pancreas and high remission rate of abdominal pain2,3,4. DPPHR only removes the diseased pancreatic head while preserving the duodenum, stomach, jejunum, common bile duct, and gallbladder that need to be removed in Whipple surgery, resulting in minimal damage and high postoperative quality of life3,5.
Laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has made significant progress in the last decade and is gradually replacing duodenum-preserving pancreatic head resection (DPPHR)6,7. The key to this surgical procedure is to ensure the blood supply of the duodenum and bile duct in order to avoid damage to the duodenum and bile duct, as well as duodenal necrosis and stenosis or atresia of the bile duct caused by ischemia7,8.&#160;A few experienced medical centers have reported LDPPHR9,10,11. As maintaining the integrity of the duodenum and biliary system and preserving complex blood supplies are necessary, the surgical procedure is challenging. It is essential to be very familiar with the special anatomical relationship between the pancreatic head and the duodenum while implementing LDPPHR, which is a difficult surgery that requires stronger surgical skills and psychological qualities.
Previous studies have proved that preserving the integrity of both anterior and posterior pancreaticoduodenal arterial arcades, as well as only preserving the posterior collateral branches of the arteries, will not cause duodenal ischemic necrosis11,12. Some surgeons preserve a thin layer of pancreatic tissue adhering to the common bile duct to avoid ischemia of the bile duct and duodenum but increase the incidence of pancreatic fistula13. In this study, the inferior infracolic approach was chosen for LDPPHR due to the patient with a thin mesenteric fat layer. By taking advantage of the amplification of the 3D laparoscopy, we successfully removed the pancreas from the lateral wall of the common bile duct (CBD) and the medial side of the duodenal ring without intraoperative fluorescence image guidance. This approach ensured the integrity of the vascular arch and reduced intraoperative blood loss, thereby minimizing the risk of pancreatic fistula.

<table><tbody><tr><td>3D Laparoscope</td><td>STORZ</td><td>TC200,TC302</td><td></td></tr><tr><td>Cisatracurium Besylate Injection</td><td>Hengrui Pharma</td><td>H20183042</td><td></td></tr><tr><td>Drainage catheters</td><td>Jiangsu YUBANG MED-DEVICE</td><td>YB-B-III</td><td></td></tr><tr><td>Harmonic ACE Ultrasonic Surgical Devices</td><td>Ethicon Endo-Surgery</td><td>HAR36</td><td></td></tr><tr><td>Ligating Clips</td><td>Teleflex Medical</td><td></td><td></td></tr><tr><td>Nacrotrend anaesthesia monitoring system</td><td>Monitor Technik</td><td>Bad Bramsted</td><td></td></tr><tr><td>Trocar</td><td>Ethicon Endo-Surgery</td><td>10 mm</td><td></td></tr></tbody></table>

laparoscopic duodenum-preserving pancreatic head resection via inferior infracolic approach: a surgical approach for benign lesions

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct.
This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms.
LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.

The patient's total pancreatic head, including the cystic tumor, was removed in 3 h with 100 mL of blood loss. The pancreatojejunal (PJ) anastomosis and jejunal anastomosis were completed in 60 min after the pancreatic head was removed from the body. The entire recovery period after surgery went smoothly, with no signs of postoperative pancreatic fistula. The amylase levels in both drains on postoperative day 3 were 1373 U/L and 804 U/L, respectively, but decreased to normal levels by day 5 when the drains were removed. The patient was discharged on the 6th postoperative day.
Postoperative pathology revealed a 2.5 x 1.5 cm intraductal papillary mucinous neoplasm (IPMN) (see Figure 4A-D). Microscopically, the resection margins were radical (R0), and no lymph nodes had tumor cells. The patient's first postoperative imaging at approximately 1 month is shown in Figure 4E,F.
<img alt="CT scan results highlighting kidney abnormalities; medical imaging analysis, axial and coronal views." class="xfigimg" src="/files/ftp_upload/66251/66251fig01.jpg" data-altupdatedat="1788304762000" data-alt="Figure 1"> 
Figure 1: CT images. (A-D) showed low-density multiple intercommunicating cystic lesions within the uncinate process of the pancreas. <a href="https://www.jove.com/files/ftp_upload/66251/66251fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Laparoscopic surgery diagram, 30-degree positioning, port placements, surgical team setup." class="xfigimg" src="/files/ftp_upload/66251/66251fig02.jpg" data-altupdatedat="1788304762000" data-alt="Figure 2"> 
Figure 2: Surgical position setting and trocar placement. <a href="https://www.jove.com/files/ftp_upload/66251/66251fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Surgical procedure on pancreatic region, laparoscopic technique, anatomical structure identification." class="xfigimg" src="/files/ftp_upload/66251/66251fig03.jpg" data-altupdatedat="1788304762000" data-alt="Figure 3"> 
Figure 3: Dissection phase of the surgery. (A) Suspend the transverse colon enteric fat over the liver falciform ligament to expose the infracolic compartment. (B) Dissect the anterior peritoneum of the duodenum horizontal part to expose the pancreatic head. (C) Transect SMV tributary using clips. (D) Transect the sub pancreaticoduodenal vessels branch into the uncinate process of the pancreas. (E) Suspend the stomach body over the liver falciform ligament to set free it from the pancreas using a red urine catheter and a clip. (F) Expose the common hepatic artery (CHA) and gastroduodenal artery (GDA). (G) The cystic tumor was circled with a blacked dashed line. (H) Expose and protect PSPDA. (I) The main pancreatic duct to the ampulla. (J) Set-up for the P-J anastomosis. <a href="https://www.jove.com/files/ftp_upload/66251/66251fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Histopathology and CT images for kidney study showing tissue samples and axial-coronal scans." class="xfigimg" src="/files/ftp_upload/66251/66251fig04.jpg" data-altupdatedat="1788304762000" data-alt="Figure 4"> 
Figure 4: Tumor sample. (A,B) Images of tumor sample, scale bars=1 cm.(C,D) The H&amp;E staining of tumor sample, scale bars=100 µm. (E,F) Postoperative CT images. <a href="https://www.jove.com/files/ftp_upload/66251/66251fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Duration of surgery</td>
			<td>180 min</td>
		</tr>
		<tr>
			<td>Blood loss</td>
			<td>100 mL</td>
		</tr>
		<tr>
			<td>Day of discharge</td>
			<td>6 days</td>
		</tr>
		<tr>
			<td>Rmovement of drainage tube</td>
			<td>5 days</td>
		</tr>
		<tr>
			<td>Tumor size</td>
			<td>2.5 cm × 1.5 cm</td>
		</tr>
		<tr>
			<td>Pathological type</td>
			<td>intraductal papillary mucinous neoplasms (IPMN)</td>
		</tr>
		<tr>
			<td>Lymphnodes metastasis</td>
			<td>negative</td>
		</tr>
		<tr>
			<td>First post-operative CT</td>
			<td>1 month after operation</td>
		</tr>
	</tbody>
</table>
Table 1: Surgical outcomes and postoperative details of the patient.

This article provides a whole technical process of laparoscopic duodenum-preserving pancreatic head resection via an inferior infracolic approach. This is a surgical approach for benign tumors without intraoperative fluorescence image guidance.

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic ...

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Research

JoVE Journal

Medicine

Laparoscopic pancreatoduodenctomy (LPD) may offer advantages over open pancreatoduodenectomy, including early postoperative mobilization, less delayed gastric emptying and a shorter hospital stay. However, LPD is technically challenging and not well-standardized, especially regarding the pancreatic anastomosis. We describe a standardized technique for the pancreatic anastomosis during LPD: modified Blumgart pancreaticojejunostomy.

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Robotic pancreatoduodenctomy (RPD) has been highly standardized in recent years and may be used in selected patients with pancreatic head cancer, including those with a replaced right hepatic artery. This case report describes a standardized and reproducible technique for RPD, which includes the approach of the Dutch LAELAPS-3 training program to an aberrant vasculature.

Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Complete resection of the uncinate process and mesopancreas is one of the most important and difficult processes in laparoscopic pancreatoduodenectomy (LPD). This article presents a method for managing the uncinate process in no-touch LPD using the median-anterior and left-posterior approaches to the superior mesenteric artery (SMA).

Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy

The current protocol delineates the use of robot-assisted pancreaticobiliary junction resection for the surgical management of benign duodenal tumors. This approach provides an effective solution for treating these tumors while minimizing duodenal loss and reducing associated complications.

Application of Robot-assisted Pancreaticobiliary Junction Resection in Benign Duodenal Tumors

This protocol presents robotic duodenum-preserving total pancreatic head resection (R-DPPHRt) for intraductal papillary mucinous neoplasms (IPMNs). A video demonstrates the technique in a patient with main duct-IPMN, highlighting its feasibility as a minimally invasive, organ-preserving alternative to pancreaticoduodenectomy.

Robotic Duodenum-preserving Total Pancreatic Head Resection for Intraductal Papillary Mucinous Neoplasms

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.

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

Various methods exist for introducing ototoxic agents to the cochleae of animal models. Presented is a surgical protocol for delivery of ototoxic agents to the round window niche. The procedure is reliable, creates targeted intra-cochlear lesions, and avoids mechanical damage to the microarchitecture. Examination of cochlear self-repair/regeneration is possible.

The Mouse Round-window Approach for Ototoxic Agent Delivery: A Rapid and Reliable Technique for Inducing Cochlear Cell Degeneration

In order to understand the pathophysiology of stroke, it is important to use reliable models. This paper will describe one of the most frequently used stroke models in mice, termed the middle cerebral artery occlusion (MCAo) model (also termed the intraluminal filament or suture model) with reperfusion.

Surgical Approach for Middle Cerebral Artery Occlusion and Reperfusion Induced Stroke in Mice

In this study, we describe the posterior semicircular canal approach as a reliable method for inner ear gene delivery in neonatal mice. We show that gene delivery through the posterior semicircular canal is able to perfuse the entire inner ear.

Posterior Semicircular Canal Approach for Inner Ear Gene Delivery in Neonatal Mouse

Learn laparoscopic duodenum-preserving pancreatic head resection via the inferior infracolic approach for benign lesions. This technique uses ultrasonic scalpels and clips to safely expose and transect vessels while preserving the duodenum.

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions (Video) | JoVE Journal

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

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