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Laparoscopic resections of liver and pancreas
Laparoscopic Resections of Liver and Pancreas Paul D. Hansen, M.D. Hepatobiliary and pancreatic (HBP) surgery and minimally invasive surgery (MIS) appear, at first glance, to represent disparate fields of surgical science. For 50 years, surgeons have been developing safer methods of performing ever larger and more technically demanding hepatic and pancreatic resections. For 15 years, minimally invasive surgeons have been striving to make surgery safer with increasingly less traumatic interventions. The benefits of each discipline are well documented in the literature. The crossover lies in our ability to achieve the goals of an open HBP procedure using minimally invasive surgery techniques and thereby receive the benefit of both practices. In 1991, the first peer-reviewed reports of laparoscopic liver resections were published. They described a wedge resection for a focal nodular hyperplasia. Similarly, the first laparoscopic distal pancreatic resection for an insulinoma was described in 1993, and the first pancreaticoduodenectomy was described in 1994. Subsequently, more than 500 journal articles have been published describing a full spectrum of resections of benign and malignant liver and pancreatic disease. The descriptions of these laparoscopic procedures give great technical detail and outline potential clinical applications. While caution is advised to avoid broadly condoning such procedures until their appropriate role has been better elucidated, such procedures must not be prematurely condemned, as it seems clear that the diminution of maximally invasive procedures is on the horizon.
improving efficiency of the OR and patient outcomes in these highly technical surgical specialties has been well documented. Our institution has made an effort to maintain a simple and standardized laparoscopic instrument tray so that our OR staff is expert in maintenance and use. A standard instrument pan includes a strong, smooth-edged retractor; a suction device; atraumatic graspers; needle drivers; a curved dissector and scissors with monopolar electrocautery attachments; and a fascial closure device. Stapling devices, harmonic shears, clip appliers, and hand assist devices are available on request. Laparoscopic ultrasound equipment is always available in the room.
SURGICAL TECHNIQUES Laparoscopic liver resection techniques have been developed for benign cyst fenestration, wedge resection, and anatomic segmental resection. Laparoscopic pancreatic resection techniques have been described for tumor enucleation, distal pancreatectomy, and pancreaticoduodenectomy. The basic tenets of such resections mimic those of open resections. Dissection and mobilization are technical exercises similar to the open counterpart. A number of different laparoscopic parenchymal transection technologies have been developed, including stapling devices, harmonic shears, water jets, ultrasonic dissectors, and others. Most surgeons adapt the technique used in their open practice. Each method has pros and cons, and its success is dependent on the familiarity of the surgeon with that method.
SURGICAL TEAM AND OPERATING ROOM REQUIREMENTS The foremost requirement for surgeons who wish to perform laparoscopic HBP procedures is that they be knowledgeable and experienced open HBP surgeons. Second, they must either be, or work closely with, skilled laparoscopic surgeons. Appropriate operating room (OR) staff and hospital resources need to be in place for both open and laparoscopic procedures. The importance of specialized OR teams in
LIVER RESECTIONS Limited laparoscopic liver resections are increasingly being reported at specialty centers throughout the world.1,2 They are technically feasible and can be performed with a low morbidity profile. If a program has appropriately trained surgeons and the facility requirements in place, it is reasonable to consider such an approach for benign disease. In patients with
From Hepatobiliary and Pancreatic Surgery, Legacy Health System, Portland, Oregon. Correspondence: Paul D. Hansen, M.D., 1040 N.W. 22nd Avenue, Portland, OR 97210. e-mail: [email protected]
쑖 2004 The Society for Surgery of the Alimentary Tract Published by Elsevier Inc.
1091-255X/04/$—see front matter doi:10.1016/j.gassur.2004.09.050
925
926
Journal of Gastrointestinal Surgery
Hansen
malignant disease, however, a larger barrier remains to be overcome.3 First, it must be proved that we can reliably comply with the defined tenets of oncologic surgery. Staging must be complete, tumor manipulation minimal, and margins and lymphadenectomies adequate. It must also be determined whether carbon dioxide pneumoperitoneum or other aspects of minimal access techniques have a harmful effect on the progression of cancer. Finally, we will need to demonstrate through controlled trials that a minimally invasive approach achieves similar or improved outcomes with regard to quality of life and survival. PANCREATIC RESECTIONS Laparoscopic pancreatic resections are also being reported with an increasing frequency. Laparoscopic pancreaticoduodenectomies do not at this point appear to be a reasonable undertaking.4 The morbidity of the procedure is less associated with the incision and more dependent on the physiologic impact of the resection, anastomoses, and re-plumbing of the bowel. The added technical difficulty of a laparoscopic approach is not made up for by the reduced invasiveness. Pancreatic enucleations and distal resections, however, are technically easier, and the reduced impact of the surgery may prove beneficial.4,5 The same concerns are at play regarding benign versus malignant disease.
SUMMARY It is our belief that there will be a significant role for minimally invasive approaches to HBP surgery in the future. There is great potential for reduction of perioperative morbidity, possibly more so than in other fields of surgery, due to the major impact on the patient after the maximally invasive open procedures. At this early stage in development, however, we must be cautious about too rapid an assimilation of the techniques without proper evaluation of the outcomes. High-quality data, collected prospectively, from randomized trials where possible, remain the key to implementing proper utilization.
REFERENCES 1. Lesurtel M, Cherqui D, Laurent A. Laparoscopic versus open left lateral hepatic lobectomy: A case controlled study. J Am Coll Surg 2003;196:236–242. 2. Descottes B, Glineur D, Lachachi F, et al. Laparoscopic liver resection of benign tumors. Surg Endosc 2003;17:23–30. 3. Gigot JF, Glineur D, Santiago Azagra J, et al. Laparoscopic liver resection for malignant liver tumors: Preliminary results of a multicenter European study. Ann Surg 2002;236:90–97. 4. Gagner M, Pomp A. Laparoscopic pancreatic resection: Is it worthwhile? J GASTROINTEST SURG 1997;1:20–26. 5. Fabre JM, Dulucq JL, Vacher C, et al. Is laparoscopic left pancreatic resection justified? Surg Endosc 2002;16:1358– 1361.
improving efficiency of the OR and patient outcomes in these highly technical surgical specialties has been well documented. Our institution has made an effort to maintain a simple and standardized laparoscopic instrument tray so that our OR staff is expert in maintenance and use. A standard instrument pan includes a strong, smooth-edged retractor; a suction device; atraumatic graspers; needle drivers; a curved dissector and scissors with monopolar electrocautery attachments; and a fascial closure device. Stapling devices, harmonic shears, clip appliers, and hand assist devices are available on request. Laparoscopic ultrasound equipment is always available in the room.
SURGICAL TECHNIQUES Laparoscopic liver resection techniques have been developed for benign cyst fenestration, wedge resection, and anatomic segmental resection. Laparoscopic pancreatic resection techniques have been described for tumor enucleation, distal pancreatectomy, and pancreaticoduodenectomy. The basic tenets of such resections mimic those of open resections. Dissection and mobilization are technical exercises similar to the open counterpart. A number of different laparoscopic parenchymal transection technologies have been developed, including stapling devices, harmonic shears, water jets, ultrasonic dissectors, and others. Most surgeons adapt the technique used in their open practice. Each method has pros and cons, and its success is dependent on the familiarity of the surgeon with that method.
SURGICAL TEAM AND OPERATING ROOM REQUIREMENTS The foremost requirement for surgeons who wish to perform laparoscopic HBP procedures is that they be knowledgeable and experienced open HBP surgeons. Second, they must either be, or work closely with, skilled laparoscopic surgeons. Appropriate operating room (OR) staff and hospital resources need to be in place for both open and laparoscopic procedures. The importance of specialized OR teams in
LIVER RESECTIONS Limited laparoscopic liver resections are increasingly being reported at specialty centers throughout the world.1,2 They are technically feasible and can be performed with a low morbidity profile. If a program has appropriately trained surgeons and the facility requirements in place, it is reasonable to consider such an approach for benign disease. In patients with
From Hepatobiliary and Pancreatic Surgery, Legacy Health System, Portland, Oregon. Correspondence: Paul D. Hansen, M.D., 1040 N.W. 22nd Avenue, Portland, OR 97210. e-mail: [email protected]
쑖 2004 The Society for Surgery of the Alimentary Tract Published by Elsevier Inc.
1091-255X/04/$—see front matter doi:10.1016/j.gassur.2004.09.050
925
926
Journal of Gastrointestinal Surgery
Hansen
malignant disease, however, a larger barrier remains to be overcome.3 First, it must be proved that we can reliably comply with the defined tenets of oncologic surgery. Staging must be complete, tumor manipulation minimal, and margins and lymphadenectomies adequate. It must also be determined whether carbon dioxide pneumoperitoneum or other aspects of minimal access techniques have a harmful effect on the progression of cancer. Finally, we will need to demonstrate through controlled trials that a minimally invasive approach achieves similar or improved outcomes with regard to quality of life and survival. PANCREATIC RESECTIONS Laparoscopic pancreatic resections are also being reported with an increasing frequency. Laparoscopic pancreaticoduodenectomies do not at this point appear to be a reasonable undertaking.4 The morbidity of the procedure is less associated with the incision and more dependent on the physiologic impact of the resection, anastomoses, and re-plumbing of the bowel. The added technical difficulty of a laparoscopic approach is not made up for by the reduced invasiveness. Pancreatic enucleations and distal resections, however, are technically easier, and the reduced impact of the surgery may prove beneficial.4,5 The same concerns are at play regarding benign versus malignant disease.
SUMMARY It is our belief that there will be a significant role for minimally invasive approaches to HBP surgery in the future. There is great potential for reduction of perioperative morbidity, possibly more so than in other fields of surgery, due to the major impact on the patient after the maximally invasive open procedures. At this early stage in development, however, we must be cautious about too rapid an assimilation of the techniques without proper evaluation of the outcomes. High-quality data, collected prospectively, from randomized trials where possible, remain the key to implementing proper utilization.
REFERENCES 1. Lesurtel M, Cherqui D, Laurent A. Laparoscopic versus open left lateral hepatic lobectomy: A case controlled study. J Am Coll Surg 2003;196:236–242. 2. Descottes B, Glineur D, Lachachi F, et al. Laparoscopic liver resection of benign tumors. Surg Endosc 2003;17:23–30. 3. Gigot JF, Glineur D, Santiago Azagra J, et al. Laparoscopic liver resection for malignant liver tumors: Preliminary results of a multicenter European study. Ann Surg 2002;236:90–97. 4. Gagner M, Pomp A. Laparoscopic pancreatic resection: Is it worthwhile? J GASTROINTEST SURG 1997;1:20–26. 5. Fabre JM, Dulucq JL, Vacher C, et al. Is laparoscopic left pancreatic resection justified? Surg Endosc 2002;16:1358– 1361.