- Email: [email protected]
Minimally Invasive Whipple's Technique for Laparoscopic-Assisted Pylorus-Preserving Pancreaticoduodenectomy
Accepted Manuscript Minimally Invasive Whipple’s Technique for Laparoscopic-Assisted Pylorus Preserving Pancreaticoduodenectomy Frederick Hong-Xiang Koh, MBBS, MRCSEd, Alfred WC. Kow, MBBS, FRCSEd, FACS PII:
S1072-7515(16)31598-8
DOI:
10.1016/j.jamcollsurg.2016.10.052
Reference:
ACS 8535
To appear in:
Journal of the American College of Surgeons
Received Date: 25 September 2016 Revised Date:
27 October 2016
Accepted Date: 27 October 2016
Please cite this article as: Hong-Xiang Koh F, Kow AW, Minimally Invasive Whipple’s Technique for Laparoscopic-Assisted Pylorus Preserving Pancreaticoduodenectomy, Journal of the American College of Surgeons (2016), doi: 10.1016/j.jamcollsurg.2016.10.052. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Minimally Invasive Whipple’s Technique for Laparoscopic-Assisted Pylorus Preserving Pancreaticoduodenectomy Frederick Hong-Xiang Koh, MBBS, MRCSEd1, Alfred WC Kow, MBBS, FRCSEd, FACS1,2 1
Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
RI PT
2
Division of Hepatobiliary and Pancreatic Surgery, University Surgical Cluster, National University Health System, Singapore
M AN U
Corresponding author: Alfred WC Kow Assistant Professor Division of Hepatobiliary and Pancreatic Surgery University Surgical Cluster National University Health System 1E Kent Ridge Road Singapore 119228 TEL: [+65]-67722002 FAX: [+65]-67764829 Email: [email protected]
SC
Disclosure Information: Nothing to disclose.
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Brief Title: Pylorus Preserving Pancreaticoduodenectomy
1
ACCEPTED MANUSCRIPT Introduction With the increasing recognition of the benefits laparoscopic surgery has over conventional open techniques, more procedures are now done using this minimally invasive method. [1] Minimally invasive pancreatic surgery has shown to be feasible and achieve
RI PT
similar outcomes compared to the conventional open techniques. [2-5] However, there have only been a few reports of laparoscopic assisted pancreaticoduodenectomy till date. [6-8] Video 1 aims to demonstrate the feasibility of the technique and its surgical oncological
SC
outcome in a patient with an ampullary tumour. Patient Selection
M AN U
Patient selection for this technically challenging procedure is paramount to achieve an optimal outcome for patients. In our institution, on top of ensuring the necessary prerequisites for any laparoscopic procedures are met, such as decent cardiorespiratory function to sustain pneumoperitoneum, tumour size should ideally be < 3.0 cm in the widest dimension, a Body
TE D
Mass Index (BMI) of < 30 kg/m2, and careful radiological inspection to ensure that the mass is not fixed or adhered to surrounding structures or vessels. In addition, it is crucial to ensure
and vein.
EP
that there is a clear radiological plane between the tumour and the superior messenteric artery
AC C
Surgical Technique
The patient is a 52-year-old gentleman with a 1cm adenocarcinoma in the Ampulla of
Vater, presenting with painless obstructive jaundice. Figure 1 shows the appearance of the lesion on CT. Endoscopic ultrasound showed a 12x10mm ampullary lesion (Figure 2). The procedure was performed in the Lloyd Davies position using a 5–port technique; 4 ports were placed along a smiley face plane from right to left flank, and 1 port located in epigastrium. Energy device that was utilized during the procedure was LigaSure™ Maryland jaw laparoscopic instrument.
2
ACCEPTED MANUSCRIPT The lesser sac was entered through the greater omentum and the hepatic flexure was taken down. The stomach was freed from the pancreas and was retracted anteriorly. We performed this retraction in our institution by passing a prolene 2/0 straight needle through the skin into the abdomen, catching full thickness of the stomach and tying the suture onto
RI PT
the cutaneous layer, to adequately expose the pancreas, reducing the need for an additional port for retraction. to dedicate a port and an instrument for gastric retraction. The gastrocolic trunk was dissected and ligated between clips. The pylorus-duodenal junction was dissected
SC
and transected using Echelon 60mm staple.
Portahepatis was then dissected to isolate hepatic artery proper up to the level to
M AN U
include the station 8 lymph nodes, left hepatic artery and right hepatic artery. The common bile duct was then divided, proximally with a bulldog clamp and distally with a silk tie, after isolating it away from right hepatic artery, which runs between it. Portal vein was dissected from lymphatics, common hepatic artery and common bile duct. The gastroduodenal artery
TE D
was isolated, clipped and divided. The superior mesenteric vein tunnel, identified at the inferior border of pancreas, was developed by blunt dissection, using the tip of suction device, to allow a nylon tape to be passed through. The pancreatic neck that was hitched up
EP
with the nylon tape was divided using LigaSure™.
AC C
Kocher’s maneuver was then performed, freeing the duodenum from all its attachments. To ensure that all peri-duodenal tissue was removed, the aorto-caval grove was bared till the level of the left renal vein. The proximal jejunum was divided using Echelon 60mm staple. The ligament of Treitz and the 4th part of the duodenum were mobilized and brought underneath the superior mesenteric artery axis. The final laparoscopic step was to complete the cholecystectomy. This was done last to allow the surgeon to use the gall bladder as a mean for retraction to facilitate hilar
3
ACCEPTED MANUSCRIPT dissection. We recommend this to be performed laparoscopically as it is difficult to access the area around the gall bladder via the midline incision. The operation was continued through a 7cm upper midline incision. The specimen was delivered through the incision with an applied Alexis wound protector. All staple lines
RI PT
were routinely inspected after transection to ensure haemostasis. Haemostatic PDS sutures were placed only if active oozing was detected during this inspection. The pancreaticojejunostomy, hepatico-jejunostomy and gastro-jejunostomy anastomoses were created
SC
through the same incision.
In our institution, the pancreatioco-jejunostomy is fashioned with 2 layers of suture –
M AN U
the inner layer was performed using interrupted duct-to-mucosal anastomosis using PDS 5/0 and an outer layer of continuous prolene 3/0 with no pancreatic duct stent left in situ. The hepatico-jejunostomy and the gastro-jejunostomy were fashioned with PDS 4/0 continuous sutures, one posterior and another for the anterior portion of the anastomosis. A piece of
TE D
clean gauze is placed above the hepatico-jejunostomy while fashioning the gastrojejunostomy to help identify any bile leakage prior to closure. Two drains were placed; one behind the gastro-jejunostomy and anterior to pancreatico-
AC C
Outcomes
EP
jejunostomy and the other behind the hepatico-jejunostomy before closure.
The operative time was 285min and the patient was stable throughout the operative
with only 100ml of blood loss. This is consistent with recent cases of Laparoscopic PPPD in our institution with the median duration for operation being 438 minutes (interquartile range: 371 – 487 minutes). Our patient recovered well with no pancreatic leak detected on postoperative day 3 drain amylase assessment. Diet was escalated uneventfully. Length of hospitalization was 7 days, the first of which was in the surgical high dependency unit mainly for closer post-operative monitoring. We achieved an R0 resection for all our patients. 4
ACCEPTED MANUSCRIPT Biochemical pancreatic anastomotic leak rate (Grade A on POPF classification) was low 11.8% and there was no clinically significant pancreatic leak in our cohort. There was only 1 patient who demised within 30 days of the surgery due to a cardiac related event. The median duration of hospitalization in our institution for Laparoscopic PPPD was 10 days
RI PT
(interquartile range: 7 – 13 days).
Histopathological assessment revealed a moderately differentiated T4 1.3cm
ampullary adenocarcinoma. None of the 20 lymph nodes harvested and none of the resection
SC
margins were involved by tumour.
The authors recommend that a skilled laparoscopic surgeon may require minimum of
M AN U
5 cases in order to be very comfortable and confident with the dissection laparoscopically. Conclusions
Laparoscopic assisted pylorus preserving pancreaticoduodenectomy is feasible and safe to perform with good visualization of anatomical structures and acceptable oncological
TE D
outcomes. As this is a technically demanding procedure, it is important that proper
AC C
EP
proctorship is present before beginning the attempt to mount the learning curve.
5
ACCEPTED MANUSCRIPT References 1. Ammori BJ. Pancreatic surgery in the laparoscopic era. JOP 2003 Nov;4(6):187-92. 2. Stauffer JA, Coppola A, Mody K, Asbun HJ. Laparoscopic Versus Open Distal
RI PT
Pancreatectomy for Pancreatic Adenocarcinoma. World J Surg 2016 Jun;40(6):1477-84. 3. Langan RC, Graham JA, Chin AB, et al. Laparoscopic-assisted versus open
pancreaticoduodenectomy: early favorable physical quality-of-life measures. Surgery 2014 Aug;156(2):379-84.
SC
4. He J, Pawlik TM, Makary MA, et al. Laparoscopic pancreatic surgery. Minerva Chir 2014
M AN U
Dec;69(6):371-378.
5. Gumbs AA, Rodriguez Rivera AM, Milone L, Hoffman JP. paroscopic pancreatoduodenectomy: a review of 285 published cases. Ann Surg Oncol 2011 May;18(5):1335-41.
6. Lee JS, Han JH, Na GH, et al. Laparoscopic pancreaticoduodenectomy assisted by mini-
TE D
laparotomy. Surg Laparosc Endosc Percutan Tech 2013 Jun;23(3):e98-102. 7. Kuroki T, Adachi T, Okamoto T, Kanematsu T. A non-randomized comparative study of
EP
laparoscopy-assisted pancreaticoduodenectomy and open pancreaticoduodenectomy. Hepatogastroenterology 2012 Mar-Apr;59(114):570-3.
AC C
8. Staudacher C, Orsenigo E, Baccari P, et al. Laparoscopic assisted duodenopancreatectomy. Surg Endosc 2005 Mar;19(3):352-6.
6
ACCEPTED MANUSCRIPT Figure Legend Figure 1. The axial and coronal CT films show dilatation of the biliary system and mild prominence of the pain pancreatic duct is seem within the transition point at the ampulla.
RI PT
Figure 2. Endoscopic ultrasound images reveals an ampullary lesion measuring 12x10mm
AC C
EP
TE D
M AN U
SC
with dilatation of main pancreatic duct (4mm) and grossly dilated CBD (13mm).
7
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S1072-7515(16)31598-8
DOI:
10.1016/j.jamcollsurg.2016.10.052
Reference:
ACS 8535
To appear in:
Journal of the American College of Surgeons
Received Date: 25 September 2016 Revised Date:
27 October 2016
Accepted Date: 27 October 2016
Please cite this article as: Hong-Xiang Koh F, Kow AW, Minimally Invasive Whipple’s Technique for Laparoscopic-Assisted Pylorus Preserving Pancreaticoduodenectomy, Journal of the American College of Surgeons (2016), doi: 10.1016/j.jamcollsurg.2016.10.052. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Minimally Invasive Whipple’s Technique for Laparoscopic-Assisted Pylorus Preserving Pancreaticoduodenectomy Frederick Hong-Xiang Koh, MBBS, MRCSEd1, Alfred WC Kow, MBBS, FRCSEd, FACS1,2 1
Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
RI PT
2
Division of Hepatobiliary and Pancreatic Surgery, University Surgical Cluster, National University Health System, Singapore
M AN U
Corresponding author: Alfred WC Kow Assistant Professor Division of Hepatobiliary and Pancreatic Surgery University Surgical Cluster National University Health System 1E Kent Ridge Road Singapore 119228 TEL: [+65]-67722002 FAX: [+65]-67764829 Email: [email protected]
SC
Disclosure Information: Nothing to disclose.
AC C
EP
TE D
Brief Title: Pylorus Preserving Pancreaticoduodenectomy
1
ACCEPTED MANUSCRIPT Introduction With the increasing recognition of the benefits laparoscopic surgery has over conventional open techniques, more procedures are now done using this minimally invasive method. [1] Minimally invasive pancreatic surgery has shown to be feasible and achieve
RI PT
similar outcomes compared to the conventional open techniques. [2-5] However, there have only been a few reports of laparoscopic assisted pancreaticoduodenectomy till date. [6-8] Video 1 aims to demonstrate the feasibility of the technique and its surgical oncological
SC
outcome in a patient with an ampullary tumour. Patient Selection
M AN U
Patient selection for this technically challenging procedure is paramount to achieve an optimal outcome for patients. In our institution, on top of ensuring the necessary prerequisites for any laparoscopic procedures are met, such as decent cardiorespiratory function to sustain pneumoperitoneum, tumour size should ideally be < 3.0 cm in the widest dimension, a Body
TE D
Mass Index (BMI) of < 30 kg/m2, and careful radiological inspection to ensure that the mass is not fixed or adhered to surrounding structures or vessels. In addition, it is crucial to ensure
and vein.
EP
that there is a clear radiological plane between the tumour and the superior messenteric artery
AC C
Surgical Technique
The patient is a 52-year-old gentleman with a 1cm adenocarcinoma in the Ampulla of
Vater, presenting with painless obstructive jaundice. Figure 1 shows the appearance of the lesion on CT. Endoscopic ultrasound showed a 12x10mm ampullary lesion (Figure 2). The procedure was performed in the Lloyd Davies position using a 5–port technique; 4 ports were placed along a smiley face plane from right to left flank, and 1 port located in epigastrium. Energy device that was utilized during the procedure was LigaSure™ Maryland jaw laparoscopic instrument.
2
ACCEPTED MANUSCRIPT The lesser sac was entered through the greater omentum and the hepatic flexure was taken down. The stomach was freed from the pancreas and was retracted anteriorly. We performed this retraction in our institution by passing a prolene 2/0 straight needle through the skin into the abdomen, catching full thickness of the stomach and tying the suture onto
RI PT
the cutaneous layer, to adequately expose the pancreas, reducing the need for an additional port for retraction. to dedicate a port and an instrument for gastric retraction. The gastrocolic trunk was dissected and ligated between clips. The pylorus-duodenal junction was dissected
SC
and transected using Echelon 60mm staple.
Portahepatis was then dissected to isolate hepatic artery proper up to the level to
M AN U
include the station 8 lymph nodes, left hepatic artery and right hepatic artery. The common bile duct was then divided, proximally with a bulldog clamp and distally with a silk tie, after isolating it away from right hepatic artery, which runs between it. Portal vein was dissected from lymphatics, common hepatic artery and common bile duct. The gastroduodenal artery
TE D
was isolated, clipped and divided. The superior mesenteric vein tunnel, identified at the inferior border of pancreas, was developed by blunt dissection, using the tip of suction device, to allow a nylon tape to be passed through. The pancreatic neck that was hitched up
EP
with the nylon tape was divided using LigaSure™.
AC C
Kocher’s maneuver was then performed, freeing the duodenum from all its attachments. To ensure that all peri-duodenal tissue was removed, the aorto-caval grove was bared till the level of the left renal vein. The proximal jejunum was divided using Echelon 60mm staple. The ligament of Treitz and the 4th part of the duodenum were mobilized and brought underneath the superior mesenteric artery axis. The final laparoscopic step was to complete the cholecystectomy. This was done last to allow the surgeon to use the gall bladder as a mean for retraction to facilitate hilar
3
ACCEPTED MANUSCRIPT dissection. We recommend this to be performed laparoscopically as it is difficult to access the area around the gall bladder via the midline incision. The operation was continued through a 7cm upper midline incision. The specimen was delivered through the incision with an applied Alexis wound protector. All staple lines
RI PT
were routinely inspected after transection to ensure haemostasis. Haemostatic PDS sutures were placed only if active oozing was detected during this inspection. The pancreaticojejunostomy, hepatico-jejunostomy and gastro-jejunostomy anastomoses were created
SC
through the same incision.
In our institution, the pancreatioco-jejunostomy is fashioned with 2 layers of suture –
M AN U
the inner layer was performed using interrupted duct-to-mucosal anastomosis using PDS 5/0 and an outer layer of continuous prolene 3/0 with no pancreatic duct stent left in situ. The hepatico-jejunostomy and the gastro-jejunostomy were fashioned with PDS 4/0 continuous sutures, one posterior and another for the anterior portion of the anastomosis. A piece of
TE D
clean gauze is placed above the hepatico-jejunostomy while fashioning the gastrojejunostomy to help identify any bile leakage prior to closure. Two drains were placed; one behind the gastro-jejunostomy and anterior to pancreatico-
AC C
Outcomes
EP
jejunostomy and the other behind the hepatico-jejunostomy before closure.
The operative time was 285min and the patient was stable throughout the operative
with only 100ml of blood loss. This is consistent with recent cases of Laparoscopic PPPD in our institution with the median duration for operation being 438 minutes (interquartile range: 371 – 487 minutes). Our patient recovered well with no pancreatic leak detected on postoperative day 3 drain amylase assessment. Diet was escalated uneventfully. Length of hospitalization was 7 days, the first of which was in the surgical high dependency unit mainly for closer post-operative monitoring. We achieved an R0 resection for all our patients. 4
ACCEPTED MANUSCRIPT Biochemical pancreatic anastomotic leak rate (Grade A on POPF classification) was low 11.8% and there was no clinically significant pancreatic leak in our cohort. There was only 1 patient who demised within 30 days of the surgery due to a cardiac related event. The median duration of hospitalization in our institution for Laparoscopic PPPD was 10 days
RI PT
(interquartile range: 7 – 13 days).
Histopathological assessment revealed a moderately differentiated T4 1.3cm
ampullary adenocarcinoma. None of the 20 lymph nodes harvested and none of the resection
SC
margins were involved by tumour.
The authors recommend that a skilled laparoscopic surgeon may require minimum of
M AN U
5 cases in order to be very comfortable and confident with the dissection laparoscopically. Conclusions
Laparoscopic assisted pylorus preserving pancreaticoduodenectomy is feasible and safe to perform with good visualization of anatomical structures and acceptable oncological
TE D
outcomes. As this is a technically demanding procedure, it is important that proper
AC C
EP
proctorship is present before beginning the attempt to mount the learning curve.
5
ACCEPTED MANUSCRIPT References 1. Ammori BJ. Pancreatic surgery in the laparoscopic era. JOP 2003 Nov;4(6):187-92. 2. Stauffer JA, Coppola A, Mody K, Asbun HJ. Laparoscopic Versus Open Distal
RI PT
Pancreatectomy for Pancreatic Adenocarcinoma. World J Surg 2016 Jun;40(6):1477-84. 3. Langan RC, Graham JA, Chin AB, et al. Laparoscopic-assisted versus open
pancreaticoduodenectomy: early favorable physical quality-of-life measures. Surgery 2014 Aug;156(2):379-84.
SC
4. He J, Pawlik TM, Makary MA, et al. Laparoscopic pancreatic surgery. Minerva Chir 2014
M AN U
Dec;69(6):371-378.
5. Gumbs AA, Rodriguez Rivera AM, Milone L, Hoffman JP. paroscopic pancreatoduodenectomy: a review of 285 published cases. Ann Surg Oncol 2011 May;18(5):1335-41.
6. Lee JS, Han JH, Na GH, et al. Laparoscopic pancreaticoduodenectomy assisted by mini-
TE D
laparotomy. Surg Laparosc Endosc Percutan Tech 2013 Jun;23(3):e98-102. 7. Kuroki T, Adachi T, Okamoto T, Kanematsu T. A non-randomized comparative study of
EP
laparoscopy-assisted pancreaticoduodenectomy and open pancreaticoduodenectomy. Hepatogastroenterology 2012 Mar-Apr;59(114):570-3.
AC C
8. Staudacher C, Orsenigo E, Baccari P, et al. Laparoscopic assisted duodenopancreatectomy. Surg Endosc 2005 Mar;19(3):352-6.
6
ACCEPTED MANUSCRIPT Figure Legend Figure 1. The axial and coronal CT films show dilatation of the biliary system and mild prominence of the pain pancreatic duct is seem within the transition point at the ampulla.
RI PT
Figure 2. Endoscopic ultrasound images reveals an ampullary lesion measuring 12x10mm
AC C
EP
TE D
M AN U
SC
with dilatation of main pancreatic duct (4mm) and grossly dilated CBD (13mm).
7
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT