Laparoscopic Whipple procedure with a two-layered pancreatojejunostomy
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Since the first report of laparoscopic pancreatic resections in the early 1990s, laparoscopic resection of tumors in the pancreas has become increasingly more common in the surgical treatment of both benign and malignant tumors . The minimally invasive approach to lesions in the head of the pancreas, however, still is performed only in highly specialized centers , principally due to concerns about the safety of dissecting tumors off the superior mesenteric/portal vein and superior mesenteric artery, the perceived difficulty controlling major hemorrhage via the laparoscopic approach, and concerns regarding the efficacy of a laparoscopically created pancreatic anastomosis.
We use the laparoscopic posterior approach first described by Gumbs and Gayet . The main differences with this approach include early performance of an extended Kocher maneuver and transection of the uncinate process using ultrasonic shears. In contrast to the previously reported video of this technique, the current video highlights the laparoscopic formation of a two-layered end-to-side pancreatojejunostomy. An internal stent consisting of a 5-Fr. pediatric feeding tube is used to prevent inadvertent closure of the pancreatic duct.
To date, five laparoscopic Whipple procedures using the posterior approach have been performed in the United States. Of the five treated patients, two patients had pancreatic adenocarcinoma, one of which was administered neoadjuvant chemoradiation therapy; one patients had a malignant neuroendocrine tumor; one patient had a malignant tumor arising from an intraductal papillary mucinous neoplasm; and a final patient had type 1 choledochocele involving her entire common bile duct.
The average estimated blood loss was 450 ml (range, 200–800 ml), and the mean operative time was 485 min (range, 370–660 min). The hospital stay averaged 11 days (range, 7–14 days).
One patient experienced a bile leak, which responded to transhepatic biliary drainage, and one patient experienced a subhepatic abscess after removal of a gastrostomy tube, which required percutaneous drainage on postoperative day 22. The average number of lymph nodes retrieved was 18 (range, 16–29). All the pancreatic margins were negative. However, one patient was found to have metastatic pancreatic cancer of the liver at the final pathology despite negative liver biopsy results at frozen section analysis. This patient was found to have a hepatic recurrence at 12 months and at this writing is alive after 15 months of follow-up evaluation. To date, all patients are currently alive after a mean follow-up period of 11 months (range, 6–20 months). The remaining four patients have no evidence of disease.
Minimally invasive techniques for laparoscopic Whipple procedures are feasible and safe. The two-layered end-to-side laparoscopic pancreatojejunostomy has a low rate of pancreatic fistula formation and may be ideal for laparoscopically created pancreatic anastomoses. Mastery of the anatomy and laparoscopic suturing is paramount before this approach with minimally invasive techniques is attempted. Currently, it should be performed only by surgeons with expertise in both open and laparoscopic pancreatic surgery.
Andrew A. Gumbs is a consultant for Ethicon, a preceptor and course instructor for Covidien, and a preceptor for Novare Surgical and has received honoraria from Novare Surgical and Applied Medical. Brice Gayet and John P. Hoffman have no conflicts of interest or financial ties to disclose.
Supplementary material 1 (MP4 279279 kb)