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Technique and audited outcomes of laparoscopic distal pancreatectomy combining the clockwise approach, progressive stepwise compression technique, and staple line reinforcement

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Abstract

Background

Laparoscopic distal pancreatectomy (LDP) has proven advantages over its open counterpart and is becoming more frequently performed around the world. It still remains a difficult operation due to the retroperitoneal location of the pancreas and limited experience and training with the procedure. In addition, complications such as bleeding or postoperative pancreatic fistula (POPF) remain a problem. A standardized approach to LDP with stepwise graded compression technique for pancreatic transection has been utilized at a single center, and we sought to describe the technique and determine the outcomes.

Methods

A review of all patients undergoing LDP by a clockwise approach including the graded compression technique from August 1, 2008 to December 31, 2017 was performed. An external audit was performed by the Dutch Pancreatic Cancer Group.

Results

Overall, 260 patients with a mean age and a BMI of 62.3 and 28, respectively, underwent LDP using this technique. Mean operative time and blood loss were 183 min and 248 mL, respectively,. Hand-assisted method and conversion to open were both 5%. Major morbidity and mortality were 9.2% and 0.4%, respectively,. POPF was noted in 8.1%. The technical steps include (1) mobilization of the splenic flexure of the colon and exposure of the pancreas, (2) dissection along the inferior edge of the pancreas and choosing the site for pancreatic division, (3) pancreatic parenchymal division using a progressive stepwise compression technique with staple line reinforcement, (4) ligation of the splenic vein and artery, (5) dissection along the superior edge of the pancreas and residual posterior attachments, and (6) mobilization of the spleen and specimen removal.

Conclusion

LDP with a clockwise approach for dissection, combined with the progressive stepwise compression technique for pancreatic transection, resulted in excellent outcomes including a very low POPF rate.

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Fig. 1

Reproduced with permission from the Mayo Foundation for Medical Education and Research. All rights reserved

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Abbreviations

LDP:

Laparoscopic distal pancreatectomy

ODP:

Open distal pancreatectomy

LOS:

Length of stay

RAMPS:

Radical antegrade modular pancreatosplenectomy

PDAC:

Pancreatic ductal adenocarcinoma

References

  1. Stauffer JA, Rosales-Velderrain A, Goldberg RF, Bowers SP, Asbun HJ (2013) Comparison of open with laparoscopic distal pancreatectomy: a single institution’s transition over a 7-year period. HPB 15:149–155

    Article  PubMed  Google Scholar 

  2. Sahakyan MA, Kazaryan AM, Rawashdeh M, Fuks D, Shmavonyan M, Haugvik SP, Labori KJ, Buanes T, Rosok BI, Ignjatovic D, Abu Hilal M, Gayet B, Kim SC, Edwin B (2016) Laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: results of a multicenter cohort study on 196 patients. Surg Endosc 30:3409–3418

    Article  PubMed  Google Scholar 

  3. Song KB, Kim SC, Park JB, Kim YH, Jung YS, Kim MH, Lee SK, Seo DW, Lee SS, Park Do H, Han DJ (2011) Single-center experience of laparoscopic left pancreatic resection in 359 consecutive patients: changing the surgical paradigm of left pancreatic resection. Surg Endosc 25:3364–3372

    Article  PubMed  Google Scholar 

  4. Mehta SS, Doumane G, Mura T, Nocca D, Fabre JM (2012) Laparoscopic versus open distal pancreatectomy: a single-institution case-control study. Surg Endosc 26:402–407

    Article  PubMed  Google Scholar 

  5. Jayaraman S, Gonen M, Brennan MF, D’Angelica MI, DeMatteo RP, Fong Y, Jarnagin WR, Allen PJ (2010) Laparoscopic distal pancreatectomy: evolution of a technique at a single institution. J Am Coll Surg 211:503–509

    Article  PubMed  Google Scholar 

  6. Venkat R, Edil BH, Schulick RD, Lidor AO, Makary MA, Wolfgang CL (2012) Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis. Ann Surg 255:1048–1059

    Article  PubMed  Google Scholar 

  7. Xie K, Zhu YP, Xu XW, Chen K, Yan JF, Mou YP (2012) Laparoscopic distal pancreatectomy is as safe and feasible as open procedure: a meta-analysis. World J Gastroenterol 18:1959–1967

    Article  PubMed  PubMed Central  Google Scholar 

  8. Sui CJ, Li B, Yang JM, Wang SJ, Zhou YM (2012) Laparoscopic versus open distal pancreatectomy: a meta-analysis. Asian J Surg 35:1–8

    Article  PubMed  Google Scholar 

  9. Pericleous S, Middleton N, McKay SC, Bowers KA, Hutchins RR (2012) Systematic review and meta-analysis of case-matched studies comparing open and laparoscopic distal pancreatectomy: is it a safe procedure? Pancreas 41:993–1000

    Article  PubMed  Google Scholar 

  10. Jin T, Altaf K, Xiong JJ, Huang W, Javed MA, Mai G, Liu XB, Hu WM, Xia Q (2012) A systematic review and meta-analysis of studies comparing laparoscopic and open distal pancreatectomy. HPB 14:711–724

    Article  PubMed  PubMed Central  Google Scholar 

  11. Nakamura M, Nakashima H (2013) Laparoscopic distal pancreatectomy and pancreatoduodenectomy: is it worthwhile? A meta-analysis of laparoscopic pancreatectomy. J Hepatobiliary Pancreat Sci 20:421–428

    Article  PubMed  Google Scholar 

  12. Mehrabi A, Hafezi M, Arvin J, Esmaeilzadeh M, Garoussi C, Emami G, Kossler-Ebs J, Muller-Stich BP, Buchler MW, Hackert T, Diener MK (2015) A systematic review and meta-analysis of laparoscopic versus open distal pancreatectomy for benign and malignant lesions of the pancreas: it’s time to randomize. Surgery 157:45–55

    Article  PubMed  Google Scholar 

  13. Ricci C, Casadei R, Taffurelli G, Toscano F, Pacilio CA, Bogoni S, D’Ambra M, Pagano N, Di Marco MC, Minni F (2015) Laparoscopic versus open distal pancreatectomy for ductal adenocarcinoma: a systematic review and meta-analysis. J Gastrointest Surg 19:770–781

    Article  PubMed  Google Scholar 

  14. de Rooij T, van Hilst J, van Santvoort H, Boerma D, van den Boezem P, Daams F, van Dam R, Dejong C, van Duyn E, Dijkgraaf M, van Eijck C, Festen S, Gerhards M, Groot Koerkamp B, de Hingh I, Kazemier G, Klaase J, de Kleine R, van Laarhoven C, Luyer M, Patijn G, Steenvoorde P, Suker M, Abu Hilal M, Busch O, Besselink M, Dutch Pancreatic Cancer G (2019) Minimally invasive versus open distal pancreatectomy (LEOPARD): a multicenter patient-blinded randomized controlled trial. Ann Surg 269:2–9

    Article  PubMed  Google Scholar 

  15. de Rooij T, Sitarz R, Busch OR, Besselink MG, Abu Hilal M (2015) Technical aspects of laparoscopic distal pancreatectomy for benign and malignant disease: review of the literature. Gastroenterol Res Pract 2015:472906

    Article  PubMed  PubMed Central  Google Scholar 

  16. Pryor A, Means JR, Pappas TN (2007) Laparoscopic distal pancreatectomy with splenic preservation. Surg Endosc 21:2326–2330

    Article  CAS  PubMed  Google Scholar 

  17. Sun Z, Zhu Y, Zhang N (2015) The detail of the en bloc technique and prognosis of spleen-preserving laparoscopic distal pancreatectomy for pancreatic cancer. World J Surg Oncol 13:322

    Article  PubMed  PubMed Central  Google Scholar 

  18. Shakir M, Boone BA, Polanco PM, Zenati MS, Hogg ME, Tsung A, Choudry HA, Moser AJ, Bartlett DL, Zeh HJ, Zureikat AH (2015) The learning curve for robotic distal pancreatectomy: an analysis of outcomes of the first 100 consecutive cases at a high-volume pancreatic centre. HPB 17:580–586

    Article  PubMed  PubMed Central  Google Scholar 

  19. Machado MA, Surjan RC, Makdissi FF (2015) Laparoscopic distal pancreatectomy using single-port platform: technique, safety, and feasibility in a clinical case series. J Laparoendosc Adv Surg Tech A 25:581–585

    Article  PubMed  Google Scholar 

  20. Ryan CE, Ross SB, Sukharamwala PB, Sadowitz BD, Wood TW, Rosemurgy AS (2015) Distal pancreatectomy and splenectomy: a robotic or LESS approach. JSLS 19:00246

    PubMed  Google Scholar 

  21. Kim SH, Kang CM, Lee WJ (2017) Robotic single-site plus ONE port distal pancreatectomy. Surg Endosc 31(10):4258–4259

    Article  PubMed  Google Scholar 

  22. Kawaguchi Y, Fuks D, Nomi T, Levard H, Gayet B (2015) Laparoscopic distal pancreatectomy employing radical en bloc procedure for adenocarcinoma: technical details and outcomes. Surgery 157:1106–1112

    Article  PubMed  Google Scholar 

  23. Ome Y, Hashida K, Yokota M, Nagahisa Y, Michio O, Kawamoto K (2017) Laparoscopic radical antegrade modular pancreatosplenectomy for left-sided pancreatic cancer using the ligament of Treitz approach. Surg Endosc 31:4836–4837

    Article  PubMed  Google Scholar 

  24. Baumgartner JM, Krasinskas A, Daouadi M, Zureikat A, Marsh W, Lee K, Bartlett D, Moser AJ, Zeh HJ 3rd (2012) Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic adenocarcinoma following neoadjuvant therapy. J Gastrointest Surg 16:1152–1159

    Article  PubMed  Google Scholar 

  25. Abu Hilal M, Richardson JR, de Rooij T, Dimovska E, Al-Saati H, Besselink MG (2016) Laparoscopic radical ‘no-touch’ left pancreatosplenectomy for pancreatic ductal adenocarcinoma: technique and results. Surg Endosc 30:3830–3838

    Article  CAS  PubMed  Google Scholar 

  26. Asbun HJ, Stauffer JA (2011) Laparoscopic approach to distal and subtotal pancreatectomy: a clockwise technique. Surg Endosc 25:2643–2649

    Article  PubMed  Google Scholar 

  27. Strasberg SM, Drebin JA, Linehan D (2003) Radical antegrade modular pancreatosplenectomy. Surgery 133:521–527

    Article  PubMed  Google Scholar 

  28. Stauffer JA, Coppola A, Mody K, Asbun HJ (2016) Laparoscopic versus open distal pancreatectomy for pancreatic adenocarcinoma. World J Surg 40:1477–1484

    Article  PubMed  Google Scholar 

  29. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibanes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien–Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196

    Article  PubMed  Google Scholar 

  30. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M, International Study Group on Pancreatic S (2017) The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 161:584–591

    Article  PubMed  Google Scholar 

  31. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Buchler MW (2007) Postpancreatectomy hemorrhage (PPH): an international study group of pancreatic surgery (ISGPS) definition. Surgery 142:20–25

    Article  PubMed  Google Scholar 

  32. van Hilst J, de Pastena M, de Rooij T, Alseidi A, Busch OR, van Dieren S, van Eijck CH, Giovinazzo F, Groot Koerkamp B, Marchegiani G, Marshall GR, Abu Hilal M, Bassi C, Besselink MG (2018) Clinical impact of the updated international postoperative pancreatic fistula definition in distal pancreatectomy. HPB 20:1044–1050

    Article  PubMed  Google Scholar 

  33. Rosales-Velderrain A, Bowers SP, Goldberg RF, Clarke TM, Buchanan MA, Stauffer JA, Asbun HJ (2012) National trends in resection of the distal pancreas. World J Gastroenterol 18:4342–4349

    Article  PubMed  PubMed Central  Google Scholar 

  34. de Rooij T, Cipriani F, Rawashdeh M, van Dieren S, Barbaro S, Abuawwad M, van Hilst J, Fontana M, Besselink MG, Abu Hilal M (2017) Single-surgeon learning curve in 111 laparoscopic distal pancreatectomies: does operative time tell the whole story? J Am Coll Surg 224:826–832

    Article  PubMed  Google Scholar 

  35. Ricci C, Casadei R, Buscemi S, Taffurelli G, D’Ambra M, Pacilio CA, Minni F (2015) Laparoscopic distal pancreatectomy: what factors are related to the learning curve? Surg Today 45:50–56

    Article  PubMed  Google Scholar 

  36. Nakamura M, Ueda J, Kohno H, Aly MY, Takahata S, Shimizu S, Tanaka M (2011) Prolonged peri-firing compression with a linear stapler prevents pancreatic fistula in laparoscopic distal pancreatectomy. Surg Endosc 25:867–871

    Article  PubMed  Google Scholar 

  37. Ariyarathenam AV, Bunting D, Aroori S (2015) Laparoscopic distal pancreatectomy using the modified prolonged prefiring compression technique reduces pancreatic fistula. J Laparoendosc Adv Surg Tech A 25:821–825

    Article  PubMed  Google Scholar 

  38. Sharpe SM, Talamonti MS, Wang E, Bentrem DJ, Roggin KK, Prinz RA, Marsh RD, Stocker SJ, Winchester DJ, Baker MS (2015) The laparoscopic approach to distal pancreatectomy for ductal adenocarcinoma results in shorter lengths of stay without compromising oncologic outcomes. Am J Surg 209:557–563

    Article  PubMed  Google Scholar 

  39. Shin SH, Kim SC, Song KB, Hwang DW, Lee JH, Lee D, Lee JW, Jun E, Park KM, Lee YJ (2015) A comparative study of laparoscopic vs. open distal pancreatectomy for left-sided ductal adenocarcinoma: a propensity score-matched analysis. J Am Coll Surg 220:177–185

    Article  PubMed  Google Scholar 

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Acknowledgements

The authors would like to thank Mauricia Buchanan for her assistance in collecting data for the purpose of this study.

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Authors and Affiliations

  1. Surgical Oncology Miami Cancer Institute, 8900 N Kendall Drive, Miami, FL, 33176, USA

    Horacio J. Asbun

  2. General Surgery Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA

    Horacio J. Asbun, Levan Tsamalaidze, Lucio Pereira & John A. Stauffer

  3. Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands

    Jony Van Hilst & Marc G. Besselink

  4. Hepato-Biliary-Pancreatic Surgery Division, University of Tokyo, Tokyo, Japan

    Yoshikuni Kawaguchi

  5. HPB Surgery, Washington University in St. Louis, 660 South Euclid Avenue, St. Louis, MO, 63110, USA

    Dominic Sanford

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  1. Horacio J. Asbun
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Correspondence to Horacio J. Asbun.

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All the authors, Dr. Asbun, Dr. Van Hilst, Dr. Tsamalaidze, Dr. Kawaguchi, Dr. Sanford, Dr. Pereira, Dr. Besselink, and Dr. Stauffer, have no conflicts of interest or financial ties to disclose.

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Asbun, H.J., Van Hilst, J., Tsamalaidze, L. et al. Technique and audited outcomes of laparoscopic distal pancreatectomy combining the clockwise approach, progressive stepwise compression technique, and staple line reinforcement. Surg Endosc 34, 231–239 (2020). https://doi.org/10.1007/s00464-019-06757-3

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