Name: laparoscopic radical left pancreatectomy for pancreatic cancer: surgical strategy and technique video
Uploaded: 2020-06-06T12:30:00
Description: Watch this Scientific Journal Video about Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video at JoVE.com

This technique was originally described by Abu Hilal et al.16.

1. Patient Selection
<ol>
	<li>Select patients with an upfront resectable pancreatic cancer in the pancreas body or tail visible on a recent contrast enhanced CT scan (maximum of 4 weeks old) without downstaging neoadjuvant therapy.</li>
	<li>Exclude patients with metastatic disease or vascular involvement of vessels other than the splenic vein or artery24.</li>
	<li>During training, it is best to exclude patients with a body max index (BMI) &#62; 35 kg/m2, recurrent acute or chronic ...

<ol>
	<li>Sui, C. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+distal+pancreatectomy:+a+meta-analysis.">Laparoscopic versus open distal pancreatectomy: a meta-analysis.</a> Asian Journal of Surgery. 35, 1-8 (2012).</li><li>Venkat, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+distal+pancreatectomy+is+associated+with+significantly+less+overall+morbidity+compared+to+the+open+technique:+A+systematic+review+and+meta-analysis.">Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: A systematic review and meta-analysis.</a> Annals of Surgery. 255, 1048-1059 (2012).</li><li>Pericleous, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Systematic+review+and+meta-analysis+of+case-matched+studies+comparing+open+and+laparoscopic+distal+pancreatectomy:+is+it+a+safe+procedure.">Systematic review and meta-analysis of case-matched studies comparing open and laparoscopic distal pancreatectomy: is it a safe procedure.</a> Pancreas. 41, 993-1000 (2012).</li><li>Jin, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+systematic+review+and+meta-analysis+of+studies+comparing+laparoscopic+and+open+distal+pancreatectomy.">A systematic review and meta-analysis of studies comparing laparoscopic and open distal pancreatectomy.</a> HPB. 14, 711-724 (2012).</li><li>Jusoh, A. C., Ammori, B. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+distal+pancreatectomy:+a+systematic+review+of+comparative+studies.">Laparoscopic versus open distal pancreatectomy: a systematic review of comparative studies.</a> Surgical Endoscopy. 26, 904-913 (2012).</li><li>Xie, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+distal+pancreatectomy+is+as+safe+and+feasible+as+open+procedure:+A+meta-analysis.">Laparoscopic distal pancreatectomy is as safe and feasible as open procedure: A meta-analysis.</a> World Journal of Gastroenterology. 18, 1959-1967 (2012).</li><li>De Rooij, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+Invasive+Versus+Open+Distal+Pancreatectomy+(LEOPARD):+A+Multicenter+Patient-blinded+Randomized+Controlled+Trial.">Minimally Invasive Versus Open Distal Pancreatectomy (LEOPARD): A Multicenter Patient-blinded Randomized Controlled Trial.</a> Annals of Surgery. 269, 2-9 (2019).</li><li>Kim, S. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+analysis+of+clinical+outcomes+for+laparoscopic+distal+pancreatic+resection+and+open+distal+pancreatic+resection+at+a+single+institution.">Comparative analysis of clinical outcomes for laparoscopic distal pancreatic resection and open distal pancreatic resection at a single institution.</a> Surgical Endoscopy. 22, 2261-2268 (2008).</li><li>Mehta, S. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+distal+pancreatectomy:+A+single-institution+case-control+study.">Laparoscopic versus open distal pancreatectomy: A single-institution case-control study.</a> Surgical Endoscopy. 26, 402-407 (2012).</li><li>Melotti, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+distal+pancreatectomy:+Results+on+a+consecutive+series+of+58+patients.">Laparoscopic distal pancreatectomy: Results on a consecutive series of 58 patients.</a> Annals of Surgery. 246, 77-82 (2007).</li><li>Abu Hilal, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+distal+pancreatectomy:+A+clinical+and+cost-effectiveness+study.">Laparoscopic versus open distal pancreatectomy: A clinical and cost-effectiveness study.</a> Surgical Endoscopy. 26, 1670-1674 (2012).</li><li>Richardson, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Implementation+of+enhanced+recovery+programme+for+laparoscopic+distal+pancreatectomy:+Feasibility,+safety+and+cost+analysis.">Implementation of enhanced recovery programme for laparoscopic distal pancreatectomy: Feasibility, safety and cost analysis.</a> Pancreatology. 15, 185-190 (2015).</li><li>Abu Hilal, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+distal+pancreatectomy:+Critical+analysis+of+preliminary+experience+from+a+tertiary+referral+centre.">Laparoscopic distal pancreatectomy: Critical analysis of preliminary experience from a tertiary referral centre.</a> Surgical Endoscopy. 23, 2743-2747 (2009).</li><li>van Hilst, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+Invasive+versus+Open+Distal+Pancreatectomy+for+Ductal+Adenocarcinoma+(DIPLOMA):+A+Pan-European+Propensity+Score+Matched+Study.">Minimally Invasive versus Open Distal Pancreatectomy for Ductal Adenocarcinoma (DIPLOMA): A Pan-European Propensity Score Matched Study.</a> Annals of Surgery. 269, 10-17 (2019).</li><li>Strasberg, S. M., Drebin, J. A., Linehan, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radical+antegrade+modular+pancreatosplenectomy.">Radical antegrade modular pancreatosplenectomy.</a> Surgery. 133, 521-527 (2003).</li><li>Abu Hilal, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+radical+'no-touch'+left+pancreatosplenectomy+for+pancreatic+ductal+adenocarcinoma:+technique+and+results.">Laparoscopic radical 'no-touch' left pancreatosplenectomy for pancreatic ductal adenocarcinoma: technique and results.</a> Surgical Endoscopy. 30, 3830-3838 (2016).</li><li>Abu Hilal, M., Takhar, A. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+left+pancreatectomy:+Current+concepts.">Laparoscopic left pancreatectomy: Current concepts.</a> Pancreatology. 13, 443-448 (2013).</li><li>De Rooij, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pan-European+survey+on+the+implementation+of+minimally+invasive+pancreatic+surgery+with+emphasis+on+cancer.">Pan-European survey on the implementation of minimally invasive pancreatic surgery with emphasis on cancer.</a> HPB. 18, 170-176 (2016).</li><li>Van Hilst, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Worldwide+survey+on+opinions+and+use+of+minimally+invasive+pancreatic+resection.">Worldwide survey on opinions and use of minimally invasive pancreatic resection.</a> HPB. 19, 190-204 (2017).</li><li>Yang, D. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+oncological+safety+in+minimally+invasive+versus+open+distal+pancreatectomy+for+pancreatic+ductal+adenocarcinoma:+a+systematic+review+and+meta-analysis.">The oncological safety in minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis.</a> Scientific Reports. 9, 1159 (2019).</li><li>Van Hilst, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Oncologic+outcomes+of+minimally+invasive+versus+open+distal+pancreatectomy+for+pancreatic+ductal+adenocarcinoma:+A+systematic+review+and+meta-analysis.">Oncologic outcomes of minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: A systematic review and meta-analysis.</a> European Journal of Surgical Oncology. 45, 719-727 (2018).</li><li>O'Morchoe, C. C. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lymphatic+system+of+the+pancreas.">Lymphatic system of the pancreas.</a> Microscopy Research and Technique. 37, 456-477 (1997).</li><li>Van Hilst, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Distal+pancreatectomy,+minimally+invasive+or+open,+for+malignancy.">Distal pancreatectomy, minimally invasive or open, for malignancy.</a> ISRCTN Registry. , (2019).</li><li>Ducreux, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cancer+of+the+pancreas:+ESMO+Clinical+Practice+Guidelines+for+diagnosis,+treatment+and+follow-up.">Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.</a> Annals of Oncology Official Journal of the European Society for Medical Oncology. 26, 56-68 (2015).</li><li>Dokmak, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Double+Gastric+Hanging+for+Gastric+Exposure+in+Laparoscopic+Distal+Pancreatectomy.">Double Gastric Hanging for Gastric Exposure in Laparoscopic Distal Pancreatectomy.</a> Digestive Surgery. , 1-6 (2019).</li><li>Asbun, H. J., Stauffer, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+approach+to+distal+and+subtotal+pancreatectomy:+A+clockwise+technique.">Laparoscopic approach to distal and subtotal pancreatectomy: A clockwise technique.</a> Surgical Endoscopy. 25, 2643-2649 (2011).</li><li>Kim, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Optimal+stapler+cartridge+selection+according+to+the+thickness+of+the+pancreas+in+distal+pancreatectomy.">Optimal stapler cartridge selection according to the thickness of the pancreas in distal pancreatectomy.</a> The American Journal of Medicine. 95, 0 (2016).</li><li>Hirota, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatoduodenectomy+using+a+no-touch+isolation+technique.">Pancreatoduodenectomy using a no-touch isolation technique.</a> The American Journal of Surgery. 199, 65-68 (2010).</li><li>Magge, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+effectiveness+of+minimally+invasive+and+open+distal+pancreatectomy+for+ductal+adenocarcinoma.">Comparative effectiveness of minimally invasive and open distal pancreatectomy for ductal adenocarcinoma.</a> JAMA Surgery. 148, 525-531 (2013).</li><li>Kooby, D. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Left-sided+pancreatectomy:+A+multicenter+comparison+of+laparoscopic+and+open+approaches.">Left-sided pancreatectomy: A multicenter comparison of laparoscopic and open approaches.</a> Annals of Surgery. 248, 438-446 (2008).</li><li>Stauffer, J. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+open+with+laparoscopic+distal+pancreatectomy:+A+single+institution's+transition+over+a+7-year+period.">Comparison of open with laparoscopic distal pancreatectomy: A single institution's transition over a 7-year period.</a> HPB. 15, 149-155 (2013).</li><li>Baker, M. S., Bentrem, D. J., Ujiki, M. B., Stocker, S., Talamonti, M. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+prospective+single+institution+comparison+of+peri-operative+outcomes+for+laparoscopic+and+open+distal+pancreatectomy.">A prospective single institution comparison of peri-operative outcomes for laparoscopic and open distal pancreatectomy.</a> Surgery. 146, 635-643 (2009).</li><li>Jayaraman, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+Distal+Pancreatectomy+Evolution+of+a+Technique+at+a+Single+Institution.">Laparoscopic Distal Pancreatectomy Evolution of a Technique at a Single Institution.</a> ACS. 211, 503-509 (2010).</li><li>van Rijssen, L. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Variation+in+hospital+mortality+after+pancreatoduodenectomy+is+related+to+failure+to+rescue+rather+than+major+complications:+a+nationwide+audit.">Variation in hospital mortality after pancreatoduodenectomy is related to failure to rescue rather than major complications: a nationwide audit.</a> HPB. 20, 759-767 (2018).</li><li>de Rooij, T., Sitarz, R., Busch, O. R., Besselink, M. G., Abu Hilal, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technical+Aspects+of+Laparoscopic+Distal+Pancreatectomy+for+Benign+and+Malignant+Disease:+Review+of+the+Literature.">Technical Aspects of Laparoscopic Distal Pancreatectomy for Benign and Malignant Disease: Review of the Literature.</a> Gastroenterology of Research and Practice. 2015, 472906 (2015).</li></ol>

Advantages of the technique 
LRLP is a standardized, reproducible, and safe procedure if performed by experienced surgeons. Moreover, this minimally invasive procedure offers low intraoperative blood loss, early mobilization, and short hospital stays as confirmed by the LEOPARD trial7. Surgery for pancreatic cancer must aim for a radical resection, adequate lymphadenectomy, and a no-touch dissection to prevent seeding and dissemination of tumor cells16...

Surgical resection combined with systemic chemotherapy is the most effective treatment for resectable pancreatic cancer. Several meta-analyses have shown comparable results for minimally invasive and open distal pancreatectomy for benign and premalignant disease1,2,3,4,5,6. Recently, the first multicenter randomized trial demonstrated a shorter time to functional recovery using laparoscopic distal pancreatectomy (LDP) as compared to open distal pancreatectomy (ODP)7. Although minimally invasive techniques have been shown to be safe and feasible for left pancreatectomy when performed by experienced surgeons8,9,10,11,12,13, the non-inferiority of minimally invasive surgery compared to the open surgical approach for the treatment of pancreatic cancer is still debated14,15,16,17. A pan-European survey showed that 31% of pancreatic surgeons considered ODP superior to minimally invasive distal pancreatectomy (MIDP) in terms of oncological margins and lymphadenectomy in pancreatic cancer18. On both a European and global level, 19&#8211;20% of participating surgeons considered malignancy a contraindication for a minimally invasive approach18,19.
Given the current lack of randomized controlled trials on the effectiveness of MIDP, the only available data to compare the procedures are limited to retrospective and prospective cohort studies. In a recent systematic review and meta-analysis on oncological safety in MIDP versus ODP for pancreatic cancer, no differences between the two groups regarding oncologic outcomes (OR = 0.49, p = 0.12) and overall survival (OS = 3 years, HR = 1.03, p = 0.66; OS = 5 years, HR = 0.91, p = 0.59) were seen20. Another systematic review showed comparable outcomes for MIDP versus ODP in overall survival and a somewhat surprising higher margin-negative (R0) resection rate but at the cost of a lower lymph node dissection in MIDP21.
The radical antegrade modular pancreatosplenectomy (RAMPS) technique, as described by Strasberg in 2003, aims to perform a better, radical resection of pancreatic ductal adenocarcinoma (PDAC) in the body or the tail of the pancreas including resection of Gerota&#8217;s fascia15. The laparoscopic radical left pancreatectomy (LRLP) technique, as described by Abu Hilal et al.16, aims to obtain the same results but during minimally invasive surgery by combining a formal lymphadenectomy with the no-touch technique. Hereby, a radical oncological resection can be obtained with a minimized risk of tumor dissemination and seeding15,22. The standardization of this technique allows for reproducibility and adoption in different health care centers. This paper describes LRLP, because this technique is currently used in the international, multicenter randomized DIPLOMA trial16,23.

<table>
	<tbody>
		<tr>
			<td>Arietta Ultrasound</td>
			<td>Hitachi</td>
			<td></td>
			<td>Intraoperative laparoscopic ultrasonography</td>
		</tr>
		<tr>
			<td>Autosuture Endo Clip applier 5 mm</td>
			<td>Covidien</td>
			<td>176620</td>
			<td>Sling use clip applier, 5 mm</td>
		</tr>
		<tr>
			<td>Blue reload for Echelon 60</td>
			<td>Ethicon</td>
			<td>GST60B</td>
			<td>Regular tissue thickness, open staple height 3.6 mm, closed staple height 1.5 mm</td>
		</tr>
		<tr>
			<td>ECHELON FLEX ENDOPATH 60mm Stapler</td>
			<td>Ethicon</td>
			<td>GST60T</td>
			<td>Powered surgical stapler with gripping surface technology</td>
		</tr>
		<tr>
			<td>Endo Catch II Pouch 15 mm</td>
			<td>Covidien</td>
			<td>173049</td>
			<td>For single lymph node extractions a cut off finger surgical glove can be used.</td>
		</tr>
		<tr>
			<td>Green reload for Echelon 60</td>
			<td>Ethicon</td>
			<td>GST60G</td>
			<td>Thick tissue thickness, open staple height 4.1 mm, closed staple height 2.0 mm</td>
		</tr>
		<tr>
			<td>Harmonic Advanced Hemostasis 36 cm</td>
			<td>Ethicon</td>
			<td>HARH36</td>
			<td>Curved tip, energy sealing and dissecting, diameter 5 mm, length 36 cm</td>
		</tr>
		<tr>
			<td>Hem-o-lok Clips MLX</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544230</td>
			<td>Vascular clip 3 mm &#8211; 10 mm Size Range</td>
		</tr>
		<tr>
			<td>Hem-o-lok clips Xl</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544250</td>
			<td>Vascular clip 7 mm &#8211; 16 mm Size Range</td>
		</tr>
		<tr>
			<td>Hem-o-Lok Polymer Ligation System</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544965</td>
			<td></td>
		</tr>
		<tr>
			<td>LigaSure Dolphin Tip Laparoscopic Sealer/Divider</td>
			<td>Medtronic</td>
			<td>LS1500</td>
			<td>Dolphin-nose tip sealer and divider, 37 cm shaft</td>
		</tr>
		<tr>
			<td>White reload for Echelon 60</td>
			<td>Ethicon</td>
			<td>GST60W</td>
			<td>Mesentery/thin tissue thickness, open staple height 2.6 mm, closed staple height 1.0 mm</td>
		</tr>
	</tbody>
</table>

laparoscopic radical left pancreatectomy for pancreatic cancer: surgical strategy and technique video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

A 61-year-old woman presented with mild liver dysfunction at the surgical outpatient clinic. On both CT and MRI scans, an incidental finding of a 3 cm mass in the pancreatic tail suspect for malignancy was seen with potential involvement of the left adrenal gland (See Figure 2). No distant metastasis or lymph node involvement was seen on the preoperative contrast-enhanced CT scan. Therefore, the patient was deemed suitable for a minimally invasive approach.
The to...

Watch this Scientific Journal Video about Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video at JoVE.com

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

Laparoscopic radical left pancreatectomy for malignancy. Adequate lymph node dissection and radical resection margins are crucial in obtaining safe oncological dissection of tumors in distal pancreatectomy. We demonstrate all steps of the laparoscopic radical left pancreatectomy as described by Abu Hilal, et al.A 61-year-old woman presented with an incidental finding of a three centimeter mass, suspect for malignancy, in the pancreatic tail. No distant metastasis, nor lymph node involvement was present on the preoperative CT scan. The patient was suitable for minimally invasive approach.The operative steps comprised trocar placement, five distinct surgical phases, and closure of the trocar sites. The pneumoperitoneum is created by a Veress needle in the left hypochondrium. First, a diagnostic laparoscopy is performed to exclude peritoneal and liver metastasis.Hereafter, the additional trocars are placed as shown. The exposure phase enables adequate handling of the pancreatic tail and identification of major vessels and planes. After opening the gastrocolic ligament, the short gastric vessels are dissected and ligated in preparation of spleen resection.The stomach is detached from the pancreas and retracted anteriorly. To do so, an umbilical tape is placed around the stomach as described by The anterior plane of the pancreas is now exposed. This enables identification of the splenic vein at the inferior border of the pancreas and incision of Gerota's fascia that remains with the pancreatic specimen.Remember, the inferior mesenteric vein could be inserted into the splenic vein at this position. Therefore, it is wise to consult imaging of this area. The splenic artery is localized at the superior margin of the pancreas.The next step is pancreatic hanging and dissection of Gerota's fascia. First, the pancreatocolic ligament and the splenocolic ligament can be transected. Especially, Gerota's fascia can be transected to expose the anterior aspect of the kidney.Now the pancreas is tunneled at the lateral position. Then it is lifted with the hanging technique. This includes Gerota's fascia that remains with the pancreatic specimen.The splenic and hepatic artery are clearly identified. The splenic artery is either occluded using a bulldog clamp or transected using Hem-o-lok clips or a stapler. Special care should be taken not to mistake the hepatic artery for the splenic artery.The now limited splenic perfusion reduces blood loss during dissection. Secondly in this phase, the pancreatic neck is tunneled and lifted using the same hanging technique. Additional posterior exposure is created anteriorly of the splenic vein.At this area, the stapler will be inserted. The next step is the pancreatic transection. The stapler is closed gently until a resistance is felt.At this point, the surgeon should wait until the resistance is decreased before continuing with compression. This creative compression technique as described by takes four to five minutes and is crucial to avoid rupture of the pancreatic capsule. If needed, sutures for further closure can be applied to the pancreatic stump.From here, the first point of tension will be transection of the splenic vein. After lifting the splenic vein, it is transected either with Hem-o-lok clips or a vascular stapler. The next operative step is the lymph node dissection.Carefully and meticulously, the arteries are freed of lymphatics. Lymphadenectomy should be extended to the left border of the aorta and the left side of the superior mesenteric artery. The left gastric artery should be preserved while performing lymphadenectomy around it.Finally, the dissection is proceeded laterally towards the spleen where any further attachment tissue is taken. Attention should be directed to the dissection of the spleen starting with the gastrosplenic ligament. The spleen is detached from the retroperitoneal adhesions.The last phase is the extraction of the specimen and drain placement. Once free, the specimen is removed with an endobag through a Pfannenstiel incision. The camera should be turned 180 degrees downward to the inferior part of the abdomen.Once surgical drain is placed, this drain enters through the most left-side trocar site and has two extra side holes cut at the location of the splenic fossa for better drainage. Care is taken to avoid direct contact with the pancreas, artery, and vein stump. The fascia of the 12 millimeter port is closed using Vicryl sutures and skin intracutaneously.The total duration of the procedure was 210 minutes with an estimated blood loss of 250 milliliters. Histopathology revealed an R0 resection of a good to moderately differentiated adenocarcinoma. It originated from an intraductal papillary mucinous neoplasm.A total of 15 tumor negative lymph nodes were resected. This is a detailed description of a laparoscopic radical left pancreatectomy for cancer as performed within the DIPLOMA trial.

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Research

JoVE Journal

Medicine

Surgical Procedures for a Rat Model of Partial Orthotopic Liver Transplantation with Hepatic Arterial Reconstruction

Orthotopic liver transplantation (OLT) in rats using a whole or partial graft is an indispensable experimental model for transplantation research, such as studies on graft preservation and ischemia-reperfusion injury 1,2, immunological responses 3,4, hemodynamics 5,6, and small-for-size syndrome 7. The rat OLT is among the most difficult animal models in experimental surgery and demands advanced microsurgical skills that take a long time to learn. Consequently, the use of this model has been limited. Since the reliability and reproducibility of results are key components of the experiments in which such complex animal models are used, it is essential for surgeons who are involved in rat OLT to be trained in well-standardized and sophisticated procedures for this model.
While various techniques and modifications of OLT in rats have been reported 8 since the first model was described by Lee et al. 9 in 1973, the elimination of the hepatic arterial reconstruction 10 and the introduction of the cuff anastomosis technique by Kamada et al. 11 were a major advancement in this model, because they simplified the reconstruction procedures to a great degree. In the model by Kamada et al., the hepatic rearterialization was also eliminated. Since rats could survive without hepatic arterial flow after liver transplantation, there was considerable controversy over the value of hepatic arterialization. However, the physiological superiority of the arterialized model has been increasingly acknowledged, especially in terms of preserving the bile duct system 8,12 and the liver integrity 8,13,14.
In this article, we present detailed surgical procedures for a rat model of OLT with hepatic arterial reconstruction using a 50% partial graft after ex vivo liver resection. The reconstruction procedures for each vessel and the bile duct are performed by the following methods: a 7-0 polypropylene continuous suture for the supra- and infrahepatic vena cava; a cuff technique for the portal vein; and a stent technique for the hepatic artery and the bile duct.

Orthotopic liver transplantation in rats is an indispensable experimental model for biomedical research. Here we present our surgical procedures for orthotopic rat liver transplantation with hepatic arterial reconstruction using a 50% partial graft.

Orthotopic liver transplantation (OLT) in rats using a whole or partial graft is an indispensable experimental model for transplantation research, such as ...

Bioluminescent Orthotopic Model of Pancreatic Cancer Progression

Pancreatic cancer has an extremely poor five-year survival rate of 4-6%. New therapeutic options are critically needed and depend on improved understanding of pancreatic cancer biology. To better understand the interaction of cancer cells with the pancreatic microenvironment, we demonstrate an orthotopic model of pancreatic cancer that permits non-invasive monitoring of cancer progression. Luciferase-tagged pancreatic cancer cells are resuspended in Matrigel and delivered into the pancreatic tail during laparotomy. Matrigel solidifies at body temperature to prevent leakage of cancer cells during injection. Primary tumor growth and metastasis to distant organs are monitored following injection of the luciferase substrate luciferin, using in vivo imaging of bioluminescence emission from the cancer cells. In vivo imaging also may be used to track primary tumor recurrence after resection. This orthotopic model is suited to both syngeneic and xenograft models and may be used in pre-clinical trials to investigate the impact of novel anti-cancer therapeutics on the growth of the primary pancreatic tumor and metastasis.

Improved understanding of pancreatic cancer biology is critically needed to enable the development of better therapeutic options to treat pancreatic cancer. To address this need, we demonstrate an orthotopic model of pancreatic cancer that permits non-invasive monitoring of cancer progression using in vivo bioluminescence imaging.

Pancreatic cancer has an extremely poor five-year survival rate of 4-6%.  New therapeutic options are critically needed and depend on improved ...

Voluntary Breath-hold Technique for Reducing Heart Dose in Left Breast Radiotherapy

Breath-holding techniques reduce the amount of radiation received by cardiac structures during tangential-field left breast radiotherapy. With these techniques, patients hold their breath while radiotherapy is delivered, pushing the heart down and away from the radiotherapy field. Despite clear dosimetric benefits, these techniques are not yet in widespread use. One reason for this is that commercially available solutions require specialist equipment, necessitating not only significant capital investment, but often also incurring ongoing costs such as a need for daily disposable mouthpieces. The voluntary breath-hold technique described here does not require any additional specialist equipment. All breath-holding techniques require a surrogate to monitor breath-hold consistency and whether breath-hold is maintained. Voluntary breath-hold uses the distance moved by the anterior and lateral reference marks (tattoos) away from the treatment room lasers in breath-hold to monitor consistency at CT-planning and treatment setup. Light fields are then used to monitor breath-hold consistency prior to and during radiotherapy delivery.

The current priority in breast cancer radiotherapy is to reduce cardiac doses without compromising target tissue coverage. The voluntary breath-hold technique described here is a simple, inexpensive solution to this problem and capable of being instituted widely without the need for specialized equipment.

Breath-holding techniques reduce the amount of radiation received by cardiac structures during tangential-field left breast radiotherapy. With these ...

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body. With technological development, the robotic surgical system has shown its advantage in minimally invasive surgery and been increasingly applied in central pancreatectomy. However, reconstruction of the continuity of pancreas with end-to-end anastomosis after robotic central pancreatectomy has not been applied. In this study, we report surgical techniques for robotic central pancreatectomy with end-to-end anastomosis. The pancreas is reconstructed by duct-to-duct anastomosis of the pancreatic duct with a pancreatic stent inserted in the two stumps of pancreatic duct, and by end-to-end anastomosis of the pancreatic parenchyma. Compared with traditional central pancreatectomy with pancreaticoenteric anastomosis, this approach decreases the operative injury to the patient, and also conserves the integrity and continuity of the digestive duct and pancreatic duct. The robotic surgical system integrated with multiple instruments with flexible and precise movement is particularly suitable for the dissection and reconstruction of the pancreatic duct. We found that robotic central pancreatectomy with end-to-end anastomosis is safe and feasible, and we need more experience to evaluate its best indications and long-term outcomes.

The robotic central pancreatectomy with end-to-end anastomosis is feasible and safe for tumor in the pancreatic neck and proximal portion of pancreatic body. The operative techniques of this operation are presented.

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of ...

Generating a Murine Orthotopic Metastatic Breast Cancer Model and Performing Murine Radical Mastectomy

In vivo mouse models to assess breast cancer progression are essential for cancer research, including preclinical drug developments. However, the majority of the practical and technical details are commonly omitted in published manuscripts which, therefore, makes it challenging to reproduce the models, particularly when it involves surgical techniques. Bioluminescence technology allows for the evaluation of small amounts of cancer cells even when a tumor is not palpable. Utilizing luciferase-expressing cancer cells, we establish a breast cancer orthotopic inoculation technique with a high tumorigenesis rate. Lung metastasis is assessed utilizing an ex vivo technique. We, then, establish a mastectomy model with a low local recurrence rate to assess the metastatic tumor burden. Herein, we describe, in detail, the surgical techniques of orthotopic implantation and mastectomy for breast cancer with a high tumorigenesis rate and low local recurrence rates, respectively, to improve breast cancer model efficiency.

We introduce a murine orthotopic breast cancer model and radical mastectomy model with bioluminescence technology to quantify the tumor burden to mimic human breast cancer progression.

In vivo mouse models to assess breast cancer progression are essential for cancer research, including preclinical drug developments. However, the majority ...

DIPLOMA Approach for Standardized Pathology Assessment of Distal Pancreatectomy Specimens

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant cancers. A minority (20%) of PDACs are found in the pancreatic body and tail. Accurate pathology assessment of the pancreatic specimen is essential for providing prognostic information and it may guide further treatment strategies. The recent 8th edition of the American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) staging system for pancreatic tumors has incorporated significant changes to tumor (pT) stage, which is predominantly based on tumor size. This change emphasizes the importance of careful block selection. Owing to the greater prevalence of tumors in the head of the pancreas, efforts are made to standardize the assessment of pancreatoduodenectomy specimens. However, consensus regarding the macroscopic assessment of distal (i.e., left) pancreatectomy specimens is lacking. The DIPLOMA approach includes the standardized measurement of pancreas and other resected organs, inking of relevant surgical margins and anatomical surfaces without removing covering layers of fat, measurement of tumor size (for T-stage), together with assessment of splenic vessel involvement (and other organs if present). All relevant margins are assessed, and relevant blocks are selected to confirm these parameters microscopically. The current protocol describes a standardized approach to the macroscopic assessment of distal pancreatectomy specimens. This approach was developed during several meetings with pathologists and surgeons during the preparation phase for an international multicenter trial (DIPLOMA, ISRCTN44897265), which focuses on radicality of distal pancreatectomy for pancreatic ductal adenocarcinoma. This standardized approach can be instrumental in the design of studies and will uniform reporting on the outcomes of distal pancreatectomy. The described technique is used in the DIPLOMA trial for pancreatic ductal adenocarcinoma but may also be useful for other indications.

The current study highlights a standardized approach to the macroscopic assessment of distal pancreatectomy specimens for pancreatic ductal adenocarcinoma, with special emphasis on the measurement of pancreatic dimensions and those of other organs, inking of margins, measurement of tumor size and proximity to margins, lymph node sampling and block selection.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant cancers. A minority (20%) of PDACs are found in the pancreatic body and tail. ...

Organotypic Slice Cultures as Preclinical Models of Tumor Microenvironment in Primary Pancreatic Cancer and Metastasis

Realistic preclinical models of primary pancreatic cancer and metastasis are urgently needed to test the therapy response ex vivo and facilitate personalized patient treatment. However, the absence of tumor-specific microenvironment in currently used models, e.g., patient-derived cell lines and xenografts, only allows limited predictive insights. Organotypic slice cultures (OTSCs) comprise intact multicellular tissue, which can be rapidly used for the spatially resolved drug response testing.
This protocol describes the generation and cultivation of viable tumor slices of pancreatic cancer and its metastasis. Briefly, tissue is casted in low melt agarose and stored in cold isotonic buffer. Next, tissue slices of 300 &#181;m thickness are generated with a vibratome. After preparation, slices are cultured at an air-liquid interface using cell culture inserts and an appropriate cultivation medium. During cultivation, changes in cell differentiation and viability can be monitored. Additionally, this technique enables the application of treatment to viable human tumor tissue ex vivo and subsequent downstream analyses, such as transcriptome and proteome profiling.
OTSCs provide a unique opportunity to test the individual treatment response ex vivo and identify individual transcriptomic and proteomic profiles associated with the respective response of distinct slices of a tumor. OTSCs can be further explored to identify therapeutic strategies to personalize treatment of primary pancreatic cancer and metastasis.

This protocol describes the preparation of organotypic slice cultures (OTSCs). This technique facilitates the ex vivo cultivation of intact multicellular tissue. OTSCs can be used immediately to test for their respective response to drugs in a multicellular environment.

Realistic preclinical models of primary pancreatic cancer and metastasis are urgently needed to test the therapy response ex vivo and facilitate ...

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.
We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

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

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation 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 (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.
The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who ...