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

Summary

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota’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.

Abstract

Radical resection margins, resection of Gerota’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's fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota’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 (>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.

Introduction

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 disease^1,2,3,4,5,6. 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)

Protocol

1. Patient Selection

1. 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.
2. Exclude patients with metastatic disease or vascular involvement of vessels other than the splenic vein or artery²⁴.
3. During training, it is best to exclude patients with a body max index (BMI) > 35 kg/m², recurrent acute or chronic .......

Discussion

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.......

Materials

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