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)⁷. Although minimally invasive techniques have been shown to be safe and feasible for left pancreatectomy when performed by experienced surgeons^{8,9,10,11,12,13}, the non-inferiority of minimally invasive surgery compared to the open surgical approach for the treatment of pancreatic cancer is still debated^14,15,16,17. 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, 19–20% of participating surgeons considered malignancy a contraindication for a minimally invasive approach^18,19.

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’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 seeding^15,22. 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 trial^16,23.

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 pancreatitis, previous major upper abdominal surgery, or pancreas targeted radiotherapy.

2. Surgical Technique

1. Operative setting
   1. Place the anesthetized patient in the French position on a bean bag. Place both arms in 90° abduction.
   2. Place sterile drapes so that the suprapubic region is exposed for the Pfannenstiel incision.
   3. Create pneumoperitoneum via a Veress needle at Palmer’s point.
   4. Perform a routine diagnostic laparoscopy to exclude peritoneal and liver metastases.
   5. The procedure is performed using a 5-port technique. Place additional trocars a shown in Figure 1.
      NOTE: Use of laparoscopic ultrasound is advisable for staging and localizing the lesion, thereby determining the extent of the resection.
2. Exploration Phase
   1. Exposure
      1. Divide the gastrocolic ligament approximately 2 cm distal from the gastroepiploic artery and vein, thus opening the lesser sac.
      2. Dissect and ligate the short gastric vessels in preparation of splenectomy. The most superior short gastric vessels may also be spared at this stage to avoid early bleeding without adequate exposure.
      3. Mobilize the stomach from the pancreas and retract upwards. The stomach may be retracted in various ways. Use of umbilical tape around the stomach, after it has been rolled backwards and secured in this position with surgical gauze between the top of the stomach and the surgical tape is recommended.
      4. Extract this tape next to the subxiphoidal trocar and grip using a surgical clamp.
         NOTE: A second piece of tape may pull the pyloric region to the right upper quadrant using a stab incision to extract it²⁵. This second tape is especially useful to obtain maximal exposure of the pancreatic neck and hepatic artery region.
      5. Divide the splenocolic ligament in order to mobilize the splenic flexure and visualize the pancreatic tail. If needed, the lesion is located using laparoscopic ultrasonography. The transection plane of the pancreas in case of pancreatic cancer is at the portal confluence.
      6. Mobilize the lower margin of the pancreas from medial to lateral including the splenic inferior border. At this stage, both the superior and inferior mesenteric vein may be visualized. Incise Gerota’s fascia.
         NOTE: Care should be taken to avoid venous bleeding. Optionally, the splenic flexure of the colon can be mobilized separately using a lateral to medial approach but often this is not required.
      7. Identify the splenic vein at the inferior border of the pancreas.
         NOTE: The inferior mesenteric vein could drain directly into the splenic vein.
      8. Identify the splenic artery at the superior border of the pancreas.
   2. Pancreatic hanging and dissection of Gerota’s fascia dissection.
      1. During the dissection of the posterior plane, mobilize and lift the Gerota’s fascia (i.e., anterior renal fascia).
      2. Create the posterior plane underneath the Gerota’s fascia superior to the adrenal gland toward the superior border of the pancreas. This is an avascular plane. If needed, the adrenal gland can be included (i.e., posterior RAMPS).
      3. Create a tunnel by dissecting the superior pancreatic margin.
      4. Pass a quarter length vessel loop through the tunnel and secure with a nonabsorbable locking clip. Use this to hang the pancreas including Gerota’s fascia.
      5. Identify the splenic artery at the superior border of the pancreas.
      6. Mobilize the splenic artery using blunt and sharp dissection and a pass quarter length vessel loop.
      7. Transect the artery using 3–4 nonabsorbable locking clips. Alternatively, a vascular endostapler may be used.
         NOTE: The splenic artery must not be transected until the entire anatomy, especially the hepatic artery, is visualized and confirmed. If the splenic artery cannot be visualized from the pancreatic superior margin, it may identified from beneath the pancreas or by following the hepatic artery towards the celiac artery.
      8. Perform the same tunneling procedure at the pancreatic neck, on the right side of the pancreatic lesion, mostly above the confluence/portal vein.
      9. The two vessel loops can be held by an assistant to literally hang the pancreas and expose the posterior margin during the retroperitoneal dissection.
      10. Determine the transection plane at the inferior border of the pancreas.
      11. Mobilize the remaining part of the pancreas, including Gerota’s fascia, exposing the anterior aspect of the kidney.
   3. Pancreatic transection
      1. Pull the pancreas ventrally using the vessel loops.
      2. Transect the pancreas at the neck using a stapler with a graded compression technique (vascular or thicker cartridge, based on the pancreatic thickness and texture at the transection level)²⁶.
         NOTE: With this technique, the stapler is closed very slowly, in steps, until resistance is felt. Before continuing with the compression, the surgeon should wait for 20–30 s until the resistance decreases. The entire process typically requires 4–5 min before the stapler is completely closed. Faster closure often leads to rupture of the pancreatic capsule²⁷. If needed, sutures can be applied to the pancreatic stump in case of rupture or bleeding.
      3. Identify the left gastric vein and the splenic vein. Clip and transect the left gastric vein.
      4. Mobilize the splenic vein, pass and secure a vessel loop.
      5. Hereafter, place 3–4 locking clips on the splenic vein: two on the patient site and at least one on the specimen site. In case of lack of space, an additional metal clip may be placed on the specimen site.
         NOTE: The standard order of transection is splenic artery, pancreas, splenic vein. This order may be varied based on local anatomy (e.g., by transecting the pancreas first). However, if the splenic vein is transected before the splenic artery, there will be venous congestion with increased risk of conversion due to bleeding.
   4. Lymph node dissection
      1. Dissect the lymph nodes in a clockwise fashion, according to the description of Strasberg’s RAMPS procedure¹⁵.
      2. Start with lymph node station 8A at the hepatic artery and station 9 at the celiac trunk.
         NOTE: If possible, the left gastric artery should be preserved while performing lymphadenectomy. If needed, it can be resected.
      3. Extend the lymphadenectomy to the left border of the aorta and the left side of the superior mesenteric artery.
      4. Proceed with the dissection laterally towards the spleen, where any further attached tissue is taken, including the Gerota’s fascia.
      5. Detach the spleen by transecting the gastrosplenic ligament, splenorenal ligament, and retroperitoneal adhesion.
   5. Extraction and drain placement
      1. Once the spleen is detached, remove the specimen using an endo-bag through a Pfannenstiel incision. Turn the camera 180° to the inferior part of the abdomen to visualize the extraction of the specimen.
      2. The Pfannenstiel incision should be an approximately 6 cm transverse skin incision and 8 cm transverse fascia incision where the midline is divided between both rectus muscles.
      3. Take caution during the extraction to avoid small bowel injury and compromising of the specimen for pathological assessment.
      4. Place one surgical drain. This drain enters through the left most trocar site, loops with 2–3 additional holes through the splenic bed, runs under the stomach, and ends next to the pancreatic stump.
         NOTE: Care must be taken to avoid direct contact with the pancreas, artery, and vein stump.
   6. Closure
      1. Close the peritoneum using an absorbable braided suture and the fascia with a monofilament absorbable suture.
      2. Re-insufflate the abdomen.
      3. Confirm hemostasis at the transection planes.
      4. Revert all loops and the gastric hanging.
      5. Inspect the stomach for any injuries.
      6. Close any fascia defect larger than 5 mm using an absorbable multifilament suture.
      7. Close the skin intracutaneously using an absorbable monofilament suture.

Results

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...

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