Name: laparoscopic pancreatoduodenectomy for pancreatic cancer using in-situ no-touch isolation technique
Uploaded: 2022-02-02T14:30:00
Description: Watch this Scientific Journal Video about Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique at JoVE.com

The authors have no acknowledgments.

This study was permitted by the Ethics Committee of the Second Affiliated Hospital of Guangzhou University of Chinese Medicine.
1. Patient selection
<ol>
	<li>Advise the patients suspected of suffering pancreatic ductal adenocarcinoma (PDAC) in the pancreas head to take a contrast-enhanced computed tomography (CT) scan at first. Then select the following patients: borderline resectable cases after neoadjuvant therapy, tumor regresses significantly and has the possibility of ...

<ol>
	<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=Pancreatectomy+using+the+no-touch+isolation+technique+followed+by+extensive+intraoperative+peritoneal+lavage+to+prevent+cancer+cell+dissemination:+a+pilot+study.">Pancreatectomy using the no-touch isolation technique followed by extensive intraoperative peritoneal lavage to prevent cancer cell dissemination: a pilot study.</a> Journal of the Pancreas. 6 (2), 143-151 (2005).</li><li>Gall, T. 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=Reduced+dissemination+of+circulating+tumor+cells+with+no-touch+isolation+surgical+technique+in+patients+with+pancreatic+cancer.">Reduced dissemination of circulating tumor cells with no-touch isolation surgical technique in patients with pancreatic cancer.</a> JAMA Surgery. 149 (5), 482-485 (2014).</li><li>Soeth, E., 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=Detection+of+tumor+cell+dissemination+in+pancreatic+ductal+carcinoma+patients+by+CK+20+RT-PCR+indicates+poor+survival.">Detection of tumor cell dissemination in pancreatic ductal carcinoma patients by CK 20 RT-PCR indicates poor survival.</a> Journal of Cancer Research and Clinical Oncology. 131 (10), 669-676 (2005).</li><li>Yap, T. A., Lorente, D., Omlin, A., Olmos, D., de Bono, J. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Circulating+tumor+cells:+a+multifunctional+biomarker.">Circulating tumor cells: a multifunctional biomarker.</a> Clinical Cancer Research. 20 (10), 2553-2568 (2014).</li><li>Fujita, 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+right+hemicolectomy+with+radical+lymph+node+dissection+using+the+no-touch+isolation+technique+for+advanced+colon+cancer.">Laparoscopic right hemicolectomy with radical lymph node dissection using the no-touch isolation technique for advanced colon cancer.</a> Surgery Today. 31 (1), 93-96 (2001).</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 (5), 65-68 (2010).</li><li>Kuroki, T., Eguchi, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=No-touch+isolation+techniques+for+pancreatic+cancer.">No-touch isolation techniques for pancreatic cancer.</a> Surgery Today. 47 (1), 8-13 (2017).</li><li>Tan, Z. 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=Clinical+experience+of+laparoscopic+pancreatoduodenectomy+via+orthotopic+resection.">Clinical experience of laparoscopic pancreatoduodenectomy via orthotopic resection.</a> Zhonghua Wai Ke Za Zhi [Chinese Journal of Surgery. 58 (10), 782-786 (2020).</li><li>Osada, 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=Reconstruction+method+after+pancreaticoduodenectomy.+Idea+to+prevent+serious+complications.">Reconstruction method after pancreaticoduodenectomy. Idea to prevent serious complications.</a> Journal of the pancreas. 13 (1), 1-6 (2012).</li><li>Mizrahi, J. D., Surana, R., Valle, J. W., Shroff, R. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatic+cancer.">Pancreatic cancer.</a> Lancet. 395 (10242), 2008-2020 (2020).</li><li>Tempero, M. 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=Pancreatic+adenocarcinoma,+version+2.2021,+NCCN+clinical+practice+guidelines+in+oncology.">Pancreatic adenocarcinoma, version 2.2021, NCCN clinical practice guidelines in oncology.</a> Journal of the National Comprehensive Cancer Network JNCCN. 19 (4), 439-457 (2021).</li><li>Bockhorn, 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=Borderline+resectable+pancreatic+cancer:+a+consensus+statement+by+the+International+Study+Group+of+Pancreatic+Surgery+(ISGPS).">Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS).</a> Surgery. 155 (6), 977-988 (2014).</li><li>Tee, M. 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=Laparoscopic+pancreatoduodenectomy+does+not+completely+mitigate+increased+perioperative+risks+in+elderly+patients.">Laparoscopic pancreatoduodenectomy does not completely mitigate increased perioperative risks in elderly patients.</a> HPB (Oxford). The Official Journal of the International Hepato Pancreato Biliary Association. 17 (10), 909-918 (2015).</li><li>Palanivelu, 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=Randomized+clinical+trial+of+laparoscopic+versus+open+pancreatoduodenectomy+for+periampullary+tumours.">Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours.</a> The British Journal of Surgery. 104 (11), 1443-1450 (2017).</li><li>Wang, 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+pancreatoduodenectomy+for+pancreatic+or+periampullary+tumours:+A+multicentre,+open-label,+randomised+controlled+trial.">Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours: A multicentre, open-label, randomised controlled trial.</a> The Lancet. Gastroenterology &amp; Hepatology. 6 (6), 438-447 (2021).</li></ol>

PDAC is one of the most lethal malignant diseases. Despite the fact that the overall 5-year survival rates are still unsatisfactory, surgery remains the only curative therapeutic method till now10. According to the National Comprehensive Cancer Network (NCCN) and International Study Group of Pancreatic Cancer (ISGPS), patients diagnosed with PDAC should be defined as borderline resectable cases while the portal-superior mesenteric vein is suspiciously involved, and in order to improve R0 resection...

Pancreaticoduodenectomy (PD) is a standard surgical procedure for cancer in the pancreaticoduodenal region. The Kocher maneuver is widely used for the efficient exposure of the duodenum and pancreatic head during conventional PD. The mobilization and squeezing of the pancreaticoduodenal area during surgery may cause metastasis of the tumor cells before the ligation of surrounding vessels1. A recent study had shown that the tumor cells had the potential possibility of being squeezed into the portal vein (PV) because of the handling and squeezing of the tumor area by the surgeons, which might further increase the risk of liver metastasis after surgery2.
With the development of biomedical technology, a scientist could detect the spread of solid tumor cells, including pancreatic cancer cells, into the vessels as circulating tumor cells (CTC)3,4.
No-Touch isolation procedures, which have been used in colon cancer, might prevent the dissemination of cancer cells, such as circulating tumor cells, from the primary tumor5. Several studies have reported the use of a no-touch isolation technique for pancreatic head cancer during laparotomy pancreaticoduodenectomy6,7. The concept of this procedure is that the surgeon does not touch the duodenum and pancreatic head region (including the tumor) before ligating and dissecting the vessels (arteries and veins) around the pancreatic head.
No-Touch isolation techniques have been reported in LPD for pancreaticoduodenal region neoplasm8. We herein present a modified in-situ No-Touch isolation LPD with partial resection and reconstruction of SMV for pancreatic cancer after neoadjuvant therapy, which dissects all the inflow arteries first, transects the involved vein with sufficient margin, resects the tumor in-situ, and removes the specimen en-bloc.
The goal and advantages of this method are to ensure that all steps follow the oncologic principles of No-Touch in order to decrease the risk of metastasis of the tumor cells. The rationale behind the development and use of this technique is that the tumor should be mobilized at the final stage, including resecting the tumor in situ and removing the specimen en bloc after tumor inflow arteries and outflow veins are occluded. However, as this procedure requires complex resection and reconstruction techniques when surgeons decide whether to use this method, they need to estimate their own situations such as the learning curve, tumor type, vascular condition, and other factors.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>3D Laparoscope</td>
			<td>STORZ</td>
			<td>TC200,TC302</td>
			<td></td>
		</tr>
		<tr>
			<td>Absorbable hemostat</td>
			<td>ETHICON, LLC</td>
			<td>2 in x 4 in</td>
			<td></td>
		</tr>
		<tr>
			<td>Artificial Interposition Graft</td>
			<td>W.L.Gore &#38; Associates, Inc.</td>
			<td>IRTH084040W</td>
			<td></td>
		</tr>
		<tr>
			<td>Drainage tube</td>
			<td>Aiyuan</td>
			<td>424280</td>
			<td></td>
		</tr>
		<tr>
			<td>Echelon Flex Powered Plus Articulating Endoscopic Linear Cutter and Endopath Echelon Endoscopic Linear Cutter Reloads with Gripping Surface Technology</td>
			<td>Ethicon Endo-Surgery</td>
			<td>ECR60G/GST60G</td>
			<td></td>
		</tr>
		<tr>
			<td>Energy Platform</td>
			<td>COVIDIEN ForceTriad Energy Platform</td>
			<td>T2131469EX</td>
			<td></td>
		</tr>
		<tr>
			<td>HARMONIC ACE Ultrasonic Surgical Devices</td>
			<td>Ethicon Endo-Surgery</td>
			<td>HAR36</td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic forceps</td>
			<td>Gimmi</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic right angle forceps</td>
			<td>KARL STORZ</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic scissors</td>
			<td>AESCULAP</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Latex T-shape Catheter</td>
			<td>ZHANJIANG STAR ENTERPRISE CO., LTD.</td>
			<td>24Fr</td>
			<td></td>
		</tr>
		<tr>
			<td>Ligating Clips</td>
			<td>Teleflex Medical</td>
			<td>5,44,22,05,44,23,05,44,000</td>
			<td></td>
		</tr>
		<tr>
			<td>PDSII</td>
			<td>Ethicon, LLC</td>
			<td>W9109</td>
			<td></td>
		</tr>
		<tr>
			<td>PROLENE</td>
			<td>Ethicon, LLC</td>
			<td>W8556</td>
			<td></td>
		</tr>
		<tr>
			<td>Trocar</td>
			<td>Surgaid</td>
			<td>NPCS-100-1-12</td>
			<td></td>
		</tr>
		<tr>
			<td>Ultrasonic Surgical &#38; Electrosurgical Generator</td>
			<td>Ethicon Endo-Surgery</td>
			<td>GEN11CN</td>
			<td></td>
		</tr>
	</tbody>
</table>

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.

A 55-year-old man with upper abdominal pain and marasmus was diagnosed with a 4.2 cm x 3.1 cm tumor in the uncinate process of the pancreas, and the SMV was involved over 180&#176; (Figure 5). The patient was previously healthy and had a relatively normal body mass index (19.47 kg/m2). No distant metastasis was found on the preoperative contrast-enhanced CT scan. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed to acquire the pathology diagnosis of adeno...

Watch this Scientific Journal Video about Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique at JoVE.com

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 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 ...

This protocol demonstrates the feasibility and safety of performing LPD using the in-situ no-touch isolation technique which might elevate the R0 resection rate. The main advantage of this method is to ensure that all steps follow the oncologic principles of no-touch in order to decrease the risk of metastasis in the tumor cells. Due to the complex resection and reconstruction techniques, this procedure can only be performed by experienced surgical teams in high-volume centers with both open and laparoscopic pancreatic surgical skills.This method is an oncological ideal operation process. To begin, explore the intraperitoneal organs and peritoneal surfaces, meticulously, for unexpected extra-pancreatic metastases. Resect the greater omentum and open the lesser sac by dividing the gastrocolic ligament.Then ligate Henle's gastrocolic trunk vein. Explore the gap between the pancreatic neck and SMV at the lower edge of the pancreas. The transverse colon and its mesentery are elevated cephalad.Then expose the second and third parts of the duodenum after the mesentery section. Expose the inferior vena cava, left renal vein, celiac trunk, aorta, and SMA to reconfirm the resectability, and mobilize the posterior of the pancreatic head. Then perform the dissection along the SMV to clear all the tissues on the right side.Ensure that there is no ischemia in the transverse colon. Ligate the root of the middle colonic artery to fully expose the SMV. Place the entire small bowel on the left side to facilitate the exposure, and then expose the dissection of the distal duodenum proximal to the ligament of Treitz.Divide the proximal jejunum with a stapler, and expose the SMA by tracing along the jejunal artery. Place a French 8 catheter for hanging and encircling the dorsal aspect of the SMA and SMV. Pull the catheter to the upper right side to allow SMA dissection on its periadventitial plane on the anterior left margin and its separation from the mesopancreas.Ligate the first jejunal artery involved by the tumor, and sacrifice. Identify the first jejunal vein and the inferior pancreaticoduodenal veins, or IPDV, which are the branches from the dorsal side of the SMV. Ligate and dissect the IPDV.Circumferentially dissect the SMA to identify the inferior pancreaticoduodenal artery, or IPDA, which either forms a common trunk with the first jejunal artery or arises directly from the SMA. Then sacrifice the IPDA. At the left posterior approach, dissect the SMA, which is identified at its origin above the LRV, free from the mesopancreas.Start the SMA approach from the upper colon region. Then, hanging the SMV through a rubber band, use a stapler device to divide the stomach three to five centimeters away from the pylorus. Remove the gallbladder.Divide the common bile duct and apply the laparoscopic bulldog clamps to occlude the CBD temporarily. Then dissect the hepatoduodenal ligament, ligate, then dissect the right gastric artery and identify the gastroduodenal artery. Doubly ligate or suture the GDA and perform a lymphadenectomy along the CHA, the proper hepatic artery, or PHA, and the portal vein.Explore the gap between the pancreatic neck and SMV at the lower edge of the pancreas, and transect the neck of the pancreas with an ultrasound knife. Next, do a frozen pathologic examination of the pancreatic stump. Suspend the splenic vein using a rubber band, and dissect the right and dorsal aspects of the SMA within the diamond-shaped window.Resect the fat and fibrous tissues around SMA and CA from the caudal side to the cephalic side. Ligate and transect the uncinate process artery under the splenic vein, leaving the specimen attached to the splenic vein SMV. Use laparoscopic bulldog clamps to temporarily clamp the splenic vein and the SMV, and transect the involved vein with sufficient margin.After that, cut off the lymphatics and dissect the duodenum from the retroperitoneum. Measure the length of the venous defect with a soft ruler. If the defect exceeds three centimeters, use an artificial interposition graft.Perform SMV reconstruction from caudal to cephalic by continuous suture, using 5-0 Prolene sutures. Then perform a single-layer running suturing hepaticojejunostomy with 4-0 absorbable sutures from end to side. Conduct pancreatic anastomosis by duct-to-mucosal end-to-side pancreaticojejunostomy with an internal stent.Finally, conduct gastrojejunal anastomosis. The representative images show the mass in the uncinate process of the pancreas. Endoscopic ultrasound-guided fine-needle aspiration was performed to acquire the pathology diagnosis of adenocarcinoma.Eight cycles of modified FOLFIRINOX regimen were performed as neoadjuvant chemotherapy on the patient. After neoadjuvant chemotherapy, the maximum diameter of the tumor reduced from 4.2 centimeters to 3.5 centimeters. When attempting this procedure, the steps that require special care include confirmation of resectability and mobilization of the posterior of the pancreatic head, placement of the French 8 catheter for hanging and encircling the dorsal aspect of the SMA and SMV, ligation of the first jejunal artery involved by the tumor, and identification of IPDA.

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