ROLE OF LAPAROSCOPY IN PANCREATIC SURGERY
C Palanivelu, Ps Rajan, K Sendhil Kumar,R ParthasarathiCoimbatore Institute of Gastrointestinal Endo Surgery (CIGES), Coimbatore-641002.
Minimal access techniques for the diagnosis and treatment of pancreatic diseases are evolving. Apart from the advantages of laparoscopic surgery such as improved cosmesis, diminished pain, shorter hospitalization and return to work, the incidence of atelectasis and pneumonia is less in laparoscopic than conventional open approach.
Laparoscopic procedures for pancreatic diseases fall in the one of the following categories:-
1.Confirmation of diagnosis-e.g-Acute pancreatitis from other clinical diagnosis.
2.Pancreatic tumour localization. Laparoscopic ultrasound evaluation of endocrine tumours.
3.Staging of malignancy e.g pancreatic cancer.
a.Pancreatic Resection Distal pancreatectomy with or without splenectomy, pancreatoduodenectomy(Whipple’s)
b.Enucleation of tumour
c.Biliary or bypass procedures
d.Decompression and pancreatic drainage procedures in obstructive pancreatic ducts.
e.Internal drainage of pseudocyst pancreas.
f.Treatment of complication of pancreatitis
- Drainage of abscess
- External drainage of infected pseudocyst.
A. Distal Pancreatic Resection
The experience with laparoscopic distal pancreatic resection has been entirely favourable, with benefit to the patient in terms of post operative recovery, minimal morbidity and short hospital stay.
- Distal benign tumours of pancreas
-Cystadenomas-spleen can be preserved or enbloc included in resection depends on size of the tumour.
- Intractable pain in chronic pancreatitis.
- Obese patients-exposure of pancreas is difficult and tedious.
- Upper abdominal surgery.
- If tumour is not locatable by laparoscopy, it is better to convert to open surgery.
Laparoscopic contact ultrasonography is extremely useful during laparoscopic pancreatic surgery - aids in the selection of transection line.
Laparoscopic distal pancreatectomy with preservation of spleen is indicated to benign, well localised neuroendocrine tumours.The experience of laparoscopic distal pancreatectomy is entirely favourable.
Only few cases have been shown in the literature. (Table 1)
TABLE 1 :
Reported Results (1999)
Name No.of Patients Conversion Hospital Stay Cushieri et al 7 1 7 Gagner et al 7 3 5 Vezakis et al 6 2 10 Lozoche et al 2 — 6 Sussman et al 1 — 5 Palanivelu et al 1 — 5
In functioning tumours, venous sampling may be performed wherever possible. Control of splenic artery is advisable to minimise bleeding as an initial step. In our case since the tumour was in the body, splenic artery could be ligated after complete mobilisation. It took 150 minutes for completion, bleeding was minimal and the post operative recovery was remarkable. There was no ileus, pain was minimal. She was on normal diet on the 2nd post operative day and discharged on 5th post operative day.
B. Laparoscopic pancreatoduodenectomy (Whipple’s) Operation
With advent of new equipment and increasing clinical experience, more and more complex procedures are being successfully done by laparoscopy to treat complicated diseases. Laparoscopic pancreatoduodenectomy and reconstruction for periampullary carcinoma, though time consuming, technically possible and may become the standard technique in future. Large series of cases have to be studied before firm opinion.
The first laparoscopic pancreatoduodenal resection was performed by Gagner in 1992 and his experience of 9 patients reported in the 6th World congress showed inconclusive results. Majority of these were performed by hand assisted. Incidence of complications were also similar to conventional surgery. His experience paved the way for evolving good techniques and better results.
First Indian Report : Our report is the second in the history of laparoscopic Whipple’s operation. On July 17th 1999, we treated a lady aged 54 years with obstructive jaundice due to periampullary carcinoma successfully by laparoscopic pylorus preserving pancreatoduodenectomy exactly following the principles of conventional pancreatoduodenectomy. Entire biliary and pancreatic reconstruction was performed by intracorporeal hand sewn anastomotic technique. There was very little blood loss. Although we took 11 hours to complete the procedure, the post operative recovery was remarkable. There was no ileus and the post operative pain was significantly less. She was on normal diet on 4th post operative day. 2nd case of Laparoscopic Whipple’s operation took only 7 hours. Our initial experience has shown laparoscopic Whipple’s may be preferred in selected patients with early malignancy. Our video bagged the Sages 2000 video library award. Dulucq, France has performed one laparoscopic pancreatoduodenal resection (personal communication).
ENUCLEATION OF PANCREATIC ENDOCRINE TUMOURS
Laparoscopic accurate localization and enucleation has been established as a standard procedurein many centres. The results have shown that laparoscopic approach is more advantageous than conventional.
BILIARY AND GASTRIC BYPASS PROCEDURES
At present most patients with obstructive jaundice due to advanced malignancy, unsuitable for resection are managed either endoscopic stenting or open surgery. Although there is no difference with survival, patients with stents have more frequent readmissions for recurrent cholangitis and jaundice due to stent occlusion, needs repeated stent replacement. Laparoscopic bypass has less morbidity and mortality than open bypass with added advantages over stenting as the incidence of recurrent jaundice and cholangitis is less. We have performed biliary bypass in five patients - laparoscopic cholecystojejunostomy and hepaticojejunostomy; of these 2 cases, gastrojejunostomy was done as well. Results are gratifying.
PANCREATIC DUCT DECOMPRESSION AND DRAINAGE PROCEDURE
Chronic obstructive calculous pancreatitis is found at a higher incidence in southern part of India. In selective patients, pancreatic duct decompression and lateral pancreatojejunostomy (modified Puestow’s operation) is the preferred procedure. The same can be performed by laparoscopic approach. Skills in intracorporeal suturing and knot tying technique is mandatory.
In chronic calculous obstructive pancreatitis decompression of the pancreatic duct and lateral pancreatojejunostomy with preservation of the tail end of the pancreas is the standard approach in conventional surgery. The same equivalent can be achieved by Laparoscopic approach. Till today only two surgeons, Gagner (USA) and the author have performed this procedure successfully. Among operations where laparoscopic suturing is required to be performed by intracorporeal method. I consider pancreatojejunostomy as one of the most difficult procedures. Adequate experience is of utmost importance. Our video presented in the 6th World congress Italy, was widely appreciated. Experience in intracorporeal knot tying and suturing is very essential to perform such anastomosis.
Various types of laparoscopic internal drainage procedures developed by various authors
J Petelin USA Transgastric-Handsewn Cystogastrostomy Litwin & Ross Stapled-Intraluminal Cystogastrostomy L way USA Supracolic Cystogastrostomy Cushieri, UK Infracolic Cystojejunostomy C Palanivelu, India Left Paracolic-Hand sewn Cystojejunostomy
INTERNAL DRAINAGE OF PSEUDOCYST
Pseudocyst accounts for over 75% of the cystic lesions of the pancreas. It contains high concentration of pancreatic enzymes and lack of an epithelial lining. Persistence of a pseudocyst implies an ongoing communication with the pancreatic duct.
ERCP is selectively done in patients with biochemical evidence of ampullary obstruction, all recurrent pseudocyst, pseudocyst arising months after recovery from pancreatitis.
• The finding of a cystic structure in or near the pancreas in a patient with no past history of pancreatitis, trauma or surgery, the diagnosis of pseudocyst is unlikely. Other differential diagnosis should be considered in this circumstances.
Therapy : Pseudocyst pancreas presenting more than 4-6 weeks after the onset of acute pancreatitis and the size more than 6 cm is treated by internal drainage in to the stomach, duodenum or jejunum depending on the location of the pseudocyst.
Treatment of pancreatic pseudocyst has traditionally been surgical and remains the principal method of treatment.
* Eventhough new innovative therapies like endoscopic internal fistula formation, percutaneous pancreatic cystogastrostomy by stenting have been developed, they have not attained popularity due to higher incidence of recurrence.
* More recently intraluminal stapled laparoscopic cystogastrostomy have been developed in which anterior gastrostomy has been avoided. Though it is less time consuming, it is too early to comment the stricturing of the stoma.
* Internal drainage of non resolving pseudocyst can be effectively performed by laparoscopic cystogastrostomy, by this an adequate surgical anastomosis is carried out without laparotomy. Cost of the procedure may be reduced by using reusable trocars and instruments and intracorporeal hand suture techniques.
Pseudocysts located in other than retrogastric area are treated by cystojejunostomy. Cystojejunostomy may be performed either by supracolic or infra colic approach. In three of our patients, pseudocysts were extending unusually down to the left iliac fossa. As it is difficult to treat by any method described earlier, we treated them successfully by laparoscopic Roux-en-Y cystojejunostomy through left paracolic approach.
TREATMENT OF COMPLICATIONS OF PANCREATITIS
Indications of Laparoscopy
1.Pancreatic necrosis-Debridement and drainage.
2.Infected acute pseudocyst - External drainage.
Laparoscopic debridement hastens recovery from acute severe pancreatitis if imaging investigation such as CT, MRI reveals pancreatic necrosis and to some extent also prevent infection. Conventional operation has shown higher incidence of secondary infection. Supra and infracolic approach may be preferred for debridement or external drainage of pancreatic abscess.
Although the recurrence rate of pseudocyst is higher immature pseudocyst particularly infected cyst, external drainage is preferred in order to prevent spread of infection to the lesser sac. In four patients drainage of pancreatic abscess and drainage of infected acute pseudocyst was carried out. In 3 cases where laparoscopic external drainage was performed, pseudocyst recurred in one patient and while another had pancreatic fistula. Internal drainage was performed later in both the cases successfully by laparoscopic method.
Laparoscopy has definite indications both in diagnostic and therapeutic pancreatic disorders. Proper selection is of utmost importance for successful performance. Adequate experience particularly in endocorporeal knotting and suturing is considered vital for Laparoscopic Pancreatic surgery.
1.Prinz RA, Kaufman BH, Folk FA, Greenlee HB. Pancreatojejunostomy for chronic pancreatitis. Arch 1978; 113 : 520.
2.Herbert B, Green EE, Roux en Y. Pancreaticojejunostomy