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LAPAROSCOPIC PANCREATIC
SURGERY
GEORGE S. FERZLI, MD FACS
ALPHONSE M. PECORARO, MD FACS
SCOTT D. STEINBERG, MD
QUESTION What is the current role of laparoscopic
surgery with regard to pancreatic disease?
LAPAROSCOPIC PANCREATIC SURGERY
• DIAGNOSTIC
– TUMOR LOCALIZATION
– TUMOR RESECTABILITY
• THERAPEUTIC
– PANCREATIC TUMORS
• ENUCLEATION
• DISTAL PANCREATECTOMY
• PANCREATICODUODENECTOMY
• PALLIATIVE SURGERY
LAPAROSCOPIC PANCREATIC SURGERY
• THERAPEUTIC
– PANCREATITIS
• PSEUDOCYST DRAINAGE
• PANCREATIC DEBRIDEMENT
– PANCREATIC TRAUMA
LAPAROSCOPIC PANCREATIC SURGERY
Tumor Staging With Laparoscopy and
Laparoscopic Ultrasonography
“In cases of ordinary exploratory operation for carcinoma, before having recourse to the usual large incision, the cystoscope is introduced through a very small and relatively unimportant incision, possibly made with cocaine, may reveal general metastases or a secondary nodule in the liver, thus rendering further procedures unnecessary and saving the patient a rather prolonged convalescence.
BERTRAM BERNHEIM, THE JOHNS HOPKINS UNIVERSITY
Bernheim B: Organoscopy: Cystoscopy of the abdominal cavity. Ann Surg 53:764-767,1911
HISTORY• 1911 Bernheim First laparoscopy for
pancreatic cancer in U.S.
• 1978 Cushieri Laparoscopy for staging, diagnosis, and assessmentof resectability in 23 patients with pancreaticcancer
• Prospective study of 88 consecutive patients
• Pancreatic and periampullary adenocarcinoma
• Preoperative evaluation– CT SCAN WITH CONTRAST 88 pts– MRI 20 pts– LAPAROSCOPY 47 pts– ANGIOGRAPHY 85 pts
Preoperative Staging and Assessment of Resectability of
Pancreatic Cancer
Warshaw,A et al: Arch Surg 1990; 125:230-233
RESULTS• Overall resectability 33/88 (38%)
• Laparoscopy found metastatic disease when present in 22/23 patients (96%)
• Laparoscopy found no metastatic disease in 24/24 patients (100%)
Warshaw,A et al: Arch Surg 1990; 125:230-233
CONCLUSIONS• Laparoscopy is particularly sensitive for
detecting small metastases (96%)
• This approach to pancreatic cancer allows the elimination of some operations and tailors others to individual circumstances
Warshaw,A et al: Arch Surg 1990; 125:230-233
The Value of Minimal Access Surgery in the Staging of Patients with
Potentially Resectable Peripancreatic Malignancies
• 115 patients- radiologically resectable
• Extensive laparoscopy performed
– assessment of the peritoneal cavity, liver, lesser sac, porta hepatis, duodenum, transverse mesocolon, and celiac and portal vessels
Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
UNRESECTABILITY• Metastases
– hepatic, serosal, peritoneal
• Extrapancreatic extension– mesocolic involvement
• Nodal involvement– celiac or portal
Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
• Vascular invasion– celiac axis or hepatic artery– portal vein, SMV, SMA
• Potential candidates for resection– Portal vein encroachment– SMV encroachment
UNRESECTABILITY
Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
• No intraoperative or postoperative complications related to laparoscopy
• 67 considered resectable 61 resected
• Laparoscopy failed to identify hepatic metastases in 5 patients and portal venous encasement in 1 patient
RESULTS
Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
LAPAROSCOPY
• Positive predictive index of 100%
• Negative predictive index of 91%
• Accuracy of 94%
RESULTS
Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
Extended laparoscopy is accurate and safe and makes exploration unnecessary in many patients with potentially resectable peripancreatic malignancy
Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
CONCLUSION
Laparoscopic Ultrasound Enhances Standard Laparoscopy in the Staging
of Pancreatic Cancer
• Prospective evaluation of 90 patients
• All patients had preoperative CT abdomen/pelvis and either ERCP or transabdominal sonography
• All patients had laparoscopy and laparoscopic ultrasound
Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
TUMOR LOCATION
PANCREATIC HEAD 64 (72%)
PANCREATIC BODY 19 (21%)
PANCREATIC TAIL 3 (3%)
AMPULLA 4 (4%)
Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
CT LAP LAP SONO
ACTUAL
UNRESECTABLE 17
(19%)
41
(46%)
49
(54%)
50
(56%)
EQUIVOCAL 8
(9%)
13
(14%)
___ ___
Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
RESULTS
LAPAROSCOPIC ULTRASOUND
• SENSITIVITY 100%
• SPECIFICITY 98%
• ACCURACY 98%
Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
CONCLUSION The addition of laparoscopic
ultrasound offers improved assessment and preoperative staging of pancreatic cancer.
Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
SUMMARYStaging laparoscopy should be
performed for all cases of pancreatic cancer prior to attempted resection
The addition of laparoscopic ultrasound improves assessment and preoperative staging of pancreatic cancer
LAPAROSCOPIC WHIPPLE
LAPAROSCOPIC PANCREATICODUODENECTOMY
• Gagner and Pomp – 1996• Strasberg, Drebin, and Soper – 1997• Cuschieri – 1998
CONCLUSION: THE MAGNITUDE OF THE RECONSTRUCTION
MAY OUTWEIGH THE BENEFIT OF THE MINIMALLY INVASIVE APPROACH
Palliative Laparoscopic Surgery for
Unresectable Pancreatic Cancer
Laparoscopic Gastro- and Hepaticojejunostomy for Palliation
of Pancreatic CancerCASE-CONTROL STUDY
14 patients – open palliation
10 patients – laparoscopic palliation
4 patients – diagnostic laparoscopy
Rothlin,M et al;Surg Endosc (1999) 13:1065-1069
RESULTSOPEN
(n=14)
LAP
(n=14)MORBIDITY 43% 7%
MORTALITY 29%
0%
HOSPITAL STAY
21 days
9 daysp<0.06
p<0.05
p<0.05
Rothlin,M et al;Surg Endosc (1999) 13:1065-1069
CONCLUSIONLaparoscopic palliation can
reduce the three major drawbacks of open bypass
surgery-i.e., high morbidity, high mortality, and long hospital stay.
Rothlin,M et al;Surg Endosc (1999) 13:1065-1069
MISCELLANEOUS PANCREATIC NEOPLASMS
STUDY DESCRIPTIONSANCHEZSurg Lap and Endo Vol 4, No 4, 1994
Laparoscopic Resection Of Pancreatic Serous
CystadenomaGAGNER, et alSurgery Vol 120, 1996
Laparoscopic Resection Of Islet Cell Tumors
SPITZ, et alSurg Lap Endo and Perc Tech: Vol10, No3, 2000
Ultrasound Guided Laparoscopic Resection Of
Pancreatic Islet Cell Tumors
PSEUDOCYST DRAINAGE
LAPAROSCOPIC INTERNAL DRAINAGE
Petelin Transgastric
Handsewn
Cystogastrostomy
Litwin & Ross Stapled
Intraluminal
Cystogastrostomy
Way Supracolic Cystogastrostomy
Cushieri Infracolic Cystojejunostomy
Palanivelu L. paracolic handsewn
Cystojejunostomy
PANCREATIC TRAUMA
Laparoscopic Distal Pancreatectomy for Blunt Injury to the Pancreas with
Splenic Preservation
• 10 yo handle bar injury
• CT –free fluid and distal transection of the pancreas
• Distal pancreatectomy with splenic preservation performed
• Reg diet POD 2
• D/C POD 3
Ferzli,G et al; Surg Endosc July2001
Ferzli,G et al; Surg Endosc July2001
Ferzli,G et al; Surg Endosc July2001
Ferzli,G et al; Surg Endosc July2001
Ferzli,G et al; Surg Endosc July2001
Ferzli,G et al; Surg Endosc July2001
Ferzli,G et al; Surg Endosc July2001
SUMMARY• Laparoscopy and laparoscopic
ultrasound are sensitive and specific tools for determining resectability in patients with pancreatic cancer
• Laparoscopic techniques can be used for the treatment of benign and malignant pancreatic diseases and pancreatic trauma