Retroperitoneoscopic Pancreatic Surgery: Animal Experiment And Initial Clinical Application

Objective:The advantages of retroperitoneoscopy in renal and adrenal gland surgery have been widely acknowledged. Retroperitoneoscopy may also be a useful approach to the pancreas, a retroperitoneal organ. This study aimed to evaluate the feasibility of retroperitoneoscopic pancreatectomy performed in an animal model and a patient cohort, and compared the clinical results with laparoscopic pancreatic surgery. Here, we hoped to provide a new surgical option for pancreatic disease.Methods:1. Initially, retroperitoneoscopic distal pancreatectomy was performed in 6-month-old Yorkshire breed piglets, since the anatomy of and around pancreas in the piglet is similar with in humans.2. Subsequently, the patients with a suspected diagnosis of distal pancreatic lesions were selected to undergo retroperitoneoscopy, included enucleation, distal pancreatectomy, and resection of retroperitoneal lesion. The clinical datas were collected prospectively with approval of institutional review board.3. Initial application of retroperitoneoscopic necrosectomy and drainage in management of severe acute pancreatitis was completed in this study.4. Finally, the clinical results of retroperitoneoscopic pancreatectomy and laparoscopic pancreatectomy were compared.Results:1. In the animal models, retroperitoneoscopic procedures were accomplished smoothly with a mean operative time of 51.6±16.3 min (range,35-70), insignificant blood loss, and only minor complications, between March 2009 and December 2009. Each piglet was euthanized after experiment.2. In clinical practice, a total eight patients were enrolled in this study. Patients with histologically-confirmed pancreatic diseases underwent retroperitoneoscopic enucleation (n=2) or retroperitoneoscopic distal pancreatectomy with splenic preservation (n=2). Operative times ranged from 30-100 min with a controllable blood loss of 10-100 ml. One case of intraoperative retroperitoneal perforation and two cases of pancreatic fistula occurred. All four patients were discharged within 7 days postoperatively. The other three patients with non-pancreatic diseases underwent a retroperitoneoscopic resection with an excellent clinical outcome.3. A 26-year-old male with SAP was enrolled, and the patient underwent 2 cases of Retroperitoneoscopic necrosectomy. Operative time was 60 min and 45 min respectively, blood loss was 20 ml both, three drainage tubes were left after 2nd surgery. Postoperative recovery was fast, length of stay was 48 days after 2nd surgery. Retroperitoneal infection was occurred after 1st surgery, which was cured conservatively, and retroperitoneal perforation during the 2nd surgery was occurred. 4. Compared with laparoscopic pancreatectomy, retroperitoneoscopic pancreatectomy had less operative time and blood loss. Patients under retroperitoneoscopic enucleation of insulinomas got a faster recovery than laparoscopic group. However, a similar recovery procedure was seen between the patients underwent retroperitoneoscopic distal pancreatectomy and laparoscopic distal pancreatectomy. Severe pancreatic fistula occurred in the laparoscopic group, but none in the retroperitoneoscopic group.Conclusions:1. Retroperitoneoscopic distal pancreatectomy was feasible and effective in the piglets, and the majority of distal pancreas could be easily exposed and safely resected under retroperitoneoscopy.2. This was the initial clinical application of retroperitoneoscopic pancreatectomy in the world. Results indicated that, retroperitoneoscopic pancreatectomy, a novel surgical approach, was feasible and effective in selected patients. The advantages of this approach include a short operating time, insignificant blood loss, simple manipulations, minor complications and excellent postoperative recovery times. Additionally, this study suggested that retroperitoneoscopy could also be feasible for the treatment of retroperitoneal non-pancreatic diseases.3. For selected SAP patient, Retroperitoneoscopic necrosectomy is safe and feasible, which has some potential advantages, such as direct surgical approach, simplified manipulation, minor complication and fast recovery.4. Retroperitoneoscopic pancreatic surgery had some potential advantages and its own indication, compared with laparoscopic pancreatic surgery. It had a direct surgical approach, easy manipulation, less operative time and insignificant blood loss, and the distal pancreas was easy to be explosed under retroperitoneoscopy, few organs were disturbed during surgical procedures. Fluent drainage after retroperitoneoscopy could effectively prevent the occurrence of severe pancreatic fistula.