Anatomy And Clinical Investigations On Laparoscopic Pancreaticoduodenectomy

With rapid development of minimally invasive surgery, laparoscopic pancreaticoduodenectomy are carried out in more and more hospitals. However, due to pancreaticoduodenectomy involving important structure such as complex organs and pipeline, the consequences are serious if these structure is damaged. Complex digestive tract reconstruction is necessary after resection of head of pancreas and duodenum. Laparoscopic pancreaticoduodenectomy is the most complicated operation of laparoscopic surgery. Laparoscopic pancreaticoduodenectomy is regarded as a new kind of minimally invasive technique and radical resection. With development of technique and surgical therapy mode, laparoscopic surgery will gradually replace traditional open surgery.Application of any kind of new surgical technology is established on the basis of the corresponding clinical anatomy theory. Anatomical plane and anatomical morphology characteristics and the relationship and location and recognition of important structure are different from the traditional open surgery owing to change of observation angle and mode of operative field in laparoscope. As exposure and localization of structure for traditional open operation is not a difficult problem, isolation of fascia and fascia space of region of head of pancreas and duodenum will not affect implementation of the traditional open operation so that the relevant anatomic research of laparoscopic pancreaticoduodenectomy is rare. In order to avoid hemorrhage of operative field in laparoscope, we must follow the principle of separation of fascia space and need a constant anatomical plane for operative localization and distinct the scope and depth of safe operation for lack of sense of direction and distance. Now the study on laparoscopic pancreaticoduodenectomy focuses on clinical application while the study of laparoscopic anatomy is still lagged. Although laparoscopic pancreaticoduodenectomy are carried out by more and more hospitals and clinical experience are accumulated and surgical operation instrument are improved, the number of operation is still relatively scarce. Lack of enough understanding of surgical approach and anatomical rules in laparoscopic operation will inevitably lead to the mistakes and influence implementation of the operation. It is necessary for us to strengthen research of related fascia and blood vessels on the basis of the clinical practice of laparoscopic pancreaticoduodenectomy.At the same time, it is urgent task to be familiar with the anatomical features and the skills of operative field in laparoscope.Part.1 Anatomy study of pancreatic surgery related fascia and fascial spaces1 Background:In order to provide anatomical basis and identify surgical planes or safe routes for pancreatic surgery, adult fresh cadaver specimens were fixed and anatomical observation was made to study the pancreatic surgery related fascia and fascial spaces.2 Objective:In order to provide anatomical basis and identify surgical planes or safe routes for pancreatic surgery, adult fresh cadaver specimens were fixed and anatomical observation was made to study the pancreatic surgery related fascia and fascial spaces.3 Materials and methods:10 formalin-fixed adult cadavers were provided by the Department of Anatomy at Southern Medical University for study. The cadavers(including6 males and 4 females)were perfused with red latex through the abdominal aorta, treated with antiseptic and antibacterial agents and then refrigerated. 5 fresh adult cadavers were selected that provided by body donation reception centers of Southern Medical University. They were perfused with red latex through the femoral artery and placed in -20 C freezer for 1 week before surgery and anatomic observation.4 Results:The fascia surrounding pancreas and duodenum were mostly filled with loose connective tissues and adipose tissues. They were mutually connected with clear fascial borders and easy to be separated and suitable for surgical operation. Integrating spaces were also the connecting borders between different tissues without nerves or blood vessels inside. They may serve as ideal surgical planes for pancreatic surgery.5 Conclusion:A better understanding of the anatomy of the fascia and fascial spaces may provide guidance for identifying surgical landmarks and planes and then help to reduce bleeding and unnecessary side injuries in pancreatic surgery.Part.2 Anatomy study on kocher maneuver approach in laparoscopic pancreaticoduodenectomy1 Background:Because of observation angle and mode of laparoscopic pancreatico-duodenectomy is changed, anatomical plane and anatomical morphology characteristics and the relationship and location and recognition of important structure are different from the traditional open surgery. To avoid hemorrhage of operative field in laparoscope, we must follow the principle of separation of fascia space and need a constant anatomical plane for operative localization and distinct the scope and depth of safe operation for lack of sense of direction and distance. Now the study on laparoscopic pancreaticoduodenectomy focuses on clinical application wheras the study of laparoscopic anatomy is still lagged. With rapid development of minimally invasive surgery, it is not enough to grasp the general anatomical knowledge. Only deep understanding of related fascia and blood vessel of laparoscopic pancreaticoduodenectomy can we do operation better and reduce complications and improve the quality of operation.2 Objective:To study anatomical characteristics of fascias and fascia space and blood vessels in laparoscopic pancreaticoduodenectomy and then provide the anatomical basis theory for laparoscopic pancreaticoduodenectomy.3 Materials and methods:10 formalin-fixed adult cadavers were provided by the Department of Anatomy at Southern Medical University for study. The cadavers(including6 males and 4 females)were perfused with red latex through the abdominal aorta, treated with antiseptic and antibacterial agents and then refrigerated. 5 fresh adult cadavers were selected that provided by body donation reception centers of Southern Medical University. They were perfused with red latex through the femoral artery and placed in -20 C freezer for 1 week before surgery and anatomic observation. Abdominal wall was opened and part of ribs and sternum were removed. Then greater omentum was lifted and the root of transverse mesocolon was separated and the above two layers of the greater omentum was lifted. Fascia and fascia space ahead of pancreas was observed. Then the kocher maneuver of laparoscopic pancreaticoduodenectomy and safety surgical plane were simulated to conduct the autopsy. Fascia and fascia space and blood vessels related to laparoscopic pancreaticoduodenectomy were observed.4 Results:Through the simulation of the kocher maneuver of laparoscopic pancreaticoduodenectomy on ormalin-fixed adult cadavers and fresh corpse, we can observe the pancreas parenchyma surrounding by fascia and fascia space and the retropancreatic fusion fascia.Deviation of fascial space will lead to damage of blood vessels and organs nearby. The important blood vessels supplying for pancreas and duodenum should be protected in laparoscopic pancreaticoduodenectomy where located between the fascia and parenchyma of pancreas. The integrity of fascia in laparoscopic pancreatico-duodenectomy can help to protect blood vessels from damage.5 Conclusion:Fully understanding related fascia and fascia space and blood vessels of kocher maneuver in laparoscopic pancreaticoduodenectomy can we reduce bleeding and unnecessary damage of operation. It can provide the anatomical instruction for laparoscopic pancreaticoduodenectomy with correct identification of anatomical marks and plane.Part.3 Clinical study on posterior approach laparoscopic pancreatico-duodenectomy1 Background:With the rapid development of laparoscopic surgical technology, laparoscopic pancreaticoduodenectomy by posterior approach are carried out in more and more hospitals.Now the study on laparoscopic pancreaticoduodenectomy focuses on clinical application while the study of laparoscopic anatomy is still lagged. Lack of enough understanding of surgical approach and anatomical rules in laparoscopic operation will inevitably lead to the mistakes and influence implementation of the operation. It is necessary for us to strengthen research of related fascia and blood vessels on the basis of the clinical practice of laparoscopic pancreaticoduodenectomy by posterior approach.At the same time, it is urgent task to be familiar with the anatomical features and the skills of operative field in laparoscope.2 Objective:To study related fascia and fascia space and blood vessels of kocher maneuver in laparoscopic pancreaticoduodenectomy by posterior approach. The study try to clarify anatomical marks of vascular localization and method of vascular exposure in laparoscopic pancreaticoduodenectomy by posterior approach.At the same time the study try to clarify the selection of surgical approach and anatomical localization of surgical plane.The operation was evaluated finally.3 Materials and methods:Distribution of blood vessels and position of fascia space and communication were observed in operation with surgical instruments of Germany Wolf laparoscope provided by Johnson Company. A group of 15 patients had been underwent posterior approach laparoscopic pancreaticoduodenctomy and another group of 15 patients had been underwent tradtional pancreaticoduodenctomy during april 2012 to march 2014.The related outcomes of intraoperative and postoperative indicators of the two groups were compared. At the same time, video data of 15 patients of laparoscopic pancreatoduodenectomy by posterior approach(including 8 male cases,7 female cases) was analysed. All operation were successfully completed.4 Results:Fascial space before the pancreas and behind the pancreas and their extension can be observed that are "small surgical plane" in posterior approach laparoscopic pancreaticoduodenectomy. Fusion fascia and fascial space behind pancreas are "big surgical plane"in posterior approach laparoscopic pancreaticoduodenectomy. Deviation of fascial space will lead to damage of blood vessels and organs nearby. Operative vision is an enlarged partial by virtue of separation of fascial space behind pancreas and amplification of laparoscope.It is easy to identify and reveal the structure including of duodenal wall and the space between duodenum and transverse colon and superior mesenteric artery and superior mesenteric vein and inferior vena cava and left renal vein. Inferior vena cava and pancreatic head can be separated completely by fascial space behind pancreas that shortened the operation time and reduced bleeding and conformed the principle of minimally invasive. Meanwhile pancreatic head and duodenum were pulled up toward inside wheras hepatic flexure of transverse colon and transverse colon did not need to be separated apart.Then pancreatic head and gastric antrum and proximal jejunum and indexes of mesenteric root and three tube of hepatoduodenal ligament around can be resected radically. The beginning ministry of the superior mesenteric artery was the mark where left renal vein across above edge of the aorta.5 Conclusions:5.1 Use of the surgical plane and the kocher maneuver in laparoscopic pancreaticoduodenectomy by posterior approach can fully embody the operation principle without damage and radical cure.Laparoscopic pancreaticoduodenectomy by posterior approach is a kind of safe and viable totally laparoscopic pancreaticoduodenectomy.5.2 The beginning ministry of the superior mesenteric artery was exposed better with mark where left renal vein across above edge of the aorta in laparoscopic pancreaticoduodenectomy by posterior approach.5.3 We should pay attention to related blood vessel of pancreaticoduodenal area and appropriate surgical plane in laparoscopic pancreaticoduodenectomy by posterior approach. Blood vessels and fascia and fascia space can be identified easily and surgical complications can be reduced and operation efficiency can be improved by virtue of amplification effect of laparoscope.Part.4 Clinical study on laparoscopic pancreaticoduodenectomy:a meta analysis1 Background:With the rapid development of laparoscopic techniques and urgent requirements of patients for minimally invasive operation, laparoscopic pancreaticoduodenectomy are carried out in more and more hospitals. The clinical effect of laparoscopic pancreaticoduodenectomy is unable to compare with open pancreaticoduodenectomy because of shortage of massive statistical reports and follow-up results.There is a lot of debate about laparoscopic pancreaticoduodenectomy. Related literature is carries out Meta analysis in order to provide an objective basis for laparoscopic pancreaticoduodenectomy.2 Objective:To analyse the feasibility and security of laparoscopic pancreati-coduodenectomy and to make its adaptations clear.3 Methods:Retrieved CNKI, VIP, WanFang, PubMed, MEDLINE, Embase, the Cochrane Library databases by keywords "Laparoscopic pancreaticoduodenectomy; Laparoscopic pancreatic resection", received a total of 874 relevant papers (included 8 papers in this study) and compared the parameters of the laparoscopic pancreatoduodenectomy and the open pancreatoduodenectomy in perioperative period.4 Results:The laparoscopic group had significantly longer operation time[WMD-69.96,95%CI (-83.34,56.57),p<0.01] and had significantly shorter intraoperative blood loss [WMD 363.15,95%CI (87.71,638.54),p<0.01]and had significantly shorter hospital stay [WMD 3.18,95%CI (2.31,4.05),p<0.01] than those in the open group.No significantly differences were detected in the others.5 Conclusion:LPD have certain advantages compared with OPD and can be carried out by the conditional unit.