Laparoscopic Pancreaticoduodenectomy A Novel Approach Based On ’Five Trocars’with33Cases

Laparoscopic technique has surged in a variety of complex surgical procedures during the last10-15years, with the advantages of less blood loss, shorter recovery time and fewer wound complication. Minimization of the invasiveness of surgical procedures has been considered as an advance that is arguably as significant as the discovery of anesthesia, and is becoming the trend of surgical development in21st century.With the complexity of resection and reconstruction, high rate of risky complications, Pancreaticoduodenectomy is one of the most complicated procedures in hepato-biliary-pancreatir surgery, and it is a major theme to master this procedure. Laparoscopic pancreaticoduodenectomy (LPD) represents one of the most advanced laparoscopic operations as ’Mount Everest’. Gagner and Pomp reported the first LPD in1994and published a case series of10patients in1997subsequently, comprising4cases for converted procedures, with8.5h for mean operative time and22.3days for hospital stay. The outcomes of LPD with quite long operative time and high conversion rate disappointed the surgeons. LPD has been establised safety and feasibility since2007when Palanivelu and colleagues reported a cohort of42LPD patients, which was considered as the first substantial series of LPD. The decreased operative time, less blood loss and shorter recovery time clearly set the challenge to investigate this further. Since then, more and more surgeons are performing LPD. To date, LPD has arisen a new upsurge with more papers and more cases. It has been a routine operation in Mayo Clinic. LPD was first reported in2003in China, and developed slowly during the last10years with the poor peri-operative results.Supported by the Key Project Crant from the Science and Technology Department of Zhejiang Province (No.2011C13036-2) and the Key Subject of Medical Science of Zhejiang Province (11-CX-21), there were33LPDs successfully performed by our team from September2012to April2014,. Here we describe a novel approach of LPD based on "Five Trocars" suitable for the Eastern body habitus and present data regarding the efficacy and safety of LPD.Part One:A Novel Approach of Laparoscopic Pancreaticoduodenectomy Based on ’Five Trocars’Objective:To describe a novel approach of laparoscopic pancreaticoduodenectomy based on "Five Trocars" suitable for the Eastern body habitusMethods:Learning from literature, observing operations when visiting Mayo Clinic, then optimizing the procedure of laparoscopic pancreaticoduodenectomy with the consciousness of the anatomic character of pancreaticoduodenectomy and the view of laparocopy based on’Five Trocars’,Results:Five trocars shaped in "V" were used in the procedure with one12mm trocar along the right midclavicular line. Under the "below-up" vision around the axis of the mesenteric-portal vein, the flow of resection is designed from caudad to cephalad, from anterior to posterior, from left to right. After the retropancreatic window is created and the common bile duct is laced, the resections are performed with transection of the jejunum, stomach, pancreatic neck, pancreatic uncinate, common bile duct in order. The reconstructions with pancreaticojejunostomy, hepaticojejunostomy, gastrojejunostomy are performed.Conclusions:This novel approach based on "Five Trocars" is suitable for the Eastern body habitus. It not only simplifies the technique, but also is more economic. Part Two:Experience on Laparoscopic Pancreaticoduodenectomy based on "Five Trocars" with33CasesObjective:To analyse our early experience on Laparoscopic pancreaticoduodenectomy with the novel approach based on ’Five Trocars’.Methods:This was a study of consecutive patients undergoing laparoscopic pancreaticoduodenectomy by a single team between September2012and April2014. Patient characteristics, operative time, blood loss, postoperative complications, length of hospital stay, and the pathology of tumors were studied.Results:Laparoscopic pancreaticoduodenectomies were performed in consecutive33patients from September2012to April2014. Mean age of patients was58.9years. One of the patients had undergone LDP3years before LPD, and another one underwent LPD combined with laparoscopic right hepatectomy simultaneously (LHPD). The mean operative time was366.67minutes with177.59minutes for resection,52.88minutes for pancreaticojejunostomy,38.52minutes for hepaticojejunostomy,22.11minutes for gastrojejunostomy. The mean blood loss was206.97ml. There were only4patient who need stay in ICU for average of2.25days. Perioperative morbidity occurred in9patients including pancreatic fistula Grade A (n=2), pancreatic fistula Grade B with incision infection (n=1), bile fistula (n=1), bleeding(n=2), bleeding with bile fistula(n=1), pulmonary infection(n=2). There was no postoperative mortality. The median length of hospital stay was16days. Pathologic diagnosis were pancreatic adenocarcinoma (n=9), cholangiocarcinoma (n=5),periampullary adnocarcinoma (n=10) pancreatic neuroendocrine neoplasm (n=2), pancreatic intraductal papillary mucinous neoplasm (n=2), duodenal interstitialoma (n=2), chronic pancreatitis with a suspicious mass lesion (n=l), pancreatic mucinous cystadenoma (n=1), pancreatic solid pseudopaillary neoplasm (n=1). The median follow-up time was5months, and all are alive. Conclusions:This novel approach of Laparoscopic pancreaticoduodenectomy based on ’Five Trocars’ is feasible and safe with good short-term results. As an extreme difficult technique, laparoscopic pancreaticoduodenectomy should be performed in "expert" hands on selected patients with the pathologic characters. Reconstructions should be performed with individual strategies according to the diameters of the pancreatic duct and bile duct.