|Year : | Volume
| Issue : | Page :
Considerations in laparoscopic resection of giant pancreatic cystic neoplasms
Srikanth Gadiyaram, Murugappan Nachiappan, Ravi Kiran Thota
Department of Surgical Gastroenterology and MIS, Sahasra Hospital, Bengaluru, Karnataka, India
|Date of Submission||17-May-2021|
|Date of Acceptance||01-Oct-2021|
|Date of Web Publication||04-Jan-2022|
Department of Surgical Gastroenterology and MIS, Sahasra Hospital, New No 30, 39th Cross, Jayanagar 8th Block, Bengaluru - 560 082, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Laparoscopic distal pancreatectomy (LDP) with (LDPS) or without splenectomy for cystic tumours in the body and tail has become the standard of care. Data on patients with large tumours of the body and tail of the pancreas are sparse.
Patients and Methods: A retrospective analysis of a prospectively maintained database of patients who were managed with laparoscopic surgery for pancreatic cystic neoplasm since 2010 was done. Patients with cysts more than 8 cm were analysed. Clinical presentation, imaging, details of the surgical procedure and the outcomes were looked into.
Results: Five patients of giant pancreatic cystic neoplasm (GPCN) were managed with LDPS. Four patients were female, mean age was 45 years (range 15–69 years). The mean cyst size was 11.2 cms (range 8–15 cm). The splenic vein was either stretched or thrombosed in all patients. Three patients had sinistral portal hypertension. All patients were operated with a modified five-port placement. None of the patients required conversion. Mean operative duration was 3½ h, blood loss was 80 ml approximately and none required a blood transfusion. One patient had a biochemical leak. All patients were discharged from the hospital by 3rd postoperative day. Drain removal was done before discharge except in the patient with biochemical leak (removed on day 6). On a median follow-up of 89 months (range 1–120 months), two patients developed diabetes. There has been no Overwhelming post-splenectomy infections (OPSI).
Conclusion: Laparoscopic distal pancreatectomy is feasible in patients with GPCN and offers the all the short-term benefits, namely lesser pain, no wound infections, early return of bowel activity, early return to orals and early discharge and early return to work. Splenectomy was required in all patients because of splenic vein thrombosis and portal hypertension in three and for technical reasons in the rest.
Keywords: Cystic neoplasms, distal pancreatetomy, giant pancreatic cysts, laparoscopy, pancreas, splenectomy
| ¤ Introduction|| |
Laparoscopic distal pancreatic resection was reported by Gagner et al. in the 90s. The feasibility and safety of this procedure with results comparable to open procedure have been reported by multiple groups. International study group on minimally invasive pancreas surgery in the Miami International Evidence-based guidelines recommended that minimally invasive distal pancreatectomy should be considered over open distal pancreatectomy for benign and low-grade malignant tumours (Grade 1b recommendation). Laparoscopic distal pancreatectomy (LDP) with (LDPS) or without splenectomy for cystic tumours in the body and tail has become the standard of care. Data on patients with large tumours of the body and tail of the pancreas is sparse. We describe a short series of giant pancreatic cystic neoplasms (GPCN), namely operative challenges and how they are overcome and follow-up in patients undergoing a laparoscopic distal pancreatectomy.
| ¤ Patients and Methods|| |
Records of patients who underwent LDPS for giant cystic tumours (≥8 cm in diameter) by first author since 2010 were reviewed. Clinical profile, imaging studies, operation details and postoperative course of these patients were studied. Follow-up was recorded at periodic outpatient visits. Details of exocrine, endocrine deficiency were recorded. A telephonic follow-up was done in all patients on 1 May, 2021. All patients received pre-operative pre-splenectomy prophylaxis. Patients were operated under general anaesthesia in a leg-split position with the operating surgeon standing between the legs, LDPS was done using a five-port technique [Figure 1]. The operative procedure was accomplished as follows.
|Figure 1: (a) Standard port placement for distal pancreatectomy, (b) Modified port placement for a giant pancreatic cystic neoplasm with camera shifted to the right side of the umbilicus and right-hand working port at the umbilicus, (c) Operative theatre setting showing the position of the patient and the operating team. C: Camera, R: Right-hand working port, LS: Left-hand working port, A: Retraction port, also used for stapling, LR: Assistant retraction port|
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Step 1. Closed pneumoperitoneum (14 mm Hg), Camera port inserted and rest of the ports under laparoscopic vision
Step 2. Opening of lesser sac by dividing the gastrocolic omentum using Harmonic ACE (Ethicon) or LigaSure™ (Medtronic Inc) when collateral vessels of 4-5 mm were encountered. A wide exposure of lesser sac is got by placement of gastric retraction suture as described by Srikanth et al.
Step 3. Splenic artery is dissected and ligated in continuity.
Step 4. Dissection begun along inferior border of pancreatic body region, and splenic flexure was taken down.
Step 5. Developing the tunnel posterior to neck of pancreas and looping it, followed by staple transection with Endo GIA™ Auto Suture™ Universal Articulating Load (60 mm-3.5 mm) in four of our patients and Endo GIA™ 60 mm Articulating Reload with Tri-Staple™ technology (Medium/Thick) in the remaining one. In one patient, the pancreatic body was staple transected to the left of superior mesenteric–portal vein, including the splenic vein but excluding the splenic artery and our preference for stapling cartridge was not influenced by this. In the rest, the transection of neck was achieved separately and splenic vessels were dealt with as under. Stapling of the pancreatic neck was done gradually after tightening and compression for 1 min followed by firing over 30 s and the transection over the next 15 s. SEAMGUARD™ staple line reinforcement was used in two patients during staple transection.
Step 6. Splenic vein and artery are secured with ligatures/hem-o-lok clips.
Step 7. Mobilisation in a 'medial to lateral' fashion in an avascular retroperitoneal plane behind pancreatic body and tail till lienorenal ligament, which is divided subsequently. LigaSure™ was used when collaterals were encountered. A blunt tipped instrument is passed from epigastrium and directed towards lower pole of spleen and posterior to the cyst to lift the distal pancreas, cyst and spleen 'en bloc' in the cranial direction gently. This facilitates medial to lateral dissection.
Step 8. Short gastric vessels are divided, and the specimen is bagged.
Step 9. Haemostasis, irrigation and suctioning followed by drain placement (28F tube) next to the transected border of pancreas.
Step 10. Retrieval of specimen was done through Pfannenstiel incision in two and subcostal incision (5–6 cm, by joining left midclavicular and left anterior axillary port sites) in the remaining three.
Step 11. Closure of extraction wound site in layers (muscle with running No1 PDS). Sheath at port sites (size 10 mm and 12 mm) closed with no1 vicryl suture. Skin was stapled.
| ¤ Results|| |
Forty-one patients underwent distal pancreatectomy during the study period. Of these 41 patients, 26 had a laparoscopic resection and two of them required a conversion to open operation (both cases of neuroendocrine tumours). There were fourteen patients of cystic neoplasms and all of them had a successful laparoscopic resection. Out of these fourteen patients, five patients had a lesion more than 8 cm and formed the part of this study. Demographic features and clinical profile of patients are shown in [Table 1]. The mean cyst size was 11.2 cm (range 8–15 cm). The first two patients presented with pain abdomen which led to detection of the cystic tumours on ultrasound (USG). Cases 3 and 4 were asymptomatic and detected on USG during routine health check. Case 5 presented with a history of pain abdomen with radiation to back of 10 days duration. Multi detector computed tomography (MDCT) and magnetic resonance imaging with cholangio-pancreatography (MRI with MRCP) were performed in all patients.
All patients had the splenic artery stretched out around the cranial parts of the lesion. Splenic vein was stretched and displaced in the first two and thrombosed in the last three patients. An upper gastrointestinal endoscopy was done in all patients. Two of the three patients with splenic vein thrombosis had gastric varices. However, none of them had a history of bleed or was anaemic at presentation. An endoscopic ultrasound (EUS) was performed in four patients. None of the patients had a dilated pancreatic duct. The imaging characteristics clearly suggested serous cystadenoma (SCN) in one solid cystic papillary neoplasm (SCPN) in two and mucinous cystic neoplasm in two others [Figure 2]. All procedures were completed successfully by laparoscopy [Figure 3] and [Figure 4]. Operative details, postoperative morbidity and histopathology of resected specimens are shown in [Table 2].
|Figure 2: (a) Contrast-enhanced computed tomography of a solid cystic papillary neoplasm replacing the entire body and tail of the pancreas showing stretched out splenic vein, (b) Contrast-enhanced computed tomography of a large mucinous cystic neoplasm abutting the portal vein and in close proximity to the superior mesenteric artery, (c) Endoscopic ultrasound of a serous cystic neoplasm demonstrating honeycombing|
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|Figure 3: Operative photographs (a) Retro-pancreatic tunnel developed at the region of the pancreatic neck anterior to the portal vein, (b) Transection of pancreatic neck, (c) looping of the splenic vein close to its drainage into the portal vein, note the space constraint in the presence of a large pancreatic cyst, (d) ligation of the splenic artery after transection of the pancreatic neck|
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|Figure 4: (a) Extraction of solid cystic papillary neoplasm by a subcostal incision, (b) cut open specimen of a solid cystic papillary neoplasm, (c) cut open specimen of a mucinous cystic neoplasm|
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All five patients made an uneventful postoperative recovery. None of the patients received peri-operative somatostatin analogues. Oral intake was started on 1st postoperative day and surgical drain was removed by the 3rd postoperative in 4 out of 5 patients and 6th postoperative day in one (at first follow-up visit). She had a biochemical leak which settled with conservative management. There were no wound infections or pancreatic fistulae. An upper GI endoscopy was done at 3 months in both the patients with gastric varices. It showed resolution of varices in both. On follow up of 89 months (range 1–120 months), two patients developed diabetes, one at 6 months and the other at 2 years after surgery. None of them had exocrine deficiency. There has been no OPSI in any of these patients till date.
| ¤ Discussion|| |
LDP has become the standard of care in patients with cystic neoplasms and neuroendocrine tumors of body/tail of the pancreas and the indications are expanding to include adenocarcinoma of body/tail pancreas in carefully selected patients., There are few case reports of LDP for large pancreatic cystic neoplasms.,,, There has been a bias towards open surgery in managing large cyst of the pancreas with case series showing the significant difference in size of the cyst between open and laparoscopy. This is because of technical difficulties with the laparoscopic approach related to large size resulting in limited 'working space', difficult ergonomics, risk of rupture, potentially greater bleed in those with sinistral portal hypertension and difficulty to control a bleed because of space constraints. Therefore, there are several pertinent questions to be answered while dealing with these tumours. First, is it technically feasible? Second, is spleen preservation possible? Third, what would be the surgical modifications required if the laparoscopic approach is chosen? Fourth, since larger tumours are likely to have splenic vein thrombosis, would the presence of sinistral portal hypertension contraindicate a laparoscopic approach? and finally, how does it compare with the open operation regarding postoperative outcomes?
Is it technically feasible?
Feasibility has been reported by others.,, Dissection of pancreatic neck and transection, dissection of splenic vessels in this region are key steps. A careful study of the imaging preoperatively is mandatory in achieving these key steps.
Splenic artery ligation in continuity is as an initial step prior to mobilising the pancreatic neck or the dissection of the splenoportal confluence. This inflow control helps in decompressing the spleen. This was done in four out of five patients. Splenic vein could be en masse staple transected along with the pancreatic body after excluding the splenic artery. This would be useful in patients with splenic vein thrombosis, compressed/stretched splenic vein or if parenchymal preservation is contemplated because of the distal disposition of the lesion. This is a topic of research in an ongoing randomised controlled trial. En masse ligation allows pancreatic parenchymal preservation when the lesions do not extend up to the pancreatic neck, thus decreasing the chances of post-operative exocrine/endocrine insufficiency. We adopted this technique of transecting the pancreas along with the splenic vein in one of our patients. The rest of the dissection is 'medial to lateral' essentially in an avascular plane, albeit dealing with the larger specimen. Modifications in port position (vide infra) were an additional requirement that enabled successful laparoscopic completion of the procedure in all five of our patients.
It is our opinion that a laparoscopic approach should be possible in the vast majority where the expertise is available and might be contraindicated in those with portal hypertension with collaterals in the region (neck/head of pancreas) making the dissection dangerous. This, however, was not the case in all the three patients in our series with sinistral portal hypertension.
Is spleen preservation possible?
Laparoscopic spleen preservation during DP is possible in PCN involving body and tail of pancreas adopting the Kimura or Warshaw techniques., However, in patients with GPCN, a significant stretch of the splenic vessels over a large cyst and encroachment into splenic hilum make splenic preservation technically difficult utilizing either of the approaches. In addition, splenic vein thrombosis and sinistral portal hypertension are common in these tumours, mandating a splenectomy as part of procedure. Finally, attempts at splenic preservation are fraught with a risk of major haemorrhage. Therefore, the strategy in these patients would be to vaccinate them and plan a distal pancreatectomy with splenectomy.
What would be the surgical modifications required if the laparoscopic approach is chosen?
In patients with large pancreatic cystic tumours, the smaller working space could pose difficulties in vision, tumour coming in the way of operating instruments risking inadvertent rupture, inadequate retraction and a serious risk of haemorrhage and inability to control the same. Shifting of operative ports to the right, as shown in [Figure 1], would ensure proper vision, appropriate ergonomics for operating instruments and increase the success of achieving the important steps. Division of the pancreatic neck and securing the splenic vessels makes the rest of the operation relatively blood less.
Some groups have suggested initial aspiration to collapse the cyst. Aspiration is done laparoscopically or after making a small incision over the left hypochondrium as reported by Nakamura et al., Potential risks with aspiration include the spillage of the contents which in cases of malignant cysts can lead to dissemination, also a collapsed cyst makes the dissection difficult by obscuring the anatomical planes. A few others have suggested aspiration of the lesion post-resection before retrieval after bagging the specimen, which we have used in two of our patients., In a large cyst occupying the entire upper abdomen, an initial aspiration may be required to create the required working space.
Would sinistral portal hypertension contraindicate a laparoscopic operation?
Careful study of preoperative MDCT/MRI images should give an idea regarding the distribution of peri-gastric, peri-splenic and lieno-renal collaterals and should help in selecting patients for a laparoscopic approach. None of the three patients in our series had collaterals in the region around pancreatic neck and the procedure went without undue difficulty. The large collaterals in the gastrocolic omentum, however, needed careful division with a LigaSure™ early during operation while opening the lesser sac and similar division of short gastric vessels in the latter part of dissection had to be performed diligently. It is our opinion that LDPS can be safely performed in patients with sinistral portal hypertension. It would be prudent to keep a low threshold for conversion to an open procedure when difficulty in dissection, bleed is encountered. Furthermore, as highlighted before, it would seem unwise to plan a laparoscopic operation when there is a more extensive thrombosis involving portal vein and those with collaterals around pancreatic head/neck regions.
How does it compare with the open operation with regards to postoperative outcomes?
LDP has become the standard of care for resection of benign and selected malignant tumours of the body and tail of the pancreas. In GPCN, the large size often requires a sizeable incision to deliver the specimen. This cannot be an argument to contraindicate the laparoscopic approach if one were to extrapolate experience in data available on laparoscopic colorectal resection having superior outcomes with laparoscopic-assisted resections for colon cancer versus open surgery. The size of the incision of the extraction site did not affect the perioperative outcomes in those undergoing laparoscopic colorectal resections. Pancreatic leak and fistula are a major concern following distal pancreatectomy. The small number of patients in the current study would make it difficult to draw any meaningful conclusions related to pancreatic fistula in these patients. However, considering that the pancreatic transection in these patients is dealt with in a way not different from those undergoing laparoscopic distal pancreatectomy in general, we feel that the incidence and outcomes in those developing pancreatic fistula would be similar. A large size of the PCN alone, should, therefore, not be a contraindication to the laparoscopic approach for surgeons with experience in laparoscopic pancreatic surgery [Figure 5].
|Figure 5: Suggested algorithm of management of a giant pancreatic cystic neoplasm|
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In summary, our series of patients with GPCN had a favourable outcome with LDPS. A detailed preoperative imaging with MDCT/MRI abdomen, careful preoperative planning, presplenectomy prophylaxis, laparoscopic approach with modification of port positions, appropriate use of energy devices, meticulous dissection to deal with the pancreatic neck division and securing splenic vessels early during operation, medial to lateral dissection were key for a successful outcome.
| ¤ Conclusion|| |
Laparoscopic distal pancreatectomy is feasible in patients with GPCN and offers the all the short-term benefits, namely lesser pain, no wound infections, early return of bowel activity, early return to orals and early discharge and early return to work. Splenectomy was required in all patients because of splenic vein thrombosis and portal hypertension in three and for technical reasons in the rest.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]