Name: application of mid-pancreatectomy with end-to-end anastomosis in pancreatic benign tumors
Uploaded: 2024-02-09T14:15:00.000+00:00
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Description: Read this Scientific Article Protocol about Application of Mid-Pancreatectomy with End-to-End Anastomosis in Pancreatic Benign Tumors at JoVE.com

This work was supported by grants from the Project of Guangdong clinical medical research center of digestive diseases (2020B1111170004), National Key Clinical Discipline and the program of Guangdong Provincial Clinical Research Center for Digestive Diseases.

The operation is routine and has received ethics approval. This study was permitted by the Ethics Committee of the Six Affiliated Hospital of Sun Yat-sen University. Meanwhile, the informed written consent was obtained from the patient. Its research contents and methods meet the medical ethics norms and requirements.
1. Patient selection
<ol>
	<li>Use the following inclusion criteria: benign pancreatic tumors, including hemangioma, benign neuroendocrine tumor, serous or mucinous cystadenoma, solid pseudopapilloma, and non-invasive intraductal myxoma.</li>
	<li>Use the following exclusion criteria: pancreatic malignant tumors, atrophy of the tail of the pancreatic body, diffuse inflammation of the pancreas, and vascular variation.</li>
</ol>
2. Preoperative preparation, operative position, and anesthesia
<ol>
	<li>Ask the patient to consume a low in fat, salt, and sugar diet 1 day before the surgical operation and then abstain from eating food and drinking water at least 8 h prior to the surgery.</li>
	<li>Place the patient in a supine position with the head elevated and slightly tilted to the left. The surgery was performed using a dual primary knife mode. 
	NOTE: In the dual primary knife mode, two skilled and experienced surgeons alternate between the roles of surgeon and assistant as needed, aiming to improve efficiency and quality.</li>
	<li>Perform endotracheal intubation and give general anesthesia. Judge the anesthetic effect according to the patient&#39;s post-anesthesia and intraoperative conditions, such as complete anesthesia block, no additional drugs during operation, and stable vital signs.</li>
</ol>
3. Surgical technique
<ol>
	<li>Make a vertical incision 2 cm above the right side of the navel and establish pneumoperitoneum with a Veress needle. Insert a 12 mm trocar and introduce the laparoscope after establishing pneumoperitoneum.</li>
	<li>Place five trocars in the following positions: a 12 mm trocar in the supraumbilical region for observation, a 5 mm trocar in the right anterior axillary line, a 12 mm trocar under the costal margin of the right midclavicular line, a 5 mm trocar horizontally 2 cm below the xiphoid process, and a 12 mm trocar horizontally 2 cm at the supraumbilical level (see Figure 2).</li>
	<li>Explorate carefully the intraperitoneal organs and peritoneal surface to reveal a mass above the pancreas, protruding from the surface of the pancreas and measuring approximately 3cm x 3 cm.</li>
	<li>Use an ultrasonic knife to separate abdominal adhesions and excise a portion of omental tissue.</li>
	<li>Use an ultrasonic knife to free the greater curvature side tissues of the gastroepiploic artery, suspend the greater curvature of the stomach using clamps (see Table of Materials), and expose the pancreas.</li>
	<li>Following intraoperative B-ultrasound localization, use an ultrasonic scalpel to cut off 1 cm of normal pancreatic tissue from the edge of the pancreatic mass near the neck of the pancreas.</li>
	<li>Use an ultrasonic knife to free the splenic artery and vein at the upper posterior of the pancreas. Then, free the connective tissue between the tail and body of the pancreas and the splenic vessels (see Figure 3).</li>
	<li>Resect completely the pancreatic mass using an ultrasonic scalpel and remove the normal pancreatic tissue 1 cm proximal to the margin of the pancreatic mass.</li>
	<li>Place the stent tubes into the proximal and distal sides of the pancreas within the pancreatic ducts (see Figure 4). 
	NOTE: The diameter and length of the stent tubes in the pancreatic duct were 2 mm and 6 cm, respectively. (see Table of Materials).</li>
	<li>Suture the pancreatic tissue continuously using 4-0 priline (see Figure 5; see Table of Materials) and make an extended incision 2 cm below the navel to remove the pancreatic mass.</li>
	<li>Rinse the abdominal cavity with saline to check for any bleeding points and place a drain above and below the pancreatic anastomosis, respectively. Finally, suture the incision (see Figure 2), and the operation is concluded.</li>
</ol>
4. Postoperative nursing and monitoring
<ol>
	<li>Perform ECG monitoring and low-flow oxygen after the operation.</li>
	<li>Give the patient a semi-liquid diet and instruct the patient to turn over and exercise in bed on the 1st day after the operation.</li>
	<li>Provide hepatoprotective, anti-inflammatory, hemostatic, analgesic, albumin, and acid suppression treatment.</li>
	<li>Monitor amylase changes in the drainage tube at the 1st, 3rd, 4th, and 5th day after operation.</li>
</ol>

<ol>
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Mattfeldt, T., Schlosser, W., Beger, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Duodenum-preserving+pancreatic+head+resection+in+patients+with+benign+and+borderline+tumors+of+the+pancreatic+head.">Duodenum-preserving pancreatic head resection in patients with benign and borderline tumors of the pancreatic head.</a> Langenbeck's Arch Surg. 385 (3), 229-233 (2000).</li><li>Iacono, C., Ruzzenente, A., Bortolasi, L., Guglielmi, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Central+pancreatectomy:+The+dagradi+serio+iacono+operation.+Evolution+of+a+surgical+technique+from+the+pioneers+to+the+robotic+approach.">Central pancreatectomy: The dagradi serio iacono operation. Evolution of a surgical technique from the pioneers to the robotic approach.</a> World J Gastroenterol. 20 (42), 15674-15681 (2014).</li><li>Wang, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnosis+and+treatment+of+solid-pseudopapillary+tumors+of+the+pancreas:+A+single+institution+experience+with+97+cases.">Diagnosis and treatment of solid-pseudopapillary tumors of the pancreas: A single institution experience with 97 cases.</a> Pancreatology. 18 (4), 415-419 (2018).</li><li>Sun, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreaticojejunal+bridge+stent+internal+drainage+as+a+safe+reconstruction+technique+after+middle+segmental+pancreatic+resection.">Pancreaticojejunal bridge stent internal drainage as a safe reconstruction technique after middle segmental pancreatic resection.</a> Chinese ed J. 131 (11), 1367-1368 (2018).</li></ol>

The authors have no conflicts of interest or financial ties to disclose.

The pancreas, an important digestive organ in the human body, has several important secretory functions. Therefore, in pancreatic surgery, attention needs to be paid to the preservation of pancreatic parenchyma and its function. With the rising detection rate of benign pancreatic tumors and low-grade malignancies, various procedures have been developed to preserve function, including local enucleation of the pancreas, mid-pancreatectomy, and pancreatic head resection with preservation of the duodenum12,13. Compared to previous pancreatoduodenectomy or the body and tail of the pancreas, these function-preserving pancreatic surgeries aim to ensure radical tumor resection while minimizing the removal of normal pancreatic tissue. However, it is important to note that these procedures may increase the risk of postoperative pancreatic fistula due to potential leakage from the pancreatic stump12,13,14.
The mid-pancreatectomy described in this case was first reported by Ehrhardt in 190814. In a patient with gastric cancer complicated by a pancreatic tumor, gastrectomy and segmental pancreatectomy were performed, and the two pancreatic stumps were directly anastomosed. The healing process occurred naturally through drainage. Mid-pancreatectomy, as a surgical procedure to preserve pancreatic parenchyma and function, reduces the risk of postoperative pancreatic exocrine and endocrine insufficiency and has been adopted to treat benign or low-grade tumors in the neck and proximal body of the pancreas. However, there is evidence suggesting that patients who underwent mid-pancreatectomy were associated with a higher risk of pancreatic fistula because the tumors of these patients were mostly benign or borderline, and the pancreatic parenchyma is soft15. Therefore, proper management of the pancreatic stump is crucial to prevent postoperative pancreatic fistula. The key point of mid-pancreatectomy is the treatment of the pancreatic stump and the selection of a suitable digestive tract to rebuild. One approach is to use an anastomotic technique. Traditionally, after a mid-pancreatic resection, it was believed that an anastomosis between the ends of the pancreas was not possible. As a result, the classic surgical approach involved closing the proximal pancreas and creating a Roux-en-Y anastomosis between the distal pancreas and the jejunum. However, this approach carries the risk of both pancreatic stump fistula and pancreatico-enteric anastomotic leakage. Additionally, intraperitoneal infection and hemorrhage secondary to pancreatic fistula pose significant challenges for pancreatic surgeons. It has been reported that Sun et al., using endo-stent drainage of the pancreatico jejunal bridge after mid-pancreatic resection by silicon tube drainage of the secretions from the pancreas into the jejunum, confirmed that this method could lower the rate of pancreatic fistula than conventional pancreatico jejunostomy or pancreatico gastric anastomosis16. In this paper, we challenge the traditional view by proposing the use of a supporting duct of the pancreatic duct followed by an end-to-end anastomosis after mid-pancreatic resection. This prevents the anastomosis of the pancreas with the digestive tract, ensuring that the pancreatic juice does not come into contact with the digestive fluid and remains inactive. As a result, the risk of pancreatic fistula bleeding is reduced to some extent. After the surgery, it is important to maintain the patency of the drainage tube and provide symptomatic support treatment, such as enzyme inhibition and nutrition. Although pancreatic fistula may still occur, the risk of bleeding and infection is greatly reduced due to the inactivation of pancreatic juice by digestive fluids.
To sum up, the placement of a pancreatic duct stent after a mid-pancreatic resection for end-to-end anastomotic reconstruction is feasible for a benign neoplasm of the pancreas. In this case, the patient had a successful recovery. The critical steps of the protocol involve performing rigorous surgical dissection and excision to ensure maximum preservation of healthy pancreatic tissue. It is crucial to have precise surgical skills and experience to achieve end-to-end anastomosis using the placement of a pancreatic duct stent. In addition, close monitoring and management are essential after the surgery, along with timely intervention if needed, to minimize the risk of complications. Our technique is based on existing mid-pancreatectomy but with some significant modifications, including the placement of a pancreatic duct stent for end-to-end anastomosis, to improve pancreatic function preservation and reduce the risk of complications. This procedure not only helps preserve pancreatic function but also avoids injury to other organs and eliminates the need for devascularization during digestive tract reconstruction. It significantly enhances the safety of the procedure, accelerates patient recovery, reduces complications, and shortens hospital stay. However, there are some limitations to the protocol since our study involved only one case, and pancreatic end-to-end anastomosis is not widely available; further evidence is needed to establish the advantages of combining middle pancreatic resection with end-to-end anastomosis.

From a clinical perspective, it is important to note that not all tumors that develop in the pancreas are classified as pancreatic cancers. Pancreatic tumors can be broadly categorized into two main groups: benign tumors of the pancreas and pancreatic malignancies. Benign neoplasms of the pancreas encompass cystadenoma, intraductal papillary mucinous neoplasm, pancreatic hemangioma, and others1. The detection rate of benign pancreatic tumors has been consistently increasing over the years, and surgery remains the most effective treatment option2. However, traditional surgical procedures such as pancreatoduodenectomy or body and tail resection of the pancreas, while ensuring complete tumor removal, often result in the removal of excessive normal pancreatic tissue. This can significantly impact the long-term quality of life for patients, particularly leading to a higher incidence of endocrine and exocrine dysfunction3,4.
In recent years, the field of laparoscopic pancreatic surgery has seen significant advancements due to the rapid development of minimally invasive techniques like laparoscopic surgery and robotic surgery5. This has led to an increase in the number of hospitals performing laparoscopic pancreatic surgery, which has yielded positive outcomes. Among the various surgical methods, laparoscopic mid-pancreatectomy is considered to be the most suitable approach for treating benign or low-grade malignant tumors located in the neck or proximal part of the pancreas6.
The first mid-pancreatectomy was performed in 2003 by the Baca team on a patient with pancreatic cystadenoma7, and since then, this procedure has been adopted worldwide. Compared to other techniques like local enucleation of pancreatic tumor, laparoscopic caudal pancreatectomy, and laparoscopic pancreaticoduodenectomy, mid-pancreatectomy offers the advantage of preserving normal pancreatic parenchyma and reducing the risk of insufficient internal and external pancreatic secretion4,6,8. However, a challenge arises after resecting the middle part of the pancreas, as traditionally, the broken ends of the pancreas were believed to be unable to be anastomosed. To reconstruct the digestive tract, two main methods are employed. The first method involves a single anastomosis, where the distal end of the pancreas is anastomosed with the stomach or jejunum after closing the proximal end. The second method is a double anastomosis, where both the proximal and distal ends of the pancreas are anastomosed with the jejunum in the shape of a &#937;. However, these reconstruction techniques pose the risk of pancreatic stump fistula and pancreatic-enterostomy fistula for patients, which can lead to abdominal infection and abdominal bleeding. Overcoming these challenges remains a significant concern for pancreatic surgeons8,9.
This paper proposes a novel treatment method called laparoscopic mid-pancreatectomy combined with end-to-end anastomosis. The method involves removing the tumor in the middle part of the pancreas and placing stent tubes into the pancreatic duct at both ends of the pancreas. The pancreatic tissue is then continuously sutured to reconstruct the pancreas. The primary objective of this method is to preserve the substance and function of the pancreas while removing the tumor, thereby reducing the risk of postoperative pancreatic fistula, secondary infection, and bleeding10,11. Additionally, it aims to improve surgical safety.
The patient, a 57-year-old male, was admitted to the hospital due to the discovery of a pancreatic mass during a CT scan. The mass was a round cystic structure with low density, measuring approximately 28 mm x 40 mm, and had an unclear boundary. The patient had a history of type II diabetes for 3 years and hepatitis B virus infection for over 10 years. Before the operation, the levels of alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) were measured to be 30.53 ng/mL and 5.8 ng/mL, respectively. Laparoscopic mid-pancreatectomy combined with end-to-end anastomosis was performed on June 15, 2022. The postoperative pathology report indicated the presence of a solid cystic mass in the pancreatic tissue, measuring 3.8 cm x 2.5 cm x 2 cm. The mass appeared gray and white, and the cyst contained transparent fluid with a clear boundary (see Figure 1). Postoperative pathology confirmed pancreatic hemangioma. Tumor markers and drainage tube amylase levels showed a decreasing trend after the surgery, and the patient had a successful recovery.

<table><tbody><tr><td>abdominal instrument button</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>abdominal instrument cap</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>abdominal instrument collar</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>abdominal instrument connector</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>Absorbable ligature clip</td><td>Sichuan Guona Technology Co., LTD</td><td>230716</td><td></td></tr><tr><td>barbs</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>blade</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>blood pad</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>Cloth towel forceps</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>disposable drainage tube</td><td>Johnson &amp;amp; Johnson</td><td>412280</td><td>6 cm x 2 mm</td></tr><tr><td>Electric knife head</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>forceps</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>hilt</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>holding flask</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>intestinal forceps</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>laparoscope</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>laparoscopic instruments</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>Ligating clip</td><td>Teleflex Medical</td><td>73H2300118</td><td></td></tr><tr><td>long curved forceps</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>medium curved forceps</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>Nail clamp</td><td>Ethicon,USA&amp;nbsp;</td><td>584C82</td><td></td></tr><tr><td>needle holders</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>ovoid forceps</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>Paraffin oil</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>purse string forceps</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>right angled forceps</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>right angled forceps</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>scissors</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>Siphonhead</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>Small cup</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>small curved forceps</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>Sonotome keyhole</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>steel ruler</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>Straight forceps</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>Suction needle plate</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>Suture needle</td><td>Johnson &amp;amp; Johnson</td><td>Vcp397H</td><td></td></tr><tr><td>Syringe</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>syringe needle</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>tissue forceps</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>trocar(XCEL)</td><td>Ethicon Endo-Surgery</td><td>695C71</td><td></td></tr><tr><td>Ultrasonic knife spacers</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>ultrasound knife</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr><tr><td>yarn ball</td><td>Johnson &amp;amp; Johnson</td><td></td><td></td></tr></tbody></table>

application of mid-pancreatectomy with end-to-end anastomosis in pancreatic benign tumors

Mid-pancreatectomy combined with end-to-end anastomosis is a surgical procedure used to treat benign pancreatic tumors. It involves removing the tumor from the middle section of the pancreas and connecting the proximal and distal ends through an anastomosis. The traditional surgical approach for resecting the middle segment of the pancreas involves closing the proximal pancreas and creating a Roux-en-Y anastomosis with the jejunum. However, this approach carries a double risk of pancreatic stump fistula and pancreatico enteric anastomotic leak postoperatively. In this paper, a new procedure is described where stent tubes were placed into the proximal and distal sides of the pancreatic ducts after ensuring sufficient freedom from the proximal distal pancreas. The pancreatic parenchyma was then sutured continuously under direct vision to achieve pancreatic end-to-end anastomosis. This procedure helps preserve pancreatic function, reducing the risk of postoperative pancreatic insufficiency. However, due to the complexity and risks involved, thorough evaluation and preparation are necessary before surgery. We carefully assess the patient's history, serology, and imaging results to determine the feasibility and effectiveness of the procedure. During surgery, we consider the use of a suitable pancreatic duct stent to ensure the flow of pancreatic juice into the intestine through physiological pathways. Our goal is to remove the tumor while preserving as much normal pancreatic tissue as possible for the anastomosis. After the operation, it is crucial to monitor the patient's pancreatic function, paying close attention to blood glucose levels, drainage fluid volume, and amylase value of the pancreatic anastomosis. During the postoperative follow-up visit, the patient's pancreatic function was assessed, and there was no significant change in quality of life compared to before the surgery. This indicates that mid-pancreatectomy combined with end-to-end anastomosis is a safe and effective procedure for treating pancreatic benign neoplasms.

The operation was completed within 1.5 h, and there was a minimal intraoperative bleeding volume of 50 mL, without the need for a blood transfusion. The dissociation of splenic arteriovenous during the surgery was sufficient to provide effective protection for preserving the pancreatic tail and spleen. The gap left after central pancreatectomy is 1.7 mm. There were no short-term complications, and the patient&#39;s postoperative recovery was successful. The duration of the hospital stay was 20 days, and the postoperative hospital stay was 10 days. The drain amylase levels decreased from 29300 U/L on postoperative day 1 to 58.39 U/L on postoperative day 5. Venous blood was collected from the patient. The level of CEA in blood decreased from 5.8 ng/mL preoperatively to 2.28 ng/mL postoperatively. Additionally, the level of AFP decreased from 30.53 ng/mL preoperatively to 7.66 ng/mL postoperatively (see Table 1). Preoperative images and postoperative images can be seen in Figure 6.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/66252/66252fig01.jpg" /> 
Figure 1: Tumor pathology. The results are from HE staining at 100x. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66252/66252fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/66252/66252fig02.jpg" /> 
Figure 2: The layout of trocars. In total, there were 5 trocars, including 1 observation hole and 4 operation holes. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66252/66252fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/66252/66252fig03.jpg" /> 
Figure 3: Free splenic artery and splenic vein. To free the splenic artery and vein at the upper posterior of the pancreas. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66252/66252fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/66252/66252fig04.jpg" /> 
Figure 4: Placement of the pancreatic duct stent. Place the stent tubes into the proximal and distal sides of the pancreas within the pancreatic ducts. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66252/66252fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/66252/66252fig05.jpg" /> 
Figure 5: Pancreatic end-to-end anastomosis. Suture the pancreatic tissue continuously using 4-0 priline for end-to-end anastomosis. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66252/66252fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/66252/66252fig06.jpg" /> 
Figure 6: Preoperative images and postoperative images. Preoperative and postoperative CT coronal view imaging. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66252/66252fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Items</td>
			<td>Results</td>
		</tr>
		<tr>
			<td>Operation time (min)</td>
			<td>90</td>
		</tr>
		<tr>
			<td>Intraoperative bleeding volume (mL)</td>
			<td>50</td>
		</tr>
		<tr>
			<td>Blood transfusion volume (mL)</td>
			<td>0</td>
		</tr>
		<tr>
			<td>Gap left after operation (mm)</td>
			<td>1.7</td>
		</tr>
		<tr>
			<td>Postoperative complication</td>
			<td>None</td>
		</tr>
		<tr>
			<td>Duration of hospital stay (day)</td>
			<td>20</td>
		</tr>
		<tr>
			<td>Postoperative hospital stay (day)</td>
			<td>10</td>
		</tr>
		<tr>
			<td>Drain amylase levels on POD1 (U/L)</td>
			<td>29300</td>
		</tr>
		<tr>
			<td>Drain amylase levels on POD5 (U/L)</td>
			<td>58.39</td>
		</tr>
		<tr>
			<td>Level of CEA preoperatively (ng/mL)</td>
			<td>5.8</td>
		</tr>
		<tr>
			<td>Level of CEA postoperatively (ng/mL)</td>
			<td>2.28</td>
		</tr>
		<tr>
			<td>Level of AFP preoperatively (ng/mL)</td>
			<td>30.53</td>
		</tr>
		<tr>
			<td>Level of AFP postoperatively (ng/mL)</td>
			<td>7.66</td>
		</tr>
	</tbody>
</table>
Table 1: Relevant outcomes of the patient. Abbreviations:&#160;POD = postoperative day; CEA = carcinoembryonic antigen; AFP = alpha-fetoprotein.

Read this Scientific Article Protocol about Application of Mid-Pancreatectomy with End-to-End Anastomosis in Pancreatic Benign Tumors at JoVE.com

Application of Mid-Pancreatectomy with End-to-End Anastomosis in Pancreatic Benign Tumors

The present protocol describes the application of mid-pancreatectomy combined with end-to-end anastomosis in the surgical treatment of pancreatic benign tumors, which presents a feasible solution for managing such tumors while concurrently preserving pancreatic function.

Mid-pancreatectomy combined with end-to-end anastomosis is a surgical procedure used to treat benign pancreatic tumors. It involves removing the tumor ...

application-mid-pancreatectomy-with-end-to-end-anastomosis-pancreatic

Nanyang Technological University

Research

JoVE Journal

Medicine

270 Views.  Sun Yat-sen University. The present protocol describes the application of mid-pancreatectomy combined with end-to-end anastomosis in the surgical treatment of pancreatic benign tumors, which presents a feasible solution for managing such tumors while concurrently preserving pancreatic function.

Video: Application of Mid-Pancreatectomy with End-to-End Anastomosis in Pancreatic Benign Tumors

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis.
The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index &#62;35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers.
The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy.
The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

Laparoscopic pancreatoduodenctomy (LPD) may offer advantages over open pancreatoduodenectomy, including early postoperative mobilization, less delayed gastric emptying and a shorter hospital stay. However, LPD is technically challenging and not well-standardized, especially regarding the pancreatic anastomosis. We describe a standardized technique for the pancreatic anastomosis during LPD: modified Blumgart pancreaticojejunostomy.

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal ...

Cancer Research

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer: Surgical Planning and Technique

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), relying on collateral flow to the liver through the gastroduodenal artery (GDA). In the current manuscript, the technical conduct of robotic DP-CAR is outlined. The greater curve of the stomach is mobilized with care to avoid sacrificing the gastroepiploic vessels. The stomach and liver are retracted cephalad to facilitate dissection of the porta hepatis. The hepatic artery (HA) is dissected and encircled with a vessel loop. The gastroduodenal artery (GDA) is carefully preserved. The common HA is clamped and triphasic flow in the proper HA via the GDA is confirmed using intra-operative ultrasound. A retropancreatic tunnel is made over the superior mesenteric vein (SMV). The pancreas is divided with an endovascular stapler at the neck. The inferior mesenteric vein (IMV) and splenic vein are ligated. The HA is stapled proximal to the GDA. The entire specimen is retracted laterally with further dissection cephalad to expose the superior mesenteric artery (SMA). The SMA is then traced back to the aorta. The dissection continues cephalad along the aorta with the bipolar energy device used to divide the crural fibers and celiac nerve plexus. The specimen is mobilized from the patient's right to left until the origin of the celiac axis is identified and oriented towards the left. The trunk is circumferentially dissected and stapled. Additional dissection with hook cautery and the bipolar energy device fully mobilizes the pancreatic tail and spleen. The specimen is removed from the left lower quadrant extraction site and one drain is left in the resection bed. A final intra-operative ultrasound of the proper HA confirms pulsatile, triphasic flow in the artery and liver parenchyma. The stomach is inspected for evidence of ischemia. Robotic DP-CAR is safe, feasible and when used in conjunction with multi-modality therapy, offers potential for long-term survival in selected patients.

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection DP-CAR for Pancreatic Cancer: Surgical Planning and Technique

We present our operative approach to robot assisted distal pancreatectomy, splenectomy, and celiac axis resection (DP-CAR), demonstrating that the procedure is safe and feasible with proper planning, patient selection, and surgeon experience.

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), ...

Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several studies have described the safety of RPD in case of a replaced or aberrant right hepatic artery, but detailed video descriptions of the approach are lacking. This case report describes a step-&#173;by-&#173;step technical video in case of a replaced right hepatic artery. A 58-year-old woman presented with an incidental finding of a 1.7 cm pancreatic head mass. RPD was performed using the da Vinci Xi system and involves a robotic-assisted pancreatico- and hepatico-jejunostomy and open gastro-jejunostomy at the specimen extraction site. The operation time was 410 min with 220 mL of blood loss. The patient had an uncomplicated postoperative course and was discharged after 5 days. Pathology revealed a pancreatic head cancer. RPD is a feasible and safe procedure in case of a replaced hepatic artery when performed in selected patients in high-volume centers by experienced surgeons.

Robotic pancreatoduodenctomy (RPD) has been highly standardized in recent years and may be used in selected patients with pancreatic head cancer, including those with a replaced right hepatic artery. This case report describes a standardized and reproducible technique for RPD, which includes the approach of the Dutch LAELAPS-3 training program to an aberrant vasculature.

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several ...

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body. With technological development, the robotic surgical system has shown its advantage in minimally invasive surgery and been increasingly applied in central pancreatectomy. However, reconstruction of the continuity of pancreas with end-to-end anastomosis after robotic central pancreatectomy has not been applied. In this study, we report surgical techniques for robotic central pancreatectomy with end-to-end anastomosis. The pancreas is reconstructed by duct-to-duct anastomosis of the pancreatic duct with a pancreatic stent inserted in the two stumps of pancreatic duct, and by end-to-end anastomosis of the pancreatic parenchyma. Compared with traditional central pancreatectomy with pancreaticoenteric anastomosis, this approach decreases the operative injury to the patient, and also conserves the integrity and continuity of the digestive duct and pancreatic duct. The robotic surgical system integrated with multiple instruments with flexible and precise movement is particularly suitable for the dissection and reconstruction of the pancreatic duct. We found that robotic central pancreatectomy with end-to-end anastomosis is safe and feasible, and we need more experience to evaluate its best indications and long-term outcomes.

The robotic central pancreatectomy with end-to-end anastomosis is feasible and safe for tumor in the pancreatic neck and proximal portion of pancreatic body. The operative techniques of this operation are presented.

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of ...

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of the pancreas. The aim of central pancreatectomy is to prevent postoperative life-long endocrine and exocrine insufficiency. The downside of central pancreatectomy is the high rate of postoperative pancreatic fistula, which is the main reason that many surgeons do not routinely use central pancreatectomy in eligible patients. Most studies report open or laparoscopic central pancreatectomy with a pancreatico-gastrostomy anastomosis in adults. This is the first description of a standardized approach to robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy reconstruction in an adolescent (16-year-old boy) with a pseudopapillary tumor in the body of the pancreas. The operation time was 248 min with 20 mL of blood loss. The postoperative course was uneventful except for the short-term medical treatment for a grade B pancreatic fistula. Robotic central pancreatectomy can be safely applied in selected patients in experienced centers.

Robotic central pancreatectomy may be used in selected patients in experienced centers. This protocol presents all steps and the feasibility of a robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy in a 16-year-old adolescent patient.

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of ...

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.
The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who ...

Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic capsule to infiltrate surrounding tissues. In conventional distal pancreatosplenectomy (DPS), tumor cells are prone to spread along the direction of blood and lymphatic reflux due to surgical compression. Additionally, inflammation makes it challenging to achieve R0 resection, leading to a lower patient survival rate. To address these limitations, radical antegrade modular pancreatosplenectomy (RAMPS) was developed, emphasizing deeper excision, including the left anterior renal fascia, the left anterior renal adipose sac, and even the left adrenal gland, to improve the R0 resection rate. With the advancement of minimally invasive surgical techniques, laparoscopic RAMPS (L-RAMPS) is being considered technically safe and feasible in oncology. However, due to technical difficulties and a lack of supporting evidence for clinical application, only a few institutions are currently conducting L-RAMPS. In this context, this article presents detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy (L-pRAMPS), offering promise for future clinical applications.

Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) is currently considered technically safe and feasible. However, due to technical challenges and a lack of supporting evidence for widespread clinical applications, only a limited number of institutions are currently conducting L-RAMPS. This article aims to provide detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy.

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic ...

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct.
This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms.
LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.

This article provides a whole technical process of laparoscopic duodenum-preserving pancreatic head resection via an inferior infracolic approach. This is a surgical approach for benign tumors without intraoperative fluorescence image guidance.

Application of Mid-Pancreatectomy with End-to-End Anastomosis in Pancreatic Benign Tumors

Summary

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