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INTRODUCTION
Total pancreaticoduodenectomy or total pancreatectomy (TP) integrates surgical procedures of distal pancreatectomy (DP) and pancreaticoduodenectomy (PD). Over the past decade, advancements in perioperative care, such as enhanced pancreatic enzyme formulations and long-acting insulin, have made TP a feasible option for treating various pancreatic conditions in carefully selected patients [1].
Over the past decade, laparoscopic surgeries have significantly advanced to encompass various pancreatectomy techniques. Laparoscopic DP has become the preferred approach for benign or low-grade malignant tumors in the pancreatic tail [2]. Laparoscopic PD has also been proven to be safe and feasible in carefully selected patients [3]. Technically, TP is positioned between PD and DP in terms of complexity and surgical scope. However, there have been limited case reports and small case series detailing fully laparoscopic or laparoscopic-assisted TP. Laparoscopic total pancreatectomy (LTP) is technically challenging and infrequently documented in the literature [4,5]. In this paper, we present a new approach for performing fully LTP based on our experience with a pancreatic tail-first approach and a counterclockwise technique to accomplish total mesopancreas dissection and standard lymphadenectomy en bloc.
DESCRIPTION OF SURGICAL TECHNIQUES
A 38-year-old male presented with epigastric abdominal pain. Abdominal computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) revealed multiple intraparenchymal cysts extending from the uncinate process to the tail of the pancreas. These cysts most likely originated from the Wirsung duct, with a maximum dilation of 20 mm. No biliary tract dilatation was detected. Tumor marker levels were within their normal ranges. Based on the Fukuoka Classification, the patient was diagnosed with a high-risk malignant intraductal papillary mucinous neoplasm (IPMN) [6]. In this context, the patient opted for a TP over a partial pancreatectomy, given the risk of requiring additional surgeries.
Patient positioning and trocar distribution: The patient was positioned supine with his legs apart. We utilized 5 or 6 trocars in the procedure. A 10 mm trocar was inserted through the umbilicus for the camera. Two 12 mm trocars were positioned at the midclavicular line, approximately 1 cm above the umbilicus on both the right and left sides for instruments. Two 5 mm trocars were placed subcostally on the right and left sides. During the first approach and dissection phase, the lead surgeon was positioned on the patient's right side, later moving to the center for subsequent surgical stages. The first assistant stood on the patient’s left side, while the second and third assistants operated cameras from the right side. Surgical procedures with detailed step-by-step are summarized below (Supplementary Video 1).
Firstly, the tail and body of the pancreas without the spleen were dissected retrogradely, starting from the lower border of the body of pancreas and then from left to right. After that, a counterclockwise dissection of the tail and body of the pancreas was performed. The splenic artery and vein were divided at the terminal end of the pancreatic tail. The spleen was preserved. The entire body and tail of the pancreas were then pulled to the right side. This maneuver facilitated the isolation and dissection of arteries in the retropancreatic region more easily via laparoscopy, including the splenic artery, gastroduodenal artery, and supporting superior mesenteric artery first-approach. It also enabled total mesopancreas dissection (Fig. 1). The inferior pancreaticoduodenal artery was resected last during this phase.
The remainder of the dissection was like that of our laparoscopic PD technique with total mesopancreas dissection [7], involving two laparoscopic manual anastomoses. The biliary-enteric anastomosis was performed with one layer of sutures. An antecolic gastrojejunostomy was subsequently performed using a distal loop of the jejunum, approximately 60 cm distal to the biliary-enteric anastomosis.
The operative time was 490 minutes and the total blood loss was 100 mL. Pathology revealed a low-grade IPMN extending from the head to tail of the pancreas. The partial splenic infarction was found in the end of the operation. However, there was no symptoms related to splenic infarction. The patient was discharged on postoperative day 7 without any complications.
DISCUSSION
Compared to PD, TP offers several potential benefits. First, TP eliminates the risk of pancreatic fistula, a critical complication and leading cause of mortality following PD. Additionally, since pancreatic adenocarcinomas can develop in multiple areas within the pancreas, TP is seen as a more radical oncological approach for treating pancreatic ductal adenocarcinomas (PDAC) [8]. However, clinical benefits of TP have been scarcely documented. Several studies including a recent meta-analysis have suggested that complications following TP are comparable to PD, resulting in no significant improvement in long-term survival [9]. Moreover, TP is associated with significant metabolic challenges, including malabsorption and insulin-dependent diabetes mellitus, which can negatively impact long-term quality of life and physical activity [10]. Spleen-preserving TP is recommended for borderline tumors (IPMN, neuroendocrine tumors [NETs], etc.) as it combines benefits of preserving the spleen's metabolic and immunological functions, potentially reducing the risk of postoperative complications associated with splenectomy [11]. The incidence of gastric varices and splenic infarction is significantly lower in spleen-preserving pancreatectomy with splenic vessel preservation than in that without splenic vessel preservation [12]. However, all cases of infarction were partial without needing reoperations. In rare instances, postoperative splenectomy was required due to total symptomatic splenic infarction [13].
However, in recent years, significant advancements in pancreatic enzyme formulations, long-acting insulin, and improvements in nutrition and critical care have helped address many challenges associated with TP [14]. Nevertheless, TP may now still be a viable option in selected cases, particularly when it enables complete tumor removal. The procedure is indicated for conditions affecting the entire pancreas, such as PDAC, chronic pancreatitis, IPMN, and multifocal NETs [15], aligning with the indication seen in this study.
Laparoscopic surgery offers several benefits over open surgery, such as quicker recovery, fewer complications, and improved cosmetic results. Moreover, a case-matched study by Berger et al. [16] comparing pediatric patients undergoing laparoscopic-assisted versus open TP with islet auto-transplantation found no significant difference in operative time, estimated blood loss, blood transfusions, morbidity, or length of hospital stay between the two groups. Due to technical complexity, reports of LTP are limited in the literature. Some surgeons have opted to divide the procedure into laparoscopic PD and laparoscopic DP by dissecting the pancreatic neck during LTP [17,18], which may simplify the surgery but contradicts the principle of en-bloc resection, particularly for diffuse malignant tumors. Our methodology, termed "tail-first approach" coupled with "counterclockwise dissection," can be utilized for en-bloc LTP with mesopancreas dissection and standard lymphadenectomy. In this approach, we initiate dissection of the pancreatic tail and body following a counterclockwise trajectory. We then reorient these structures to the right side. The remainder of the procedure follows the protocol of a laparoscopic PD, incorporating total mesopancreas dissection.
This report confirms the feasibility of a fully LTP and introduces a novel technique involving a pancreatic tail-first approach and a counterclockwise dissection with total mesopancreas dissection and standard lymphadenectomy en bloc.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found at https://doi.org/10.14701/ahbps.24-176.
Supplementary Video 1. Surgical procedure with detailed step-by-step.
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