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Total Laparoscopic Pancreaticoduodenectomy
Table 2: Operative outcome expertise of the operating surgeon, and have therefore evolved our
Parameter Operative outcome methods over time.
The magnified view offered by the laparoscopic approach
Conversion to open surgery 1 along with better energy sources allows meticulous dissection and
Operative time (range in minutes) 200–390 hemostasis thus limiting blood loss. Thus, in our operated patients
Estimated blood loss (range in mL) 110–350 only one patient required blood transfusion postoperatively who
Transfusion requirement 1 required conversion to open surgery due to hypervascularity
Margin negative 33 due to history of cholangitis. A reduced mean blood loss (110 ±
Number of lymph nodes retrieved 12–16 22 mL) by minimally invasive approach has also been mentioned by
(range) Senthilnathan et al. in their experience of 130 cases of laparoscopic
Reintervention 2 patients OGD scopy pancreaticoduodenectomy for malignant indications. 9
OGD, oesophagogastroduodenoscopy Reoperation in the early postoperative period has been
reported for indications of bleeding and obstruction. However,
dIscussIon in our case series, no patient required reoperation and all
complications were successfully managed conservatively.
The enthusiasm for minimally invasive hepatopancreaticobiliary The uncertainty of achieving a R0 resection with the
surgeries has been encouraging. The laparoscopic approach for laparoscopic approach is often cited as a disadvantage of the
pancreaticoduodenectomy, however, has received much criticism procedure. All our operated cases had tumor-free gross and
in view of long duration of surgery, need for laparoscopic expertise, microscopic margins supporting the oncological soundness of
long learning curve, and the frequent need for conversion to open. this procedure.
Experience in this field of surgery is limited due to complexity of
the procedure leading to several reports of laparoscopic-open lIMItAtIons
hybrid surgeries. Also, the need for an advanced laparoscopic Our study has the limitation of a small sample size and lack of
setup, robotic assistance, and hemostatic instruments discourages comparison between the open and laparoscopic approach. We also
its widespread applicability. emphasize the need of a long-term follow-up for tumor recurrence
In this case series, we have operated on 33 patients with and disease-free survival.
routinely available laparoscopic instruments, ultrasonic shear and
electrocautery for dissection and hemostasis at a civic run hospital. conclusIon
In our experience, the need for laparoscopic expertise is a must.
With a good clarity and knowledge of anatomical details, the Total laparoscopic pancreaticoduodenectomy is a safe and
procedure can be performed in basic well-equipped surgical setup. feasible procedure with standard laparoscopic setup in patients
We have noted a decline in duration of surgery with increasing with malignant periampullary disease. Precision of dissection
experience in the procedure while adhering to oncological and hemostasis is better achievable with the magnified view of
principles of resection. An improvement in operative time was laparoscopy. Adequate resection of tumor is achievable by this
similarly reported in case series by Kendrick and Cusati (7.7 hours approach if case selection is appropriate with thorough review of
4
for the first 10 patients to 5.3 hours for the last 10 patients) and computed tomography of patients. Surgical expertise is required
5
Kim et al. (9.8–6.6 hours). Although robotic surgery does offer an and key for favorable outcomes.
advantage of more precise surgery with better maneuverability of
instruments, it is time-consuming, expensive, and often unavailable AcknowledgMent
to surgical setups in developing nations. We are thankful to our Dean for allowing us to publish the hospital
As we progressed from one case to another, we noticed some data.
technical difficulties in performing pancreaticoenteric anastomosis
that we tried to overcome by altering the methods of anastomosis. references
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duct was cannulated with a 6-Fr feeding tube in eight patients, ASA physical status class. ASA Monitor 2015;79:38–39.
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was cannulated with outer sheath of intravenous catheter which is fistula: an international study group (ISGPF) definition. Surgery
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patients too. There are numerous case series comparing the outcome Surg Endosc 2013;27(1):95–103. DOI: 10.1007/s00464-012-2427-9.
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92 World Journal of Laparoscopic Surgery, Volume 13 Issue 2 (May–August 2020)