laparoscopic pancreatic surgery

LAPAROSCOPIC PANCREATIC

SURGERY

GEORGE S. FERZLI, MD FACS

ALPHONSE M. PECORARO, MD FACS

SCOTT D. STEINBERG, MD

QUESTION What is the current role of laparoscopic

surgery with regard to pancreatic disease?

LAPAROSCOPIC PANCREATIC SURGERY

• DIAGNOSTIC

– TUMOR LOCALIZATION

– TUMOR RESECTABILITY

• THERAPEUTIC

– PANCREATIC TUMORS

• ENUCLEATION

• DISTAL PANCREATECTOMY

• PANCREATICODUODENECTOMY

• PALLIATIVE SURGERY

LAPAROSCOPIC PANCREATIC SURGERY

• THERAPEUTIC

– PANCREATITIS

• PSEUDOCYST DRAINAGE

• PANCREATIC DEBRIDEMENT

– PANCREATIC TRAUMA

LAPAROSCOPIC PANCREATIC SURGERY

Tumor Staging With Laparoscopy and

Laparoscopic Ultrasonography

“In cases of ordinary exploratory operation for carcinoma, before having recourse to the usual large incision, the cystoscope is introduced through a very small and relatively unimportant incision, possibly made with cocaine, may reveal general metastases or a secondary nodule in the liver, thus rendering further procedures unnecessary and saving the patient a rather prolonged convalescence.

BERTRAM BERNHEIM, THE JOHNS HOPKINS UNIVERSITY

Bernheim B: Organoscopy: Cystoscopy of the abdominal cavity. Ann Surg 53:764-767,1911  

HISTORY• 1911 Bernheim First laparoscopy for

pancreatic cancer in U.S.

• 1978 Cushieri Laparoscopy for staging, diagnosis, and assessmentof resectability in 23 patients with pancreaticcancer

• Prospective study of 88 consecutive patients

• Pancreatic and periampullary adenocarcinoma

• Preoperative evaluation– CT SCAN WITH CONTRAST 88 pts– MRI 20 pts– LAPAROSCOPY 47 pts– ANGIOGRAPHY 85 pts

Preoperative Staging and Assessment of Resectability of

Pancreatic Cancer

Warshaw,A et al: Arch Surg 1990; 125:230-233

RESULTS• Overall resectability 33/88 (38%)

• Laparoscopy found metastatic disease when present in 22/23 patients (96%)

• Laparoscopy found no metastatic disease in 24/24 patients (100%)

Warshaw,A et al: Arch Surg 1990; 125:230-233

CONCLUSIONS• Laparoscopy is particularly sensitive for

detecting small metastases (96%)

• This approach to pancreatic cancer allows the elimination of some operations and tailors others to individual circumstances

Warshaw,A et al: Arch Surg 1990; 125:230-233

The Value of Minimal Access Surgery in the Staging of Patients with

Potentially Resectable Peripancreatic Malignancies

• 115 patients- radiologically resectable

• Extensive laparoscopy performed

– assessment of the peritoneal cavity, liver, lesser sac, porta hepatis, duodenum, transverse mesocolon, and celiac and portal vessels

Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140

UNRESECTABILITY• Metastases

– hepatic, serosal, peritoneal

• Extrapancreatic extension– mesocolic involvement

• Nodal involvement– celiac or portal

Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140

• Vascular invasion– celiac axis or hepatic artery– portal vein, SMV, SMA

• Potential candidates for resection– Portal vein encroachment– SMV encroachment

UNRESECTABILITY

Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140

• No intraoperative or postoperative complications related to laparoscopy

• 67 considered resectable 61 resected

• Laparoscopy failed to identify hepatic metastases in 5 patients and portal venous encasement in 1 patient

RESULTS

Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140

LAPAROSCOPY

• Positive predictive index of 100%

• Negative predictive index of 91%

• Accuracy of 94%

RESULTS

Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140

Extended laparoscopy is accurate and safe and makes exploration unnecessary in many patients with potentially resectable peripancreatic malignancy

Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140

CONCLUSION

Laparoscopic Ultrasound Enhances Standard Laparoscopy in the Staging

of Pancreatic Cancer

• Prospective evaluation of 90 patients

• All patients had preoperative CT abdomen/pelvis and either ERCP or transabdominal sonography

• All patients had laparoscopy and laparoscopic ultrasound

Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)

TUMOR LOCATION

PANCREATIC HEAD 64 (72%)

PANCREATIC BODY 19 (21%)

PANCREATIC TAIL 3 (3%)

AMPULLA 4 (4%)

Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)

CT LAP LAP SONO

ACTUAL

UNRESECTABLE 17

(19%)

41

(46%)

49

(54%)

50

(56%)

EQUIVOCAL 8

(9%)

13

(14%)

___ ___

Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)

RESULTS

LAPAROSCOPIC ULTRASOUND

• SENSITIVITY 100%

• SPECIFICITY 98%

• ACCURACY 98%

Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)

CONCLUSION The addition of laparoscopic

ultrasound offers improved assessment and preoperative staging of pancreatic cancer.

Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)

SUMMARYStaging laparoscopy should be

performed for all cases of pancreatic cancer prior to attempted resection

The addition of laparoscopic ultrasound improves assessment and preoperative staging of pancreatic cancer

LAPAROSCOPIC WHIPPLE

LAPAROSCOPIC PANCREATICODUODENECTOMY

• Gagner and Pomp – 1996• Strasberg, Drebin, and Soper – 1997• Cuschieri – 1998

CONCLUSION: THE MAGNITUDE OF THE RECONSTRUCTION

MAY OUTWEIGH THE BENEFIT OF THE MINIMALLY INVASIVE APPROACH

Palliative Laparoscopic Surgery for

Unresectable Pancreatic Cancer

Laparoscopic Gastro- and Hepaticojejunostomy for Palliation

of Pancreatic CancerCASE-CONTROL STUDY

14 patients – open palliation

10 patients – laparoscopic palliation

4 patients – diagnostic laparoscopy

Rothlin,M et al;Surg Endosc (1999) 13:1065-1069

RESULTSOPEN

(n=14)

LAP

(n=14)MORBIDITY 43% 7%

MORTALITY 29%

0%

HOSPITAL STAY

21 days

9 daysp<0.06

p<0.05

p<0.05

Rothlin,M et al;Surg Endosc (1999) 13:1065-1069

CONCLUSIONLaparoscopic palliation can

reduce the three major drawbacks of open bypass

surgery-i.e., high morbidity, high mortality, and long hospital stay.

Rothlin,M et al;Surg Endosc (1999) 13:1065-1069

MISCELLANEOUS PANCREATIC NEOPLASMS

STUDY DESCRIPTIONSANCHEZSurg Lap and Endo Vol 4, No 4, 1994

Laparoscopic Resection Of Pancreatic Serous

CystadenomaGAGNER, et alSurgery Vol 120, 1996

Laparoscopic Resection Of Islet Cell Tumors

SPITZ, et alSurg Lap Endo and Perc Tech: Vol10, No3, 2000

Ultrasound Guided Laparoscopic Resection Of

Pancreatic Islet Cell Tumors

PSEUDOCYST DRAINAGE

LAPAROSCOPIC INTERNAL DRAINAGE

Petelin Transgastric

Handsewn

Cystogastrostomy

Litwin & Ross Stapled

Intraluminal

Cystogastrostomy

Way Supracolic Cystogastrostomy

Cushieri Infracolic Cystojejunostomy

Palanivelu L. paracolic handsewn

Cystojejunostomy

PANCREATIC TRAUMA

Laparoscopic Distal Pancreatectomy for Blunt Injury to the Pancreas with

Splenic Preservation

• 10 yo handle bar injury

• CT –free fluid and distal transection of the pancreas

• Distal pancreatectomy with splenic preservation performed

• Reg diet POD 2

• D/C POD 3

Ferzli,G et al; Surg Endosc July2001

Ferzli,G et al; Surg Endosc July2001

Ferzli,G et al; Surg Endosc July2001

Ferzli,G et al; Surg Endosc July2001

Ferzli,G et al; Surg Endosc July2001

Ferzli,G et al; Surg Endosc July2001

Ferzli,G et al; Surg Endosc July2001

SUMMARY• Laparoscopy and laparoscopic

ultrasound are sensitive and specific tools for determining resectability in patients with pancreatic cancer

• Laparoscopic techniques can be used for the treatment of benign and malignant pancreatic diseases and pancreatic trauma