A Novel Approach to Pancreaticoduodenectomy - Utilization of a Laparoscopic Hand Assisted Technique
Nicholas N. Nissen*, Vijay Menon
Hepatobiliary Surgery and Liver Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA
Introduction: The application of laparoscopic techniques to pancreaticoduodenectomy (PD) has not received widespread acceptance. Unlike in distal pancreatic surgery, where laparoscopy clearly offers improved visibility and smaller incisions, the benefits of laparoscopy during complex phases of PD are less clear. We have utilized a technique of laparoscopic hand assist (LHA) during PD to perform the early phases of dissection and mobilization, which in turn allows the remainder of the procedure to be performed through a handport incision in the right subcostal area (see figure.1). This report examines our experience with LHA-PD compared to a matched control group undergoing standard PD through a bilateral subcostal incision.Methods: 31 patients underwent LHA-PD between 2007-2010 for benign lesions or malignant tumors < 3cm and without vascular invasion. A group of 31 consecutive patients undergoing standard PD and matched for clinicopathological features was used as the control group. All procedures were performed by a single surgeon.Results: LHA-PD and standard PD groups were similar with respect to operative time (385 vs 379 minutes) and need for transfusion (4 vs 7 patients). Pathological measures of the adequacy of resection were similar in both groups, with a positive posterior margin in 3 patients in each group and lymph node recovery slightly greater in the LHA-PD group than in the standard PD group (19 vs 14, p=0.02). Frequency of post-operative complications including pancreatic leak, wound infection and gastroparesis was similar in each group and there was no perioperative mortality. Overall length of stay was lower in the LHA-PD group (10 vs 14 days), although this did not reach statistical significance (p=0.1). When adjusting for extreme outliers (two standard deviations above the mean), the LHA-PD group had significantly shorter length of stay than the standard PD group (8.2 vs 10.8 days, p=0.02).Conclusion: LHA-PD is safe and feasible and can be accomplished with operative time and morbidity similar to standard PD and without compromising oncologic principles. This laparoscopic approach has the benefit of smaller abdominal incisions, improved visualization during early phases of surgery and decreased length of stay.
Figure 1. Pancreaticoduodenectomy performed through a handport incision
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