ADVANCED LAPAROSCOPIC PANCREAS SURGERY A HANDS-ON WORKSHOP

Transcription

1 ADVANCED LAPAROSCOPIC PANCREAS SURGERY A HANDS-ON WORKSHOP 3-4 November 2017 at the AMC in Amsterdam Organizing committee: Mo Abu Hilal, Professor of Surgery at Southampton University Marc Besselink, Professor of Pancreas and Hepato-Biliary (HPB) surgery at AMC Misha Luyer, HPB-Surgeon at Catharina Hospital Eindhoven Sjors Klompmaker, PhD Candidate at AMC Maurice Zwart, PhD Candidate at AMC POWERED BY:

2 Contents: 1. Faculty 2. Program Outline 3. Operation Instructions: Laparoscopic Pancreatoduodenectomy 4. Operation Instructions: Laparoscopic Distal Pancreatectomy

3 1. Faculty Mo Abu Hilal Professor of Surgery at Southampton University Sjors Klompmaker (organization) PhD Candidate at AMC Marc Besselink Professor of HPB & Pancreas surgery at AMC Maurice Zwart (organization) PhD Candidate at AMC Sebastiaan Festen (training assistant) HPB-Surgeon at OLVG Amsterdam Baki Topal (guest lecturer) Professor of Surgery at Leuven University Hospital Misha Luyer HPB-Surgeon at Catharina Hospital Eindhoven

4 3. Operation Instructions: Laparoscopic Pancreatoduodenectomy

5 LAPAROSCOPIC PANCREATODUODENECTOMY De Rooij-Topal-Gerhards-Busch-Festen*-Besselink* 2015 *Principal investigators Surgical equipment: - Bean bag - Bair Hugger TM - Support stockings - Trocars: 3-4 x 12mm en 1-3 x 5mm - Tissue sealer (e.g. ENSEAL or LigaSure ) - Ultrasonic dissector (e.g. HARMONIC ACE 7+ ) - Endostapler (e.g. ECHELON white and blue) - Laparoscopic fenestrated bipolar forceps - Laparoscopic Lahey - Endoclip 5mm and 10mm - Laparoscopic Hem-o-lok clips purple (gastroduodenal artery) - Laparoscopic bulldog (biliary tract) - Laparoscopic ultrasound (optional) - 10cm 4-8fr baby feeding tube (used as internal pancreatic stent) - Surgical drain 2x - V-loc 3/0 sutures 5-6x (PJ, GJ and HJ) - PDS 4/0 12cm long (8-10 times) - Vessel loop (1/4 length) - Endo Catch TM Details surgical procedure: I) Preparation: No epidural. Bair Hugger TM. The patient is placed in French position on a bean bag. Right arm is placed along the body and left arm in 90 degrees abduction. The suprapubic region is kept free for a Pfannenstiel incision. Trocarts are placed in a semi-circular fashion: subumbilical (12mm), left and right of this trocar 12mm, 2 to 3cm subcostal 2 x 5mm trocarts and a 5mm subxihpoidal trocart. Diagnostic laparoscopy is performed to exclude peritoneal and liver metastases. Resection phase II) Mobilization The procedure starts with the mobilization of the hepatic flexure of the colon and the Kocher maneuver up to the superior mesenteric artery. The duodenum towards Treitz ligament is

6 mobilized from the right side. Dissecting the greater omentum from the colon opens the lesser sac. III) Mobilization of pancreatic head The inferior border of the pancreas becomes visible and the superior mesenteric vein is visualized. The gastro-epiploic artery and vene are transected, either with a sealing device or using Hem-o-lok clips. The superior mesenteric vein is followed under the pancreas. Cranial from the stomach, the hepatic artery, gastroduodenal artery and portal vein are identified. Lymphatic station 8a is dissected and stored separately for later pathological examination. The gastroduodenal artery is transected using Hem-o-lok clips (two clips at the patient s side). A tunnel is created under the pancreas after which a 15cm length vesselloop is guided through the tunnel and secured to itself using a Hem-o-lok clip. IV) Transection of stomach and pancreas When the resectability of the tumor is confirmed, the stomach is transected just proximal to the pylorus using an endostapler (e.g. ECHELON green or blue), after temporarily removing the nasogastric tube. The stomach is placed in the upper left abdomen. The pancreas is transected using an ultrasonic dissector, where the pancreatic duct is transected using a pair of scissors (or the active blade of the dissector) in order to preclude sealing of the duct. V) Treitz ligament The colon is stretched cranially by the first assistant (standing at the patient s left side). The first jejunal limb is stretched towards the right-lower abdomen by the second assistant (standing at the patient s right side). The first jejunal limb is transected using an endostapler (e.g. ECHELON white). The duodenum is mobilized up to the posterior area of the mesenteric root. The duodenum is then replaced to the patient s right side, optionally including the remaining jejunal loop. These two ends can be fixated using a suture. VI) Dissecting the pancreatic head and ligament The duodenum is stretched and mobilized from the uncinate process. First the portal vein and then the superior mesenteric artery are mobilized using a sealing (e.g. ENSEAL ) and/or dissecting device (e.g. Harmonic ACE +7) until the pancreatic head is now fully dissected. The common hepatic artery is followed up to the right hepatic artery. The hepatic duct is

7 tunneled and transected after a bulldog clamp is placed at the patient s side and a Hem-olok clip at the specimen s side. Retroportal lymph nodes are resected en bloc. Cholecystectomy is performed. VII) Specimen extraction When the resection phase is completed, the specimen is extracted using an Endo Catch TM via a Pfannenstiel incision which is immediately closed in multiple layers after extraction. BREAK (15 to 20 minutes) Reconstruction phase VIII) Pancreatojejunostomy A Blumgart pancreatojejunostomy using 4 x 3/0 v-loc sutures and a 10 cm 6 Fr pancreatic stent. First the jejunal limb is guided posterior to the mesenteric root and positioned anterior to the pancreas. A v-loc suture is placed through the pancreas (from anterior to posterior), placed through the posterior wall of the jejunum, placed back through the pancreas and looped. This is performed for every suture separately. The loop of every v-loc suture is pulled to the pancreas and all needles are positioned separately. A small hole is made into the jejunum using an ultrasonic dissector. In case of a wide pancreatic duct, a duct to mucosa anastomosis is performed using a MonoPlus 5/0 HR 13 PDS suture. In case of a very wide pancreatic duct, four sutures are performed in a clock-wise fashion. In case of a duct of moderate width, two sutures are performed. Meanwhile, a pancreatic stent is brought 6 cm into the pancreatic duct and the other end is brought 4cm into the jejunum. Every v-loc suture is guided through the ventral side of the jejunum and guided back through the anterior side of the pancreas. The sutures are pulled tight, clipped and cut. IX) Hepatojejunostomy Approximately 10 cm down the jejunal loop, a small hole is made using an ultrasonic dissector. An end-to-side hepatojejunostomy is performed, either using 10 to 15 x 12 cm long PDS 4/0 interrupted sutures or using 2 x v-loc 3/0 or 4/0 running sutures. Via the patient s right side a surgical drain is placed through Winslow up to the superior border of the pancreas. Alternatively, a second drain can be placed from the left upper abdomen at the inferior border of the pancreas.

8 X) Gastrojejunostomy An antecolic gastrojejunostomy is performed using an endostapler (e.g. ECHELON blue). The posterior wall of the stomach is stapled to the jejunum, after placing a supporting suture from the stomach to the jejunum. This anastomosis is closed using a v-loc 3/0 suture. In case of a pylorus-preserving pancreatoduodenectomy, this anastomosis is performed using a running v-loc 3/0 sutures. XI) Reposition and closure The greater omentum is placed between the pancreatojejunostomy and the hepatojejunostomy. The colon, coecum, jejunum and ileum are repositioned. The abdomen is checked for possible bleeding and after extracting the trocarts, the abdomen is closed. For study purposes, patients will receive a large 30cm x 30cm abdominal dressing to mask their treatment (laparoscopy or open). This abdominal dressing can be changed when all criteria for functional recovery are met or for medical reasons, such as expected wound infection.

9 Appendix Figure 1. Trocart placement.

10 Figure 2. Lymph node stations.

11 Figure 3. Blumgart pancreaticojejunostomy.

12 4. Operation Instructions: Laparoscopic Distal Pancreatectomy

13 LAPAROSCOPIC DISTAL PANCREATECTOMY AbuHilal-Besselink, Southampton 2013 Surgical equipment: - Bean bag - Trocarts: 2 x 12mm and 2-3 x 5mm - Ultrasonic dissector (e.g. Ultracision, HARMONIC ACE 7+ ) - Endostapler (e.g. Echelon white and blue) - Laparoscopic fenestrated bipolar forceps - Laparoscopic Lahey (90 degrees) - Endoclips 5mm and 10mm - Laparoscopic Hem-o-Lok purple and gold - Laparoscopic bulldog (optional: splenic artery clamping in spleen-preservation) - Laparoscopic ultrasound (optional) - Surgical Braid (1/4 length) - Vessel loops (1/4 length, red/blue) - Prolene 2/0 - Endocatch TM - Surgical drain Details surgical procedure: 1. Preparation: General anesthesia, no epidural. The patient is placed in the French position on a bean bag, which is elevated to 30 degrees on the left side. The suprapubic region is kept free for a Pfannenstiel incision. Trocarts are placed in a semi-circular fashion: 1x 12mm supra-umbilical, 1x 5 mm subxyphoidal, 1x 5mm left subcostal anterior axillary line, 1x 12mm between umbicilicus and the left subcostal trocart. The 1st operator stands on the right side, the camera assistant in between the legs, and the assistant operator on the left side. See Fig. 1. In case of lymph node dissection or corpus tumor: 1x 5mm trocart above the umbilicus to the right (Fig.1). The 1st operator stands in between the legs. In case of milt hilus inspection: use the left lateral decubitus position. The left side can be elevated higher in case of a distal pancreas lesion. 2. The laparoscopic ultrasound device is prepared in case lesions need to be localised to determine the extent of the resection. 3. Diagnositc laparoscopy is performed to exclude peritoneal and/ or liver metastases.

14 4. The gastrocolic ligament is opened. The short gastric vessels are ligated in case of a milt-resection. In case of a milt-preserving procedure: aim to preserve the left gastroepiploic artery and the short gastric vessels, see Fig Attach a Prolene 2/0 double suture to the posterior fundus of the stomach and fixate the endings through the subxyphoidal trocart. Alternatively, use a retractor. 6. Identify the pancreatic lesion(s) visually or with laparscopic ultrasonograpy. 7. Aim to identify the splenic artery superiorly to the pancreas. If mobilisation is possible, sling a vessel loop around it and fixate it with a Hem-o-Lok or use a bulldog to clamp the artery. The artery is not transected until the anatomy is fully visualized. Alternatively, the common hepatic artery and the splenic artery can be identified by pulling the stomach caudally. A vessel loop can be used to secure them. The artery can be clamped in case of a splenectomy. 8. Consequently, a medial to lateral approach is taken. The lower pancreas is mobilized. Optionally, the superior and inferior mesenteric veins are identified until the lower border of the spleen. Be careful of the colon. See Fig Tunnel behind the pancreas in between the lesion and the milt, or in case of an oncological procedure, behind Gerota's fascia. Sling the braid behind the pancreas and secure it tusing a Hem-o-Lok. The same is done on the right side of the lesion, for instance above the portal vein. See Fig In case of an oncological resection: perform lymph node dissection according to Strasbeg's RAMPS procedure. Fold the stomach back, open the lesser sac, and procede from the common hepatic artery to the celiac trunk and the splenic artery. Aim to preserve the left gastric artery. See Fig Identify the splenic artery and vein by pulling the pancreas cranially. Use vessel loops to rein the splenic artery and vein, see Fig. 6. Upon transection of the splenic vessels, leave 2 Hem-o-Loks on the patient's side in situ; at least 3 mm cuff for the artery. Alternatively, use a stapling device if not too bulky. In case of benign or premalignant disease with a low risk of malignancy: attempt to preserve the splenic arteries (Kimura procedure, Fig. 7). In case this fails, there is a chance that the spleen survives on the left gastroepiploc artery and the short gastric vessels (Warshaw procedure, Fig. 8). 12. The pancreas is now transected using the endostapler; a white cardridge for a normal pancreas or a blue cardridge otherwise. Be careful to slowly close the stapling device, wait for 30 seconds, then fire and maintain pressure for 4-5 minutes. In case of resistance, break for 20 seconds before continuing. Optionally, sutures can be applied to further close the pancreatic stump.

15 13. After transection of the pancreas, remove the pancreas and optionally the spleen via a Pfannenstiel incision using an extraction bag (e.g. the Endocatch TM ). 14. Place one (or two) drains near the pancreatic stump in the left upper abdomen. Loop the drain along the diaphragm back to the pancreatic stump. In case of a splenectomy: 1-2 extra holes can be made in the drain near the former milt hilus. Fig. 1 Fig. 2

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17 Fig. 6 Fig. 7 Fig. 8