JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 24, Number 12, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2014.0151
Single-Port Laparoscopic Distal Pancreatectomy: Initial Experience Hyung Joon Han, MD,1 Sam-Youl Yoon, MD,1 Tae-Jin Song, MD, FACS,1 Sae Byeol Choi, MD,2 Wan-Bae Kim, MD,2 Sang-Yong Choi, MD,2 and Seong-Heum Park, MD 3
Introduction: Laparoscopic distal pancreatectomy has become the standard treatment of choice for pancreatic tail cystic and solid tumors when technically feasible. Technological advances have led to the development of single-port laparoscopic surgery, a safe alternative procedure. We present our experiences with single-port laparoscopic distal pancreatectomy. Materials and Methods: We retrospectively reviewed clinical records and compared clinical outcomes in 40 patients diagnosed with a pancreatic tail mass between 2007 and 2013 who received either conventional laparoscopic (n = 28) or single-port laparoscopic distal pancreatectomy (n = 12). Results: The mean surgery time in the single-port group (279.8 – 53.0 minutes) was significantly longer than in the conventional group (186.9 – 86.6 minutes) (P = .001). The mean duration of postoperative hospital stay in the single-port group (12.2 – 5.4 days) was also significantly longer than in the conventional group (8.3 – 4.7 days) (P = .028). The spleen was preserved more in the conventional group (60.7%) than in the single-port group (33.3%), but the difference was not significant (P = .112). There were no significant differences in intraoperative blood loss, tumor size, conversion rate, or postoperative complications between the two groups. Conclusions: Blood loss and postoperative complications of single-port laparoscopic distal pancreatectomy are similar to those of conventional laparoscopic distal pancreatectomy. Single-port laparoscopic distal pancreatectomy can be performed safely and effectively in select patients with pancreas tail neoplasms, but is associated with a longer surgery time and postoperative hospital stay.
ith recent advances in instrument technology, surgeon experience, and surgical skills, laparoscopic surgery has become widely accepted and is the standard technique for multiple abdominal surgical procedures.1–3 Laparoscopic resection of pancreatic lesions has been undertaken with more caution than other laparoscopic operations, because of positional relationships with major vessels, deep retroperitoneal location, and the risk of pancreatic fistulas. Furthermore, pancreatic surgery is less common, making it difficult for surgeons to overcome the learning curve of laparoscopic pancreas resection.4 Despite the lack of difference in both overall postoperative morbidity and pancreatic fistula rate, several studies have demonstrated that laparoscopic distal pancreatectomy is associated with a shorter length of hospital stay in comparison 1 2 3
with open procedures,4–8 making laparoscopic distal pancreatectomy an attractive treatment of choice for benign and borderline pancreatic lesions. Minimally invasive surgery has become increasingly popular, and new development have further decreased surgical trauma by reducing the number and size of ports. In the past few years, techniques using a single-port laparoscopic approach have shown great promise and become well established in the field of minimally invasive surgery. The reported literature suggests that a single-port laparoscopic approach has been widely applied to appendectomies, cholecystectomies, preoperative staging, peritoneal biopsies, and hernia repair. More advanced surgeries are also being performed through a single port or incision, such as gastrectomies, colon resections, and liver resections, among others. Technical descriptions and clinical experiences with singleport laparoscopic distal pancreatectomy have also been
Department of Surgery, Korea University Ansan Hospital, Ansan, Republic of Korea. Department of Surgery, Korea University Guro Hospital, Seoul, Republic of Korea. Department of Surgery, Korea University Anam Hospital, Seoul, Republic of Korea.
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reported recently.9–15 Laparoscopic distal pancreatectomy has become the treatment of choice for pancreatic distal tumors,16 but single-port laparoscopic distal pancreatectomy can now be accomplished with the angulated laparoscopic instruments, energy-sealing devices, high-definition telescope, and laparoscopic staplers available today. We present our initial experiences with distal pancreatectomy through a single small transumbilical incision and demonstrate the feasibility and safety of single-port laparoscopic distal pancreatectomy as compared with conventional laparoscopic distal pancreatectomy. Materials and Methods Patients
All 40 patients who consecutively underwent laparoscopic distal pancreatectomy between January 2007 and December 2013 at the Hepatobiliopancreas Division of the Department of Surgery, Korea University Medical Center, were included. Informed consent was obtained from the patients. All patients were diagnosed with a pancreatic mass on the pancreas body or tail, which was identified as a premalignant pancreatic lesion by radiologic studies or a patient’s risk factor for pancreatic cancer. A total of seven surgeons did all the cases, and there were no previously defined criteria for patient selection. Moreover, there were no selection criteria for singleport laparoscopic distal pancreatectomy. Twelve patients underwent single-port laparoscopic distal pancreatectomy (single-port group) consecutively, and 28 patients underwent conventional laparoscopic distal pancreatectomy (conventional group) consecutively. We retrospectively reviewed patient medical records and extracted patient age, gender, body mass index, operation
time, amount of intraoperative bleeding, postoperative complications, and length of hospital stay. Postoperative pancreatic fistulas were defined according to the guidelines of the International Study Group of Pancreatic Fistula.17 Surgical technique for single-port laparoscopic distal pancreatectomy
Patients were placed under general endotracheal anesthesia in the supine position. A glove port (Nelis, Bucheon, Republic of Korea) was introduced through a 2.5-cm vertical transumbilical incision. Pneumoperitoneum was achieved with 15 mm Hg intraabdominal pressure via carbon dioxide insufflation. The patient was then placed left side up in the reverse Trendelenburg position. The surgeon stood on the right side of the patient, and the first and second assistants were on the left, with the monitor placed on the patient’s cranial side. Standard laparoscopic instruments (36 cm and 42 cm long) and articulating laparoscopic instruments were used. The operation began with the division of the gastrocolic ligament and the lower part of the gastrosplenic ligament to expose the body and tail of the pancreas and confirm the location. The left-sided transverse colon was detached from the spleen and peritoneum. We hung the stomach using gauze, from the greater to the lesser curvature along the posterior aspect (hanging method, Fig. 1B), or displaced the stomach using gauze and an articulating instrument (pushing method, Fig. 1C). The inferior border of the pancreas and the pancreatic mass were surveyed with laparoscopic ultrasonography (Fig. 1D). A laparoscopic LigaSure (Valleylab, Boulder, CO) or Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH) was used for ligation of peripancreatic vessels and dissection of the inferior border of the pancreas. The splenic artery was
FIG. 1. Intraoperative images taken during single-port laparoscopic distal pancreatectomy. (A) A glove port was inserted via a 2.5-cm vertical transumbilical incision. (B) The hanging method was used for stomach (S) traction to improve visibility. An articulating instrument was usually used to elevate the gauze and stomach. (C) A simple and easy pushing method was used to expose the pancreas. An articulating instrument was essential for this method. (D) The laparoscopic intraoperative ultrasound probe introduced through the single port was helpful for confirming tumor location and resection margin on the pancreas (P) after elevation of the S. (E) The splenic artery (black arrows), which was ligated with Hem-o-lok clips and laparoscopic surgical clips, was divided with laparoscopic scissors below the S. Gauze was frequently used for compression to stop bleeding. (F) P transection was performed with a laparoscopic stapler. The P was tunneled and elevated with nylon tape for secure P transection. (G) The P stump was reinforced with surgical clips along the stapled line. After clipping, fibrin glue and Neoveil were used. (H) A closed suction drain was located in the operative field and brought out via the single port.
isolated with a dissector and right-angle laparoscopic instruments and was dual-ligated with laparoscopic Hem-o-lok (Weck Closure Systems, Research Triangle Park, NC) and laparoscopic surgical (Endo Clip [Covidien Autosuture, Mansfield, MA] or Ligamax [Ethicon Endo-surgery]) clips (Fig. 1). The inferior border of the pancreas was dissected and elevated for pancreas parenchymal division. Nylon tape was used for elevation of the pancreas and as a guide for stapling of pancreas parenchyma. Endo GIA (60 mm, purple color cartridge; Covidien) or Echelon Endopath (60 mm, gold color cartridge; Ethicon Endo-surgery) staplers were used for pancreas parenchymal transection. Before stapling, clamping was performed with the stapler for 1 minute to assess the potential efficacy of stapling for transection of the pancreas parenchyma. After transection of the pancreas, the proximal pancreas parenchyma was meticulously examined for bleeding. Additionally, we applied surgical clips along the stapling line for additional reinforcement to prevent bleeding or on the pancreatic duct to prevent pancreatic fistulas (Fig. 1). The distal transected pancreas was encircled and ligated with a laparoscopic ligation device (Round Laploop; Sejong Medical, Paju, Republic of Korea) for retraction. The dissection and detachment of the distal pancreas were performed with a LigaSure or Harmonic scalpel. In the case of concomitant splenectomy, the superior parts of the gastrosplenic ligament and the splenophrenic ligament were also dissected, and the short gastric arteries were ligated and divided with laparoscopic Hem-o-lok clips, surgical clips, or a LigaSure. The resected specimen was enveloped with an endo-bag and retrieved from the abdominal cavity via the single port. After the glove port was reinstalled, warm saline irrigation and careful hemostasis were performed. The proximal transected pancreas parenchyma was enveloped with Neoveil (Gunje, Tokyo, Japan) and fibrin glue. A closed suction drain was placed in the left upper quadrant close to the pancreatic stump and brought out through the umbilical port. The single port was removed, and the umbilical incision was closed in layers. Statistical analysis
Groups were compared using the Mann–Whitney test or independent t test for continuous data, and Fisher’s exact test or chi-squared test was used for categorical data of paired samples. A value of P < .05 was considered statistically significant. Results
Of the 40 patients, 13 (32.5%) were male, and 27 (67.5%) were female. There were 24 patients with a comorbid disease (60%), including diabetes mellitus (n = 11, 27.5%), hypertension (n = 11, 27.5%), adrenal insufficiency (n = 1, 2.5%), tuberculosis (n = 2, 5.0%), depressive disorder (n = 2, 5.0%), cerebral infarction (n = 1, 2.5%), cerebral hemorrhage (n = 1, 2.5%), hepatocellular carcinoma (n = 1, 2.5%), lymphoma (n = 1, 2.5%), and aplastic anemia (n = 1, 2.5%). Pathology reports revealed mucinous cystadenoma (n = 6, 15%), serous cystadenoma (n = 8, 20.0%), neuroendocrine tumor (n = 3, 7.5%), intraductal papillary mucinous tumor (n = 5, 12.5%), a pancreatic cyst (n = 4, 10.0%), pseudocyst (n = 1, 2.5%), solid pseudopapillary tumor (n = 3, 7.5%), accessory spleen (n = 5,
HAN ET AL.
12.5%), Castleman’s disease (n = 1, 2.5%), and pancreatic adenocarcinoma (n = 4, 10.0%). The pancreatic resection margin was free in all cases. Complications occurred in 12 patients (30.0%). Remnant splenic vein thrombosis was revealed through postoperative computed tomography in 2 patients in the single-port group, and they were successfully treated with intravenous heparin and oral warfarin medication. Three cases (25.0%) in the single-port group and 6 cases (21.4%) in the conventional group experienced postoperative pancreatic fistula as defined by the International Study Group of Pancreatic Fistula guidelines.17 There was no statistical difference in pancreatic fistula between the two groups (P = .804). Grade A postoperative pancreatic fistulas occurred in 4 cases (14.3%) in the conventional group and 1 case (8.3%) in the single-port group, and all were successfully treated successfully with conservative therapy (P = .602). Grade B postoperative pancreatic fistulas occurred in 2 cases in both the conventional group (7.1%) and the single-port group (16.7%) (P = .570), requiring percutaneous drainage. One patient in the conventional group had postoperative bleeding that was successfully treated with angiographic embolization. Comparisons between single-port and conventional laparoscopic distal pancreatectomy
The mean age of the patients who underwent single-port laparoscopic distal pancreatectomy was significantly older than that of the conventional group (mean – standard deviation, 61.3 – 17.2 versus 49.1 – 15.8 years; P = .035). There was no significant difference in the gender ratio between the singleport and conventional laparoscopic groups, although the ratios were different (male:female, 2:10 versus 11:17; P = .162). The mean operation time in the conventional group was significantly shorter than in the single-port group (186.9 – 86.6 versus 279.8 – 53.0 minutes; P = .001). The mean duration of postoperative hospital stay was also significantly shorter in the conventional group compared with the single-port group (8.3 – 4.7 days versus 12.2 – 5.4 days; P = .028). Patients with pancreatic fistulas experienced significantly longer hospital stays on average than patients without a fistula (14.7 – 7.7 versus 7.9 – 3.0 days; P < .0001). Among patients with pancreatic fistulas, the mean duration of hospital stay was shorter in the conventional group than in the single-port group (20.0 – 2.0 versus 12.0 – 8.2 days), but the difference did not reach the level of significance (P = .150). Spleen preservation was more frequently performed in the conventional group (60.7% versus 33.3%), but there was no significant difference (P = .112). Mean tumor size was similar between the groups (single port versus conventional, 3.8 – 1.8 versus 3.4 – 2.5; P = .595). We observed no significant difference in body mass index, preoperative serum carbohydrate antigen 19-9 level, presence of comorbid diseases, intraoperative blood loss, pancreatic fistula, or complication rates between the groups (Table 1). Single-port laparoscopic distal pancreatectomies were performed in 12 patients. Two of these cases were converted to two-port laparoscopic distal pancreatectomy in order to control intraoperative bleeding (Table 2). Discussion
We found that single-port laparoscopic distal pancreatectomy could be performed safely and effectively without any
SINGLE-PORT LAPAROSCOPIC DISTAL PANCREATECTOMY
Table 1. Comparisons of Clinical Outcomes Between Single-Port and Conventional Laparoscopic Distal Pancreatectomy Groups Single-port Conventional group group (n = 12) (n = 28) P value Gender (male:female) 2:10 11:17 Age (years) 61.3 – 17.2 49.1 – 15.8 Body mass index (kg/m2) 23.5 – 4.6 23.6 – 4.0 Comorbid disease 7 (58.3) 17 (60.7) CA 19-9 level (IU/mL) 13.1 – 12.2 16.1 – 14.6 Operation time (minutes) 279.8 – 53.0 186.9 – 86.6 Spleen preservation 4 (33.3) 17 (60.7) Blood loss (mL) 185 – 125 334 – 468 Hospital stay (days) 12.2 – 5.4 8.3 – 4.7 Tumor size (cm) 3.8 – 1.8 3.4 – 2.5 Conversion 2 (20.0) 0 Pancreatic fistula 3 (25.0) 6 (21.4) Grade A 1 (8.3) 4 (14.3) Grade B 2 (16.7) 2 (7.1) Remnant splenic 2 (16.7) 0 vein thrombosis Complications 5 (41.6) 7 (25.0)
.162 .035a .931 .888 .555 .001a .112 .286 .028a .595 .163 .804 .602 .570 .085 .292
Data are mean – standard deviation values or number (%) as indicated. a Statistically significant difference. CA 19-9, carbohydrate antigen 19-9.
extracorporeal traction or specific traction device in patients with distal pancreas neoplasms. We demonstrated that blood loss and complications of single-port laparoscopic distal pancreatectomy were similar to those after conventional laparoscopic resection, although single-port surgery was associated with a longer surgery time, longer postoperative hospital stay, and relatively lower incidence of spleen preservation. Clinical outcomes, including intraoperative blood loss and incidence of complications, were similar between
surgical techniques. The transumbilical incision over the umbilicus enabled removal of a larger-sized specimen, including the spleen. Yao et al.15 demonstrated the feasibility of single-port laparoscopic distal pancreatectomy for select patients with relatively small lesions and low body mass index. Haugvik et al.12 successfully applied single-port laparoscopic distal pancreatectomy for removal of benign lesions that were not suspected exocrine carcinomas. These two observational studies and several technical reports have shown positive results. We encountered a significantly longer surgical time for single-port laparoscopic distal pancreatectomy compared with the conventional method. Because the pancreas is surrounded by critical structures and located in the retroperitoneum, laparoscopic distal pancreatectomy is a challenging procedure.18 The most challenging task in single-port laparoscopic distal pancreatectomy is to achieve sufficient visibility, which is difficult because of the absence of effective stomach traction, the deep location of the pancreas, limitations of forward dissection, and instrument length. Four case reports have described the feasibility and safety of single-port laparoscopic distal pancreatectomy using extracorporeal traction sutures for stomach traction to maintain the operative field.9,10,13,14 We obtained effective stomach traction using gauze and an instrument (via the pushing or hanging method) without the need for any percutaneous sutures. We further overcame the disadvantage of forward dissection using articulating instruments and a flexible telescope. We used longer straight laparoscopic instruments for better handling of the distal pancreas and spleen and tied the transected pancreas with a laparoscopic ligation device to minimize mishandling the specimen. Even so, further investigation into the ligation and division of vessels, dissection of the inferior border of the pancreas, pancreas transection, and posttransection medial to lateral dissection
Table 2. Patient Demographics and Postoperative Outcomes in the Single-Port Laparoscopic Distal Pancreatectomy Group Body Gender/ mass index Patient age number (years) (kg/m2) 1 2 3 4
F/47 F/72 F/79 F/73
20.4 26.1 13.5 26.0
8 9 10
F/57 F/72 M/76
24.8 28.0 24.1
History — DM — DM, HTN, Adr Insuf — DM, HTN, depression DM, HTN, cerebral infarction — HTN Aplastic anemia — —
Operation Blood Hospital time loss stay Size (minutes) (mL) Conversion (days) Pathology (cm) Splenectomy Complication 230 340 240 240
110 200 100 250
No No No No
5 10 8 8
MCN Cyst NET SCN
5.5 2.5 5.0 2.4
Yes Yes Yes Yes
— — — SVT
210 330 255
50 450 50
No Yes No
8 23 12
4.5 1.7 2.5
No Yes No
— PF —
SCN Adenoca Ectopic spleen Cyst Cyst
Adenoca, adenocarcinoma; Adr Insuf, adrenal insufficiency; DM, diabetes mellitus; F, female; HTN, hypertension; M, male; MCN, mucinous cystic neoplasm; NET, neuroendocrine tumor; PF, pancreatic fistula; SCN, serous cystic neoplasm; SVT, splenic vein thrombosis.
are needed to overcome the technical limitations of singleport laparoscopic distal pancreatectomy. Our transumbilical 2.5-cm vertical incision allowed for removal of larger pancreatic tumors and the spleen without extension of the skin incision. Resected tumor size was not significantly different between groups, although tumor size in the single-port group tended to be larger than that of the conventional group. The specimen in the single-port group often contained the spleen, however, suggesting that the single-port laparoscopic surgery enabled the removal of a larger-sized specimen. The glove port has four trocar channels: one 12-mm and three 5-mm sized channels. Those channels have pliability and allow multiple approaches for the laparoscopic stapler device to enter the abdomen easily. The range of motion of the laparoscopic instruments via the glove port was much wider than the range of other single ports and was similar to that of a homemade single port.11 Two cases of splenic vein thrombosis occurred in the single-port group. Splenic vein thrombosis has been reported in cases of distal pancreatectomy.19,20 In patients with pancreatitis, the etiology of splenic vein thrombosis is a direct inflammatory process.19 The rate and severity of splenic vein thrombosis are significantly associated with a pancreatic fistula.20 In our study, however, splenic vein thrombosis was not associated with pancreatitis or pancreatic fistulas. We speculate that the inflammatory process around the pancreas might be associated with splenic vein thrombosis, brought about not only by pancreatic fistula, but also by the technique required for combined transection of the pancreas and splenic vein and excessive manipulation of the pancreas during pancreas transection. Because splenic vein thrombosis does not evoke disease-specific symptoms, it is sometimes considered an incidental finding on imaging studies performed to assess the severity of pancreatic fistulas or during follow-up after distal pancreatectomy.19 Two cases of grade B pancreatic fistulas extended the hospital stay in our single-port group, and the mean duration of hospital stay was significantly longer in patients with a pancreatic fistula. Accordingly, efforts to decrease the incidence of postoperative pancreatic fistulas could reduce the number of days in the hospital after surgery. Clamping the pancreas with a stapler before firing for transection to access the transectability, as well as the application of additional surgical clips or barbed sutures on the stapled line of the remnant pancreas, might help reduce the incidence of postoperative pancreatic fistulas. Conversion to conventional laparoscopic distal pancreatectomy was performed in 2 cases of single-port laparoscopic distal pancreatectomy. In these cases, an additional 5-mmsized port was inserted in the left upper quadrant area to control intraoperative bleeding. In another study, conversion to open surgery occurred in 9.2% of the 806 patients who underwent laparoscopic distal pancreatectomy.21 These investigators reported that the most common indications were bleeding, adhesions, and malignancy.21 Experience managing bleeding is essential and crucial during laparoscopic pancreas surgery. Increasing experience with other single-port laparoscopic surgeries will make such surgeries more successful and decrease conversions to conventional laparoscopic surgery. Surgeons must face the dilemma of converting conventional laparoscopic surgery or continuing single-port surgery during
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single-port laparoscopic surgery. A low threshold for conversion to conventional laparoscopic surgery is important11 for the safety of patients, but completion of single-port laparoscopic surgery is also important for the development of skills. We did not perform enough single-port laparoscopic distal pancreatectomies to exhaust the learning curve, but success was helped by precise individual anatomical knowledge, quality surgical instruments, an excellent surgical team, and specific efforts of each surgeon. The role of splenic preservation remains controversial, but overall it has been reported more frequently in laparoscopic distal pancreatectomy.18 Song et al.16 found spleen preservation of 49.6% among 359 patients who underwent laparoscopic distal pancreatectomy in a single large center. Based on previously reported cases using the single port that favored the spleen-preserving technique10,13,14 and surgical trends of laparoscopic distal pancreatectomy toward spleen preservation,16,18 it might be necessary to decrease postsplenectomy complications by performing spleen-preserving laparoscopic distal pancreatectomy with a single-port technique. Our study is limited by its retrospective observational design, which was based on data collection from heterogeneous pancreas disease cases. Selection biases were present because of the small number of surgeries and different operators with different surgical experiences. Although a single surgeon at a time performed the single-port laparoscopic distal pancreatectomies, technical limitations and insufficient experience with the technique might have influenced the clinical outcome in our study. Except for operation time and postoperative hospital stay, clinical outcomes were similar between the two types of surgery. Currently, single-port laparoscopic distal pancreatectomy could be performed in patients with a benign or low-grade malignancy of the distal pancreas. Prospective trials would offer more information about the merits and shortcomings of single-port laparoscopic distal pancreatectomy and will allow surgeons to gain more experience with minimally invasive pancreatic surgery. Conclusions
Blood loss and postoperative complications of single-port laparoscopic distal pancreatectomy are similar to those of conventional laparoscopic distal pancreatectomy. Single-port laparoscopic distal pancreatectomy can be performed safely and effectively in highly selected patients with pancreas tail neoplasms, although the method is associated with a longer operation time and postoperative hospital stay compared with the conventional approach. Acknowledgments
This work was supported by the research seed fund from the Korea University Research and Business Foundation. Disclosure Statement
No competing financial interests exist. References
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Address correspondence to: Seong-Heum Park, MD Department of Surgery Korea University Anam Hospital Anam-dong 5-ga Seongbuk-gu, Seoul, 136-705 Republic of Korea E-mail: [email protected]