World J Surg DOI 10.1007/s00268-013-2404-z
Transumbilical Single-Incision Laparoscopic Distal Pancreatectomy: Primary Experience and Review of the English Literature Dianbo Yao • Shuodong Wu • Yu Tian Ying Fan • Jing Kong • Yongnan Li
•
Ó Socie´te´ Internationale de Chirurgie 2013
Abstract Background Single-incision laparoscopic surgery (SILS) may represent an improvement over conventional laparoscopic surgery, and has been applied in many surgical procedures. However, for pancreatic surgery, experience is rather limited. Methods The clinical records of 11 cases in which transumbilical single-incision laparoscopic distal pancreatectomy (TUSI-LDP) was performed at our institution since June 2009 were retrospectively analyzed, and all the literatures concerning TUSI-LDP were retrospectively reviewed. Results All the 11 patients were female. The ages ranged from 20 to 73 years, with an average age of 38.0 years. The average body mass index (BMI) was 22.67 (18.6–26.2). Most TUSI-LDPs were successfully performed, with only one conversion to multi-incision surgery. Splenic preservation was performed in six cases. The mean operation time was 163.18 ± 63.18 minutes (range 95–300), and the mean intraoperative blood loss was 159.09 ± 181.02 ml (range 10–500 ml). The surgical wounds healed well, with good cosmetic wound healing, and the patients were discharged from hospital in a mean of 7.45 ± 1.44 days (range 5–10). Only one patient developed pancreatic leakage, which ceased spontaneously with only a drain for 61 days. The parameters were comparable with those found in the English literature. Conclusions These recent experiences suggest that SILS in pancreatic surgery is feasible for a select group of
D. Yao S. Wu (&) Y. Tian Y. Fan J. Kong Y. Li Department of Vascular and Bile Duct Surgery, Shengjing Hospital of China Medical University, No. 36, San Hao Street, Heping District, Shenyang 110004, Liaoning Province, China e-mail: [email protected]; [email protected]
patients with relatively small lesions and low BMI, and that, with the gradual accumulation of surgeons’ experience with SILS and improvement of laparoscopic instruments, it might become a safe option for some patients.
Introduction Currently, laparoscopic surgery has been preferred as an alternative to open surgery owing to its clear visual field, reduced injury, decreased postoperative pain, better cosmetic results, and accelerated patient recovery. Pancreatic surgery is an extremely challenging field. To treat pancreatic lesions via a laparoscopic approach, in the past several years, various attempts have been gradually attempted, from diagnostic purposes to surgical intervention, giving rise to resection procedures [1, 2]. At the same time, the increasing diagnoses of cystic or solid and benign tumors in young individuals, mostly females, has led to an increasing demand for laparoscopic surgical procedures, to eradicate the tumor and minimize the cosmetic impact of the surgical wound. Recently, to further minimize the surgical trauma by reducing numbers and sizes of the ports, many experienced laparoscopic surgeons have tried to develop a new minimally invasive technique, called ‘single incision laparoscopic surgery’ (SILS). This approach has been now successfully and widely applied in many fields of abdominal surgery [3–5], both for the less invasive wishes of surgeons and more cosmetic requests of patients. However, reports of SILS for pancreatic lesions is rather limited. To summarize and update the current clinical experiences of SILS in pancreatic surgery, in this study, we report 11 cases in which transumbilical single-incision laparoscopic distal pancreatectomy (TUSI-LDP) was
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World J Surg Fig. 1 a Operating room setting: the operator, assistants, and monitor. b Access site in the umbilicus: the two trocars for the lens, grasper, and the plastic disposable trocar. c Ultrasound image showing the cystic lesion with the largest diameter of the 11 cases. d Computed tomographic view of pancreatic lesions. e After the contrast injection, the mass was slightly enhanced, especially on the edge. f Exposure of the pancreas. The lesion is seen at the right side of the picture. g The body to tail of the pancreas is mobilized and lifted from the retroperitoneum by the tug-exposure technique, and pancreatic body is transected with an endoscopic linear stapler device. h The lesion was put into a retrieval bag. i The cyst contents were aspirated within the retrieval bag. j The closed drains brought out through the transumbilical incision
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performed in the Shengjing Hospital of China Medical University. Further, all the literature concerning SILS performed on pancreatic lesions were retrospectively reviewed. To the best of our knowledge, this is the largest patient cohort reported for this technique to date [6–9].
Methods Patients The criteria for patient selection in our department are as follows: a benign lesion found in preoperative examination, and intent to perform distal pancreatectomy. The diameter of the lesion should be less than 3.5 cm, and the diameter of a cystic lesion could be a little larger. The patient has strong preferences for cosmetic appearance and no history of abdominal operations or contraindications for laparoscopic surgery. All the patients participating in this study gave informed consent before surgery.
body and tail of the pancreas from the normal pancreatic tissue on the right of the mass to the tail of pancreas near the hilum of spleen was completely separated, the pancreas would be divided with an endoscopic linear stapler device (Fig. 1g). A retrieval bag was placed through the plastic disposable trocar (Fig. 1h). The specimen was wrapped in the retrieval bag and extracted from the umbilical incision (Fig. 1i). If a splenectomy was to be simultaneously performed, the superior part of the gastrosplenic ligament, splenophrenic ligament should be also dissected, and then the spleen was removed with the pancreas specimen. In cases in which a spleen-preserving laparoscopic distal pancreatectomy (LDP) was to be performed, the splenic vessels were mostly divided, with the short gastric vessels preserved to provide a blood supply. In some cases, the pancreatic branches of splenic vessels could easily be dissected and divided, and the splenic vessels could also be separated from the pancreas and preserved. At the end of surgery, a closed drain was placed near the stump of the pancreas, with the drain brought out through
Surgical Procedures The patient was placed in a supine position with legs apart (Fig.1a). A transumbilical 3 cm superficial longitudinal incision was made. After the maintenance of pneumoperitoneum, a 10 mm trocar was inserted into the lower margin of the incision for the lens. Two accessory trocars were inserted on the superior margin of incision. The left one was 5 mm for the grasper, and the right one was for the plastic disposable trocar, 12 mm in diameter (Fig. 1b). For the patient’s position, a slight (35°) anti-Trendelenburg tilt was obtained, and a rotation about 30° to the right was made. The location and size of the lesion could usually be revealed in the ultrasound, computed tomography, or magnetic resonance imaging (Fig. 1c–e). The operation began with the division of the gastrocolic ligament and the lower part of the gastrolienal ligament, to expose the body and tail of the pancreas and confirm the location and range of the mass or cyst (Fig. 1f). The serous membrane was then dissected along the lower edge of pancreas on the right of the lesion. Loose connective tissue between the dorsal surface of the pancreas and the posterior abdominal wall was then dissociated carefully, so as to not injure the splenic artery or splenic vein. When the ultrasonic scalpel got the superior border from the inferior border, a tunnel would be built behind the normal pancreatic body. The grasper was then inserted into the tunnel and carried forward to enlarge the visual fields behind the pancreas, and the loose connective tissue was dissociated carefully by the ultrasonic scalpel towards the tail of the pancreas. The mass in the body and tail of the pancreas was then lifted and separated from the posterior abdominal wall. When the
Table 1 General information of 11 cases Pt no.
Diagnosis
Tumor location
Age
Sex
BMI
Maximum lesion diameter (cm)
1
Mucinous cystadenoma
Body of pancreas
46
F
24.6
5
2
Fibromatosis
Abdominal cavity
20
F
18.6
3.5
3
Serositic cyst
Tail of pancreas
36
F
23.4
4.5
4
Pancreatic cyst
Body of pancreas
42
F
22.2
4.5
5
Artery aneurysm
Body and tail of pancreas
22
F
21.6
3.5
6
Mucinous cystadenoma and SPT
Body and tail of pancreas
34
F
22.8
3.5
7
Pancreatic cyst
Tail of pancreas
34
F
23.4
3.5
8
Mucinous cystadenoma
Body and tail of pancreas
39
F
22.6
3
9
Islet cell tumor
Tail of pancreas
73
F
26.2
1.2
10
Mucinous cystadenoma
Body and tail of pancreas
27
F
22.2
4
11
Mucinous cystadenoma
Tail of pancreas
45
F
21.8
6.2
BMI body mass index, F female, pt patient, SPT solid-pseudopapillary tumor
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163.18 ± 63.18 minutes (range 95–300), and the mean intraoperative blood loss was 159.09 ± 181.02 ml (range 10–500). In terms of postoperative complications, pancreatic leakage occurred in only one case, and ceased spontaneously with only a drain for 61 days. There were no other complications such as postoperative hemorrhage, venous thrombosis, infections, and so on. Postoperative umbilical incisions healed well. There were no obvious scars, and cosmetic result was good. The patients were discharged from hospital in a mean of 7.45 ± 1.44 days (range 5–10), and resumed daily activities quickly. All 11 patients were followed up, including nine cases with a follow-up time of over 1 year, and no incisional hernia was found in any of the cases.
the transumbilical incision (Fig. 1j). A purse-string suture was reserved beforehand, surrounding the drainage tube. The drainage tube could be pulled out when the drainage volume was less than 10 ml in 24 h. Then the purse-string suture can be tensed, and the hole at the umbilicus closed.
Results Clinical Records of 11 Cases Since June 2009, a total of 11 patients underwent TUSILDP in our department. The 11 patients in this study were all women. The ages ranged from 20 to 73 years, with an average age of 38.0 years. The average body mass index (BMI) was 22.67 (18.6*26.2). Among the 11 cases, five were diagnosed as pancreatic mucinous cystadenoma, three were diagnosed as a pancreatic cyst, and the other three were diagnosed as a splenic artery aneurysm, islet cell tumor, and abdominal cavity fibromatosis involving the tail of pancreas, respectively (Table 1). TUSI-LDPs were successfully performed in ten cases, while in the other case the operation converted to conventional multi-incision surgery due to severe adhesion between the pancreatic cyst and surrounding tissues. LDP with splenectomy was performed in five cases (cases 1, 3, 4, 5, 10), while spleen-preserving LDP was performed in the other six cases (Table 2). In one case, an insulinoma was found on preoperative investigation to lie in the tail of pancreas, and a laparoscopic ultrasound was applied to confirm the position of the insulinoma during operation. The mean operation time of the 11 cases was
Review of the English Literature We searched the English literature for SILS performed on pancreatic lesions, and only found five cases (Table 3) [6– 9]. Four of the patients were women. The mean age of the five patients was 54.2 years (range 40–79). Diagnoses were metastatic tumor from renal clear cell carcinoma, cystadenoma, borderline lesion of mucinous cystadenoma and mucinous cystadenocarcinoma without invasion, metastatic tumor from a thyroid carcinoma, and macrocystic serous cystadenoma. In three cases, the lesions were found in the body of the pancreas, and the lesions in the other two cases were confined to the tail of the pancreas. The lesions were cystic in three cases, and solid in two cases that were diagnosed as metastatic pancreatic tumors. The diameter of the lesions ranged from 15 mm to 65 mm. Most of the
Table 2 Operative parameters and postoperative recovery of patients Cases
Operation time (min)
Intraoperative blood loss (ml)
Conversion to multiincision surgery
Postoperative evacuating time (day)
Food intake time (day)
Drainage time (day)
Hospital stay (day)
Postoperative hemorrhage
Pancreatic leakage
Hernia/ followup time (month)
1
300
500
yes
3
3
4
8
no
no
no/46
2a
240
500
no
4
4
7
9
no
no
no/43
3
150
10
no
3
3
[7
7
no
yes
no/38
4
125
100
no
4
5
7
8
no
no
no/31
5
170
10
no
3
3
4
6
no
no
no/29
6a
110
30
no
3
3
4
6
no
no
no/25
7a
115
50
no
2
3
7
8
no
no
no/23
8a
165
100
no
5
5
10
10
no
no
no/17
9a
170
50
no
3
4
7
8
no
no
no/16
10
155
200
no
4
5
7
7
no
no
no/11
11a
95
200
no
3
4
5
5
no
no
no/5
min minute a
Splenic preservation
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World J Surg Table 3 General information, operative parameters, and postoperative recovery of patients in the English literature Study, year
Age
Size of lesion
Tumor location
Diagnosis
Operation time (min)
Intraoperative blood loss (ml)
Hospital stay (day)
Postoperative hemorrhage
Pancreatic leakage
Barbaros et al. [6], 2010
59
30 9 22
Body and tail
Metastatic tumor
330
100
7
No
Yes
Kuroki et al. [7], 2011
79
15 9 15
Body
Metastatic tumor
285
20
11
No
No
Chang et al. [8], 2012
40
35 9 35
Body
Macrocystic serous cyst adenoma
233
100
3
No
No
Misawa et al. [9], 2012
53
65 9 65
Tail
Cystadenoma
240
0
7
No
No
40
35 9 35
Tail
Borderline lesion
225
100
5
No
No
lesions were smaller than 35 mm, and the only large lesion, with a diameter of 65 mm, was the cystic lesion. In five cases, the SILS were all successfully completed without conversion to multi-incision or open surgery. In two cases, the spleen was resected, while it was preserved in the other three cases. The overall procedures of the five cases were reported to be similar to ours. In particular, in all five cases, a special SILS port was placed through the abdominal incision at the umbilicus and, after dividing the gastrocolic ligament, a similar stomach hanging method was used to help expose the pancreas, obtain sufficient working space, and ensure adequate laparoscopic view. In two of these five cases, laparoscopic ultrasonography was also reported as being used. The mean operation time for the five cases was 262.6 ± 44.3 minutes (range 225–330), and the mean intraoperative blood loss was 64 ± 49.8 ml (range 0–100). In terms of postoperative complications, pancreatic leakage also occurred in only one patient, who was diagnosed with clear cell type renal cell cancer metastases in pancreatic tissue. The patient was discharged on postoperative day 7 with the drain, and the low-volume (20 ml/day) pancreatic fistula ceased spontaneously with only a drain for 35 days. There were no other complications such as postoperative hemorrhage, venous thrombosis, infections, and so on. Postoperative umbilical incisions healed well, and the cosmetic result was good. The patients were discharged from hospital in a mean of 6.6 ± 3.0 days (range 3–11).
Discussion Over the past several years, one of the most significant advances in the field of surgery is the continued evolution of minimally invasive technologies, among which laparoscopic surgery is the most important part. Partly owing to the retroperitoneal location of the pancreas, the wide range and influence of operation, numerous potential
postoperative complications, and so on, the application of laparoscopic surgery for the treatment of pancreatic diseases has only recently gained widespread popularity, including diagnostic explorative laparoscopy for cancer staging [10, 11], pancreatic drainage [12], enucleation [13], distal pancreatectomy [2, 14], and even pancreaticoduodenectomy [15]. LDP is the most widely used of these different laparoscopic procedures, possibly because of its acceptable technical feasibility without the necessity for anastomoses [16]. Nowadays, due to the reduced number of ports, SILS has been recognized as an improvement over conventional laparoscopic surgery, with some additional benefits. Since the first attempt at single-incision laparoscopic cholecystectomy [17], SILS has been applied in many other surgical procedures, such as appendectomy [18], total extraperitoneal inguinal hernia repair [19], sleeve gastrectomy [20], gastrojejunostomy [21], splenectomy [22], nephrectomy [23], liver resection [24], and so on. However, SILS is still not a common surgical method in pancreatic surgery [6–9]. Summarizing the related experience would certainly be helpful for the future application of SILS on pancreatic surgery. SILS has also now gradually been applied in distal pancreatectomy. However, to date, and to the best of our knowledge, there have been only a total of five cases reported in the English literature [6–9]. In 2010, Barbaros et al. [6] first reported on the TUSI-LDP, where the operation was successfully completed even though there was dense fibrosis in the retroperitoneal region caused by a previous left nephrectomy, confirming that even TUSILDP together with splenectomy could be performed technically, and postoperative recovery was good. In the next four cases, the procedures were also reported as uneventful [7–9], suggesting that TUSI-LDP is feasible. Among these cases, even for the patients who had undergone previous surgical procedures, the TUSI-LDPs, together with splenectomy or with spleen preservation, were all performed
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successfully. Our experiences with these 11 cases now reconfirms the feasibility and safety of the TUSI-LDP in selected cases. During the surgery procedures, it is critical to obtain favorable exposure of the lesion and the operative field. In laparoscopic surgery, gravity is usually used. During operations on the pancreas, it is essential to rotate or position the patient in the anti-Trendelenburg position, allowing gravity to pull the pancreas and spleen close to the umbilicus and help afford good exposure during the operation. In laparoscopic surgery, to favorably expose the pancreas and operative field, some other methods could also be used. In the five cases in the English literature, a similar stomach-hanging method was used, helping maintain a stable operative field during the operation [6–9]. Further, a balloon retractor was also useful for retracting the stomach, spleen, and pancreas. Furthermore, the tugexposure technique was also beneficial for TUSI-LDP, to allow optimal tension on the tissue as well as easy dissection and stapling of the pancreas. Certainly, with the accumulation of operators’ experiences, these methods could be gradually omitted. In our surgery, neither the stomach-hanging method nor the balloon retractor were used, but our operations were also performed smoothly, with shorter operation times. Whole and intact resection of the lesion is the general goal for surgeons. For some small lesions, the detection of lesions is another important part of the operation, especially for some pancreatic neuroendocrine tumors. During LDP, lesion detection is much more difficult. Now, the intraoperative laparoscopic ultrasound probe introduced through the 12 mm trocar is very helpful, and sometimes essential for localization of the tumor and exploration of the gland for additional tumors in selected cases. In one case in our department, intraoperative laparoscopic ultrasound was just used to detect lesions. Besides, in one case reported in the English literature [9], intraoperative laparoscopic ultrasound was also used to confirm the lesion and that no other lesions were present. Due to the usefulness and convenience of the intraoperative laparoscopic ultrasound, maybe it could become a routine method in TUSILDP. In addition, Newman and colleagues recently described an endoscopic ultrasound-guided tattooing technique before LDP [25]. This technique was recognized to be safe and useful for the identification of lesions, as the tattoo could be visible during the operation without significant complications. The potential of decreasing operative time and demarcating a precise line of resection for laparoscopic surgeons makes this procedure attractive, and might be used in future TUSI-LDPs. Due to the close relationship between the pancreas and splenic vessels, during the distal pancreatectomy, the branches of the splenic vessels in the body and tail of
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pancreas must be treated simultaneously, or even the spleen could be resected in some cases. Thus, laparoscopic resection of the pancreatic body and tail can be generally divided into spleen-preserving distal pancreatectomy and distal pancreatectomy with splenectomy. Spleen conservation (or not) during the distal pancreatectomy is still a controversial issue [26]. Previously, due to the special relationship between the spleen and the pancreas, splenectomy was generally performed with distal pancreatectomy. In five cases in our department and two reported in the English literature [6, 9], TUSI-LDP with splenectomy was performed, certainly mainly due to the close relationship between the pancreatic lesion and splenic vessels. Now, comprehension of the immunologic role of the spleen, postsplenectomy morbidity, and the difficulty of delivering the spleen out through the small port site has prompted efforts in splenic conservation during distal pancreatectomy. Two techniques to preserve the spleen have been described. One is the so-called Warshaw technique [27], in which the splenic artery or vein is ligated, and the short gastric vessels are preserved to spare the blood supply to the spleen. The other method is to preserve the splenic vessels, with only the distal part of the pancreas resected. The splenic vessels are stripped from the pancreas, and the small branches of the splenic artery and vein are divided using a sealing instrument. In terms of the two methods, the former is still mostly used, as it can be performed smoothly without carefully preserving the main splenic vessels, though a postoperative part plenic infarction might occur postoperatively [28]. In our cases, we still preferred the former method, also for its particularly low challenges. As regards the operation range, dissection of the pancreas was initially mostly carried out at the region of the body, which was recognized as a suitable option for most benign and indolent tumors located in the body or tail of the gland, regardless of the actual location of the tumor. The advantage of this method is a theoretically lower risk of hemorrhage from small splenic branches, as there are not many branches of splenic vessels at this point. However, the disadvantage of such a proximal transection is that a large amount of normal pancreatic tissue might be sacrificed, especially for lesions in the tail of the pancreas. The pancreas is now always selected to be divided to the right of the lesion with a minimal margin. The parenchyma-sparing resections are more frequently performed in order to decrease the rate of postoperative pancreatic insufficiency [29]. The body and tail region of the pancreas is no longer the difficult part, as the laparoscope can enlarge the visual fields of operation five times, to show the anatomy and inter-relationship of related tissues more clearly, so that the operation can be more sophisticated. Among the reported cases, three in the English literature and four in our study, dissections along the pancreatic tail
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were all successfully performed [7–9], suggesting the feasibility and safety of parenchyma-sparing resections in TUSI-LDPs. For lesions in the body of the pancreas, at present, to afford a lower risk of endocrine insufficiency, conventional laparoscopic central pancreatectomy or even TUSI laparoscopic central pancreatectomy can be gradually performed [30]. With respect to the operative parameters and postoperative recovery, in our cases, the mean operation time was 163.18 ± 63.18 minutes and mean intraoperative blood loss was 159.09 ± 181.02 ml. In the English literature, the mean operation time was 262.6 ± 44.3 minutes (range 225–330), and the mean intraoperative blood loss was 64 ± 49.8 ml (range 0–100). The time was similar to, or even less than, the average time used for conventional LDP in other institutions [31, 32]. Furthermore, it could be found that the operative parameters in our cases were also comparable to those of the five TUSI-LDPs reported in the literature [6–9], and the operation times in our cases were even less, implying that TUSI-LDP could also be undertaken smoothly, especially for experienced laparoscopic surgeons [33–35]. Regarding postoperative complications, the good visual fields of operation provided by the laparoscope, and the rational utilization of sealing devices have made complications rare. It was found that, compared with open distal pancreatectomy, LDP patients had significantly fewer complications [36]. Pancreatic fistula is one of the most serious complications of distal pancreatectomy. A closed drainage should be placed near the stump of the pancreas, and the content and volume of pancreatic amylase, and bleeding, should be closely monitored. For slight pancreatic leakage, the remaining drainage time should be extended, and the regulation of food and use of somatostatin could be helpful for healing. Pancreatic fistula is usually conservatively managed, while revision surgery is performed rarely for persistent pancreatic fistula. Cho et al. [37] employed risk factors for pancreatic fistula after distal pancreatectomy, and found that preoperative characteristics may identify cohorts of patients who will benefit more from LDP. No patient cohorts had higher postoperative complication rates after LDP than those undergoing open distal pancreatectomy, suggesting that LDP may be the operative procedure of choice for most patients with leftsided pancreatic lesions [37]. Pancreatic fistula occurred in only one of our ten TUSI-LDP cases and one case was reported in the English literature [6], and conservative treatment was effective. There were no other complications such as postoperative hemorrhage, venous thrombosis, infections, and so on. These results suggest that patients undergoing TUSI-LDP may also benefit. In addition, as for postoperative complications of SILS, the occurrence of postoperative umbilical hernia has
recently become a topic of focus [38]. A more sizable umbilical incision is required for SILS than with conventional laparoscopy, and some surgeons have begun to suspect that this could increase the risk of umbilical hernia, as previous studies have demonstrated a correlation between trocar incision size and risk of subsequent incisional hernia [39, 40]. These findings have raised concerns about the SILS-related wound complication rates. Weiss et al. [3] found that, for SILS, the incidence of wound complications was acceptably low and could be further reduced once the learning curve has been passed. Furthermore, though some studies have revealed an increase in hernia formation for SILS patients [41], some more recent research concerning the complication of umbilical hernia for SILS has also suggested that the hernia rate in the SILS group is not increased, especially when SILS is performed by advanced laparoscopic surgeons [38, 42, 43]. It was revealed that factors associated with wound complications included higher patient BMI, longer skin incisions, multiport SILS, and a learning curve effect [3]. Incisional hernias did not form in any of our cases. This may be closely related to the considerable attention that was given to the incisional closure process in our cases, our abundant SILS experience [33–35], the small diameter of the lesion, and low BMI of the patients, although our inclusion criteria did not restrict this in patient selection in our department [3, 44]. It is now shown that SILS might include the benefits of reduced pain, a more cosmetic incision, and a faster recovery [18–24]. Although SILS has so many advantages over conventional laparoscopic surgery, SILS also carries some difficulties, and a higher level of operational skills is required. The major problem is that all instruments are closely packed together [6]. The introduction of a camera and several instruments parallel to each other results in a decreased range of motion and in instruments crossing over each other. This decreased freedom of motion increases the technical complexity of the operation and results in a significantly increased learning curve for performing SILS, principally in navigating the instruments within a limited range of motion. In our operations, to overcome clashes between instruments, sometimes the lens was appropriately regressed, and then pushed forward after the exact details were seen. It was demonstrated that this process would not hamper but does help the operation process. Certainly, as the experiences of the surgeons accumulate, the performance of the operation will be easier, and the advances in laparoscopic instruments in the near future will also help the operation and increase the comfort of surgeons. Recently, in SILS, some more new and specialized instruments might be able to be utilized. It was reported that a combination of articulated grasper or dissector, and telescope-like endoeye might be useful to overcome the
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lack of triangulation and the clashing of instruments during single-port laparoscopic surgery [45, 46]. This allows for good dissection and traction and prevents instrument clashes within the abdomen. Furthermore, some flexible instruments might also increase freedom and alleviate the clashing of instruments. Certainly, in the near future, some industries and academic centers will explore more useful instruments, and these will promote the application of SILS in surgical procedures, including in pancreatic surgery. At present, the application of SILS in pancreatic surgery is just beginning, and to date, a total of only five cases are present in the English literature [6–9]. Certainly, for the performance of TUSI-LDP, accumulations of SILS experience for a period of time is essential in the beginning for pancreatic surgeons without extensive SILS experience, or they could team up with a SILS expert for initial operations. We began to perform SILS in 2009, and with the experiences gradually accumulating, 6 months later, we attempted the first TUSI-LDP. Although the first operation converted to conventional multi-incision surgery due to severe adhesion between the pancreatic cyst and surrounding tissues, TUSI-LDP was successfully performed in our department in the next ten cases to date. Our experience suggests that TUSI-LDP is feasible and safe, in well selected cases. In our department, the criteria for patient selection includes that the diameter of a benign lesion should be smaller than 3.5 cm (the diameter of a cystic lesion could be a little larger), and the patient has no history of abdominal operation, or contraindications for laparoscopic surgery. In addition, what we still want to highlight is that the average BMI of the patients in our study is 22.7, although our patient selection criteria does not specifically restrict this. This may be related to eating habits in China. For patients with a high BMI, careful consideration should be given before attempting TUSILDP, as a high BMI would increase the difficulty and risks of SILS, as well as the wound complication rate [44].
Conclusion Today, SILS is becoming popular, and its purpose is to cure disease in a cosmetic method with minimal invasion. Recent reports suggest that TUSI-LDP in pancreatic surgery is feasible and safe in well selected cases. TUSI-LDP could reduce injuries and contribute to an improved cosmetic effect. With the gradual accumulation of surgeons’ experience with SILS, it could be attempted in suitable cases where patients have a strong concerns about cosmetic appearance; maybe in the future, improvements in laparoscopic instruments will also render SILS more straightforward.
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Acknowledgments research funding.
This work was not supported by any outside
Disclosures The authors have no conflicts of interest or financial ties to disclose.
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World J Surg 20. Reavis KM, Hinojosa MW, Smith BR et al (2008) Single-laparoscopic incision transabdominal surgery sleeve gastrectomy. Obes Surg 11:1492–1494 21. Bucher P, Pugin F, Morel P (2009) Transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy: case report. Surg Endosc 7:1667–1670 22. Barbaros U, Dinc¸c¸ag˘ A (2009) Single incision laparoscopic splenectomy: the first two cases. J Gastrointest Surg 13:1520–1523 23. Raman JD, Bagrodia A, Cadeddu JA (2008) Single-incision, umbilical laparoscopic versus conventional laparoscopic nephrectomy: a comparison of perioperative outcomes and shortterm measures of convalescence. Eur Urol 5:1198–1204 24. Zhao G, Hu M, Liu R et al (2011) Laparoendoscopic single-site liver resection: a preliminary report of 12 cases. Surg Endosc 25:3286–3293 25. Newman NA, Lennon AM, Edil BH et al (2010) Preoperative endoscopic tattooing of pancreatic body and tail lesions decreases operative time for laparoscopic distal pancreatectomy. Surgery 148:371–377 26. Hwang HK, Chung YE, Kim KA et al (2012) Revisiting vascular patency after spleen-preserving laparoscopic distal pancreatectomy with conservation of splenic vessels. Surg Endosc 26:1765–1771 27. Warshaw AL (1988) Conservation of the spleen with distal pancreatectomy. Arch Surg 123:550–553 28. Shimizu S, Tanaka M, Konomi H et al (2004) Spleen-preserving laparoscopic distal pancreatectomy after division of the splenic vessels. J Laparoendosc Adv Surg Tech A 14:173–177 29. Belyaev O, Herzog T, Chromik AM et al (2013) Early and late postoperative changes in the quality of life after pancreatic surgery. Langenbecks Arch Surg 398:547–555 30. Iacono C, Verlato G, Ruzzenente A et al (2013) Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy. Br J Surg 100:873–885 31. Ammori BJ, Ayiomamitis GD (2011) Laparoscopic pancreaticoduodenectomy and distal pancreatectomy: a UK experience and a systematic review of the literature. Surg Endosc 25:2084–2099 32. Nigri GR, Rosman AS, Petrucciani N et al (2011) Meta analysis of trials comparing minimally invasive and open distal pancreatectomies. Surg Endosc 25:1642–1651 33. Kong J, Wu SD, Su Y (2013) Translumenal single-incision laparoscopy radical gastrectomy with D2 lymph node dissection for early gastric cancer–primary experience with less invasive surgery in China. J Laparoendosc Adv Surg Tech A 23:141–145
34. Fan Y, Wu SD, Kong J et al (2013) Transumbilical single-incision laparoscopic fundoplication: a new technique for liver retraction using cyanoacrylate. J Laparoendosc Adv Surg Tech A 23:356–360 35. Wu S, Chen Y, Tian Y et al (2013) Transumbilical single-incision laparoscopic multiple organ procedures: initial experience of 20 cases. J Laparoendosc Adv Surg Tech A 23:56–59 36. Kooby DA, Gillespie T, Bentrem D et al (2008) Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches. Ann Surg 248:438–446 37. Cho CS, Kooby DA, Schmidt CM et al (2011) Laparoscopic versus open left pancreatectomy: can preoperative factors indicate the safer technique? Ann Surg 253:975–980 38. Lee DY, Rehmani SS, Guend H et al (2013) The incidence of trocar-site hernia in minimally invasive bariatric surgery: a comparison of multi versus single-port laparoscopy. Surg Endosc 27:1287–1291 39. Kadar N, Reich H, Liu CY et al (1993) Incisional hernias after major laparoscopic gynecologic procedures. Am J Obstet Gynecol 168:1493–1495 40. Montz FJ, Holschneider CH, Munro MG (1994) Incisional hernia following laparoscopy: a survey of the American Association of Gynecologic Laparoscopists. Obstet Gynecol 84:881–884 41. Marks JM, Phillips MS, Tacchino R et al (2013) Single-incision laparoscopic cholecystectomy is associated with improved cosmesis scoring at the cost of significantly higher hernia rates: 1-year results of a prospective randomized, multicenter, singleblinded trial of traditional multiport laparoscopic cholecystectomy vs single-incision laparoscopic cholecystectomy. J Am Coll Surg 216:1037–1047 42. Gunderson CC, Knight J, Ybanez-Morano J et al (2012) The risk of umbilical hernia and other complications with laparoendoscopic single-site surgery. J Minim Invasive Gynecol 19:40–45 43. Wagner MJ, Kern H, Hapfelmeier A et al (2013) Single-port cholecystectomy versus multi-port cholecystectomy: a prospective cohort study with 222 patients. World J Surg 37:991–998. doi:10.1007/s00268-013-1946-4 44. Yilmaz H, Alptekin H, Acar F et al (2013) Single-incision laparoscopic cholecystectomy and overweight patients. Obes Surg [Epub ahead of print] 45. Goldsmith ZG, Astroza GM, Wang AJ et al (2012) Optical performance comparison of deflectable laparoscopes for laparoendoscopic single-site surgery. J Endourol 26:1340–1345 46. Rodriguez AR, Hakky T, Spiess PE (2011) Laparo-endoscopic single site retroperitoneal partial nephrectomy: a novel concept. Int Braz J Urol 37:136
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Transumbilical Single-Incision Laparoscopic Distal Pancreatectomy: Primary Experience and Review of the English Literature Dianbo Yao • Shuodong Wu • Yu Tian Ying Fan • Jing Kong • Yongnan Li
•
Ó Socie´te´ Internationale de Chirurgie 2013
Abstract Background Single-incision laparoscopic surgery (SILS) may represent an improvement over conventional laparoscopic surgery, and has been applied in many surgical procedures. However, for pancreatic surgery, experience is rather limited. Methods The clinical records of 11 cases in which transumbilical single-incision laparoscopic distal pancreatectomy (TUSI-LDP) was performed at our institution since June 2009 were retrospectively analyzed, and all the literatures concerning TUSI-LDP were retrospectively reviewed. Results All the 11 patients were female. The ages ranged from 20 to 73 years, with an average age of 38.0 years. The average body mass index (BMI) was 22.67 (18.6–26.2). Most TUSI-LDPs were successfully performed, with only one conversion to multi-incision surgery. Splenic preservation was performed in six cases. The mean operation time was 163.18 ± 63.18 minutes (range 95–300), and the mean intraoperative blood loss was 159.09 ± 181.02 ml (range 10–500 ml). The surgical wounds healed well, with good cosmetic wound healing, and the patients were discharged from hospital in a mean of 7.45 ± 1.44 days (range 5–10). Only one patient developed pancreatic leakage, which ceased spontaneously with only a drain for 61 days. The parameters were comparable with those found in the English literature. Conclusions These recent experiences suggest that SILS in pancreatic surgery is feasible for a select group of
D. Yao S. Wu (&) Y. Tian Y. Fan J. Kong Y. Li Department of Vascular and Bile Duct Surgery, Shengjing Hospital of China Medical University, No. 36, San Hao Street, Heping District, Shenyang 110004, Liaoning Province, China e-mail: [email protected]; [email protected]
patients with relatively small lesions and low BMI, and that, with the gradual accumulation of surgeons’ experience with SILS and improvement of laparoscopic instruments, it might become a safe option for some patients.
Introduction Currently, laparoscopic surgery has been preferred as an alternative to open surgery owing to its clear visual field, reduced injury, decreased postoperative pain, better cosmetic results, and accelerated patient recovery. Pancreatic surgery is an extremely challenging field. To treat pancreatic lesions via a laparoscopic approach, in the past several years, various attempts have been gradually attempted, from diagnostic purposes to surgical intervention, giving rise to resection procedures [1, 2]. At the same time, the increasing diagnoses of cystic or solid and benign tumors in young individuals, mostly females, has led to an increasing demand for laparoscopic surgical procedures, to eradicate the tumor and minimize the cosmetic impact of the surgical wound. Recently, to further minimize the surgical trauma by reducing numbers and sizes of the ports, many experienced laparoscopic surgeons have tried to develop a new minimally invasive technique, called ‘single incision laparoscopic surgery’ (SILS). This approach has been now successfully and widely applied in many fields of abdominal surgery [3–5], both for the less invasive wishes of surgeons and more cosmetic requests of patients. However, reports of SILS for pancreatic lesions is rather limited. To summarize and update the current clinical experiences of SILS in pancreatic surgery, in this study, we report 11 cases in which transumbilical single-incision laparoscopic distal pancreatectomy (TUSI-LDP) was
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World J Surg Fig. 1 a Operating room setting: the operator, assistants, and monitor. b Access site in the umbilicus: the two trocars for the lens, grasper, and the plastic disposable trocar. c Ultrasound image showing the cystic lesion with the largest diameter of the 11 cases. d Computed tomographic view of pancreatic lesions. e After the contrast injection, the mass was slightly enhanced, especially on the edge. f Exposure of the pancreas. The lesion is seen at the right side of the picture. g The body to tail of the pancreas is mobilized and lifted from the retroperitoneum by the tug-exposure technique, and pancreatic body is transected with an endoscopic linear stapler device. h The lesion was put into a retrieval bag. i The cyst contents were aspirated within the retrieval bag. j The closed drains brought out through the transumbilical incision
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performed in the Shengjing Hospital of China Medical University. Further, all the literature concerning SILS performed on pancreatic lesions were retrospectively reviewed. To the best of our knowledge, this is the largest patient cohort reported for this technique to date [6–9].
Methods Patients The criteria for patient selection in our department are as follows: a benign lesion found in preoperative examination, and intent to perform distal pancreatectomy. The diameter of the lesion should be less than 3.5 cm, and the diameter of a cystic lesion could be a little larger. The patient has strong preferences for cosmetic appearance and no history of abdominal operations or contraindications for laparoscopic surgery. All the patients participating in this study gave informed consent before surgery.
body and tail of the pancreas from the normal pancreatic tissue on the right of the mass to the tail of pancreas near the hilum of spleen was completely separated, the pancreas would be divided with an endoscopic linear stapler device (Fig. 1g). A retrieval bag was placed through the plastic disposable trocar (Fig. 1h). The specimen was wrapped in the retrieval bag and extracted from the umbilical incision (Fig. 1i). If a splenectomy was to be simultaneously performed, the superior part of the gastrosplenic ligament, splenophrenic ligament should be also dissected, and then the spleen was removed with the pancreas specimen. In cases in which a spleen-preserving laparoscopic distal pancreatectomy (LDP) was to be performed, the splenic vessels were mostly divided, with the short gastric vessels preserved to provide a blood supply. In some cases, the pancreatic branches of splenic vessels could easily be dissected and divided, and the splenic vessels could also be separated from the pancreas and preserved. At the end of surgery, a closed drain was placed near the stump of the pancreas, with the drain brought out through
Surgical Procedures The patient was placed in a supine position with legs apart (Fig.1a). A transumbilical 3 cm superficial longitudinal incision was made. After the maintenance of pneumoperitoneum, a 10 mm trocar was inserted into the lower margin of the incision for the lens. Two accessory trocars were inserted on the superior margin of incision. The left one was 5 mm for the grasper, and the right one was for the plastic disposable trocar, 12 mm in diameter (Fig. 1b). For the patient’s position, a slight (35°) anti-Trendelenburg tilt was obtained, and a rotation about 30° to the right was made. The location and size of the lesion could usually be revealed in the ultrasound, computed tomography, or magnetic resonance imaging (Fig. 1c–e). The operation began with the division of the gastrocolic ligament and the lower part of the gastrolienal ligament, to expose the body and tail of the pancreas and confirm the location and range of the mass or cyst (Fig. 1f). The serous membrane was then dissected along the lower edge of pancreas on the right of the lesion. Loose connective tissue between the dorsal surface of the pancreas and the posterior abdominal wall was then dissociated carefully, so as to not injure the splenic artery or splenic vein. When the ultrasonic scalpel got the superior border from the inferior border, a tunnel would be built behind the normal pancreatic body. The grasper was then inserted into the tunnel and carried forward to enlarge the visual fields behind the pancreas, and the loose connective tissue was dissociated carefully by the ultrasonic scalpel towards the tail of the pancreas. The mass in the body and tail of the pancreas was then lifted and separated from the posterior abdominal wall. When the
Table 1 General information of 11 cases Pt no.
Diagnosis
Tumor location
Age
Sex
BMI
Maximum lesion diameter (cm)
1
Mucinous cystadenoma
Body of pancreas
46
F
24.6
5
2
Fibromatosis
Abdominal cavity
20
F
18.6
3.5
3
Serositic cyst
Tail of pancreas
36
F
23.4
4.5
4
Pancreatic cyst
Body of pancreas
42
F
22.2
4.5
5
Artery aneurysm
Body and tail of pancreas
22
F
21.6
3.5
6
Mucinous cystadenoma and SPT
Body and tail of pancreas
34
F
22.8
3.5
7
Pancreatic cyst
Tail of pancreas
34
F
23.4
3.5
8
Mucinous cystadenoma
Body and tail of pancreas
39
F
22.6
3
9
Islet cell tumor
Tail of pancreas
73
F
26.2
1.2
10
Mucinous cystadenoma
Body and tail of pancreas
27
F
22.2
4
11
Mucinous cystadenoma
Tail of pancreas
45
F
21.8
6.2
BMI body mass index, F female, pt patient, SPT solid-pseudopapillary tumor
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163.18 ± 63.18 minutes (range 95–300), and the mean intraoperative blood loss was 159.09 ± 181.02 ml (range 10–500). In terms of postoperative complications, pancreatic leakage occurred in only one case, and ceased spontaneously with only a drain for 61 days. There were no other complications such as postoperative hemorrhage, venous thrombosis, infections, and so on. Postoperative umbilical incisions healed well. There were no obvious scars, and cosmetic result was good. The patients were discharged from hospital in a mean of 7.45 ± 1.44 days (range 5–10), and resumed daily activities quickly. All 11 patients were followed up, including nine cases with a follow-up time of over 1 year, and no incisional hernia was found in any of the cases.
the transumbilical incision (Fig. 1j). A purse-string suture was reserved beforehand, surrounding the drainage tube. The drainage tube could be pulled out when the drainage volume was less than 10 ml in 24 h. Then the purse-string suture can be tensed, and the hole at the umbilicus closed.
Results Clinical Records of 11 Cases Since June 2009, a total of 11 patients underwent TUSILDP in our department. The 11 patients in this study were all women. The ages ranged from 20 to 73 years, with an average age of 38.0 years. The average body mass index (BMI) was 22.67 (18.6*26.2). Among the 11 cases, five were diagnosed as pancreatic mucinous cystadenoma, three were diagnosed as a pancreatic cyst, and the other three were diagnosed as a splenic artery aneurysm, islet cell tumor, and abdominal cavity fibromatosis involving the tail of pancreas, respectively (Table 1). TUSI-LDPs were successfully performed in ten cases, while in the other case the operation converted to conventional multi-incision surgery due to severe adhesion between the pancreatic cyst and surrounding tissues. LDP with splenectomy was performed in five cases (cases 1, 3, 4, 5, 10), while spleen-preserving LDP was performed in the other six cases (Table 2). In one case, an insulinoma was found on preoperative investigation to lie in the tail of pancreas, and a laparoscopic ultrasound was applied to confirm the position of the insulinoma during operation. The mean operation time of the 11 cases was
Review of the English Literature We searched the English literature for SILS performed on pancreatic lesions, and only found five cases (Table 3) [6– 9]. Four of the patients were women. The mean age of the five patients was 54.2 years (range 40–79). Diagnoses were metastatic tumor from renal clear cell carcinoma, cystadenoma, borderline lesion of mucinous cystadenoma and mucinous cystadenocarcinoma without invasion, metastatic tumor from a thyroid carcinoma, and macrocystic serous cystadenoma. In three cases, the lesions were found in the body of the pancreas, and the lesions in the other two cases were confined to the tail of the pancreas. The lesions were cystic in three cases, and solid in two cases that were diagnosed as metastatic pancreatic tumors. The diameter of the lesions ranged from 15 mm to 65 mm. Most of the
Table 2 Operative parameters and postoperative recovery of patients Cases
Operation time (min)
Intraoperative blood loss (ml)
Conversion to multiincision surgery
Postoperative evacuating time (day)
Food intake time (day)
Drainage time (day)
Hospital stay (day)
Postoperative hemorrhage
Pancreatic leakage
Hernia/ followup time (month)
1
300
500
yes
3
3
4
8
no
no
no/46
2a
240
500
no
4
4
7
9
no
no
no/43
3
150
10
no
3
3
[7
7
no
yes
no/38
4
125
100
no
4
5
7
8
no
no
no/31
5
170
10
no
3
3
4
6
no
no
no/29
6a
110
30
no
3
3
4
6
no
no
no/25
7a
115
50
no
2
3
7
8
no
no
no/23
8a
165
100
no
5
5
10
10
no
no
no/17
9a
170
50
no
3
4
7
8
no
no
no/16
10
155
200
no
4
5
7
7
no
no
no/11
11a
95
200
no
3
4
5
5
no
no
no/5
min minute a
Splenic preservation
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World J Surg Table 3 General information, operative parameters, and postoperative recovery of patients in the English literature Study, year
Age
Size of lesion
Tumor location
Diagnosis
Operation time (min)
Intraoperative blood loss (ml)
Hospital stay (day)
Postoperative hemorrhage
Pancreatic leakage
Barbaros et al. [6], 2010
59
30 9 22
Body and tail
Metastatic tumor
330
100
7
No
Yes
Kuroki et al. [7], 2011
79
15 9 15
Body
Metastatic tumor
285
20
11
No
No
Chang et al. [8], 2012
40
35 9 35
Body
Macrocystic serous cyst adenoma
233
100
3
No
No
Misawa et al. [9], 2012
53
65 9 65
Tail
Cystadenoma
240
0
7
No
No
40
35 9 35
Tail
Borderline lesion
225
100
5
No
No
lesions were smaller than 35 mm, and the only large lesion, with a diameter of 65 mm, was the cystic lesion. In five cases, the SILS were all successfully completed without conversion to multi-incision or open surgery. In two cases, the spleen was resected, while it was preserved in the other three cases. The overall procedures of the five cases were reported to be similar to ours. In particular, in all five cases, a special SILS port was placed through the abdominal incision at the umbilicus and, after dividing the gastrocolic ligament, a similar stomach hanging method was used to help expose the pancreas, obtain sufficient working space, and ensure adequate laparoscopic view. In two of these five cases, laparoscopic ultrasonography was also reported as being used. The mean operation time for the five cases was 262.6 ± 44.3 minutes (range 225–330), and the mean intraoperative blood loss was 64 ± 49.8 ml (range 0–100). In terms of postoperative complications, pancreatic leakage also occurred in only one patient, who was diagnosed with clear cell type renal cell cancer metastases in pancreatic tissue. The patient was discharged on postoperative day 7 with the drain, and the low-volume (20 ml/day) pancreatic fistula ceased spontaneously with only a drain for 35 days. There were no other complications such as postoperative hemorrhage, venous thrombosis, infections, and so on. Postoperative umbilical incisions healed well, and the cosmetic result was good. The patients were discharged from hospital in a mean of 6.6 ± 3.0 days (range 3–11).
Discussion Over the past several years, one of the most significant advances in the field of surgery is the continued evolution of minimally invasive technologies, among which laparoscopic surgery is the most important part. Partly owing to the retroperitoneal location of the pancreas, the wide range and influence of operation, numerous potential
postoperative complications, and so on, the application of laparoscopic surgery for the treatment of pancreatic diseases has only recently gained widespread popularity, including diagnostic explorative laparoscopy for cancer staging [10, 11], pancreatic drainage [12], enucleation [13], distal pancreatectomy [2, 14], and even pancreaticoduodenectomy [15]. LDP is the most widely used of these different laparoscopic procedures, possibly because of its acceptable technical feasibility without the necessity for anastomoses [16]. Nowadays, due to the reduced number of ports, SILS has been recognized as an improvement over conventional laparoscopic surgery, with some additional benefits. Since the first attempt at single-incision laparoscopic cholecystectomy [17], SILS has been applied in many other surgical procedures, such as appendectomy [18], total extraperitoneal inguinal hernia repair [19], sleeve gastrectomy [20], gastrojejunostomy [21], splenectomy [22], nephrectomy [23], liver resection [24], and so on. However, SILS is still not a common surgical method in pancreatic surgery [6–9]. Summarizing the related experience would certainly be helpful for the future application of SILS on pancreatic surgery. SILS has also now gradually been applied in distal pancreatectomy. However, to date, and to the best of our knowledge, there have been only a total of five cases reported in the English literature [6–9]. In 2010, Barbaros et al. [6] first reported on the TUSI-LDP, where the operation was successfully completed even though there was dense fibrosis in the retroperitoneal region caused by a previous left nephrectomy, confirming that even TUSILDP together with splenectomy could be performed technically, and postoperative recovery was good. In the next four cases, the procedures were also reported as uneventful [7–9], suggesting that TUSI-LDP is feasible. Among these cases, even for the patients who had undergone previous surgical procedures, the TUSI-LDPs, together with splenectomy or with spleen preservation, were all performed
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successfully. Our experiences with these 11 cases now reconfirms the feasibility and safety of the TUSI-LDP in selected cases. During the surgery procedures, it is critical to obtain favorable exposure of the lesion and the operative field. In laparoscopic surgery, gravity is usually used. During operations on the pancreas, it is essential to rotate or position the patient in the anti-Trendelenburg position, allowing gravity to pull the pancreas and spleen close to the umbilicus and help afford good exposure during the operation. In laparoscopic surgery, to favorably expose the pancreas and operative field, some other methods could also be used. In the five cases in the English literature, a similar stomach-hanging method was used, helping maintain a stable operative field during the operation [6–9]. Further, a balloon retractor was also useful for retracting the stomach, spleen, and pancreas. Furthermore, the tugexposure technique was also beneficial for TUSI-LDP, to allow optimal tension on the tissue as well as easy dissection and stapling of the pancreas. Certainly, with the accumulation of operators’ experiences, these methods could be gradually omitted. In our surgery, neither the stomach-hanging method nor the balloon retractor were used, but our operations were also performed smoothly, with shorter operation times. Whole and intact resection of the lesion is the general goal for surgeons. For some small lesions, the detection of lesions is another important part of the operation, especially for some pancreatic neuroendocrine tumors. During LDP, lesion detection is much more difficult. Now, the intraoperative laparoscopic ultrasound probe introduced through the 12 mm trocar is very helpful, and sometimes essential for localization of the tumor and exploration of the gland for additional tumors in selected cases. In one case in our department, intraoperative laparoscopic ultrasound was just used to detect lesions. Besides, in one case reported in the English literature [9], intraoperative laparoscopic ultrasound was also used to confirm the lesion and that no other lesions were present. Due to the usefulness and convenience of the intraoperative laparoscopic ultrasound, maybe it could become a routine method in TUSILDP. In addition, Newman and colleagues recently described an endoscopic ultrasound-guided tattooing technique before LDP [25]. This technique was recognized to be safe and useful for the identification of lesions, as the tattoo could be visible during the operation without significant complications. The potential of decreasing operative time and demarcating a precise line of resection for laparoscopic surgeons makes this procedure attractive, and might be used in future TUSI-LDPs. Due to the close relationship between the pancreas and splenic vessels, during the distal pancreatectomy, the branches of the splenic vessels in the body and tail of
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pancreas must be treated simultaneously, or even the spleen could be resected in some cases. Thus, laparoscopic resection of the pancreatic body and tail can be generally divided into spleen-preserving distal pancreatectomy and distal pancreatectomy with splenectomy. Spleen conservation (or not) during the distal pancreatectomy is still a controversial issue [26]. Previously, due to the special relationship between the spleen and the pancreas, splenectomy was generally performed with distal pancreatectomy. In five cases in our department and two reported in the English literature [6, 9], TUSI-LDP with splenectomy was performed, certainly mainly due to the close relationship between the pancreatic lesion and splenic vessels. Now, comprehension of the immunologic role of the spleen, postsplenectomy morbidity, and the difficulty of delivering the spleen out through the small port site has prompted efforts in splenic conservation during distal pancreatectomy. Two techniques to preserve the spleen have been described. One is the so-called Warshaw technique [27], in which the splenic artery or vein is ligated, and the short gastric vessels are preserved to spare the blood supply to the spleen. The other method is to preserve the splenic vessels, with only the distal part of the pancreas resected. The splenic vessels are stripped from the pancreas, and the small branches of the splenic artery and vein are divided using a sealing instrument. In terms of the two methods, the former is still mostly used, as it can be performed smoothly without carefully preserving the main splenic vessels, though a postoperative part plenic infarction might occur postoperatively [28]. In our cases, we still preferred the former method, also for its particularly low challenges. As regards the operation range, dissection of the pancreas was initially mostly carried out at the region of the body, which was recognized as a suitable option for most benign and indolent tumors located in the body or tail of the gland, regardless of the actual location of the tumor. The advantage of this method is a theoretically lower risk of hemorrhage from small splenic branches, as there are not many branches of splenic vessels at this point. However, the disadvantage of such a proximal transection is that a large amount of normal pancreatic tissue might be sacrificed, especially for lesions in the tail of the pancreas. The pancreas is now always selected to be divided to the right of the lesion with a minimal margin. The parenchyma-sparing resections are more frequently performed in order to decrease the rate of postoperative pancreatic insufficiency [29]. The body and tail region of the pancreas is no longer the difficult part, as the laparoscope can enlarge the visual fields of operation five times, to show the anatomy and inter-relationship of related tissues more clearly, so that the operation can be more sophisticated. Among the reported cases, three in the English literature and four in our study, dissections along the pancreatic tail
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were all successfully performed [7–9], suggesting the feasibility and safety of parenchyma-sparing resections in TUSI-LDPs. For lesions in the body of the pancreas, at present, to afford a lower risk of endocrine insufficiency, conventional laparoscopic central pancreatectomy or even TUSI laparoscopic central pancreatectomy can be gradually performed [30]. With respect to the operative parameters and postoperative recovery, in our cases, the mean operation time was 163.18 ± 63.18 minutes and mean intraoperative blood loss was 159.09 ± 181.02 ml. In the English literature, the mean operation time was 262.6 ± 44.3 minutes (range 225–330), and the mean intraoperative blood loss was 64 ± 49.8 ml (range 0–100). The time was similar to, or even less than, the average time used for conventional LDP in other institutions [31, 32]. Furthermore, it could be found that the operative parameters in our cases were also comparable to those of the five TUSI-LDPs reported in the literature [6–9], and the operation times in our cases were even less, implying that TUSI-LDP could also be undertaken smoothly, especially for experienced laparoscopic surgeons [33–35]. Regarding postoperative complications, the good visual fields of operation provided by the laparoscope, and the rational utilization of sealing devices have made complications rare. It was found that, compared with open distal pancreatectomy, LDP patients had significantly fewer complications [36]. Pancreatic fistula is one of the most serious complications of distal pancreatectomy. A closed drainage should be placed near the stump of the pancreas, and the content and volume of pancreatic amylase, and bleeding, should be closely monitored. For slight pancreatic leakage, the remaining drainage time should be extended, and the regulation of food and use of somatostatin could be helpful for healing. Pancreatic fistula is usually conservatively managed, while revision surgery is performed rarely for persistent pancreatic fistula. Cho et al. [37] employed risk factors for pancreatic fistula after distal pancreatectomy, and found that preoperative characteristics may identify cohorts of patients who will benefit more from LDP. No patient cohorts had higher postoperative complication rates after LDP than those undergoing open distal pancreatectomy, suggesting that LDP may be the operative procedure of choice for most patients with leftsided pancreatic lesions [37]. Pancreatic fistula occurred in only one of our ten TUSI-LDP cases and one case was reported in the English literature [6], and conservative treatment was effective. There were no other complications such as postoperative hemorrhage, venous thrombosis, infections, and so on. These results suggest that patients undergoing TUSI-LDP may also benefit. In addition, as for postoperative complications of SILS, the occurrence of postoperative umbilical hernia has
recently become a topic of focus [38]. A more sizable umbilical incision is required for SILS than with conventional laparoscopy, and some surgeons have begun to suspect that this could increase the risk of umbilical hernia, as previous studies have demonstrated a correlation between trocar incision size and risk of subsequent incisional hernia [39, 40]. These findings have raised concerns about the SILS-related wound complication rates. Weiss et al. [3] found that, for SILS, the incidence of wound complications was acceptably low and could be further reduced once the learning curve has been passed. Furthermore, though some studies have revealed an increase in hernia formation for SILS patients [41], some more recent research concerning the complication of umbilical hernia for SILS has also suggested that the hernia rate in the SILS group is not increased, especially when SILS is performed by advanced laparoscopic surgeons [38, 42, 43]. It was revealed that factors associated with wound complications included higher patient BMI, longer skin incisions, multiport SILS, and a learning curve effect [3]. Incisional hernias did not form in any of our cases. This may be closely related to the considerable attention that was given to the incisional closure process in our cases, our abundant SILS experience [33–35], the small diameter of the lesion, and low BMI of the patients, although our inclusion criteria did not restrict this in patient selection in our department [3, 44]. It is now shown that SILS might include the benefits of reduced pain, a more cosmetic incision, and a faster recovery [18–24]. Although SILS has so many advantages over conventional laparoscopic surgery, SILS also carries some difficulties, and a higher level of operational skills is required. The major problem is that all instruments are closely packed together [6]. The introduction of a camera and several instruments parallel to each other results in a decreased range of motion and in instruments crossing over each other. This decreased freedom of motion increases the technical complexity of the operation and results in a significantly increased learning curve for performing SILS, principally in navigating the instruments within a limited range of motion. In our operations, to overcome clashes between instruments, sometimes the lens was appropriately regressed, and then pushed forward after the exact details were seen. It was demonstrated that this process would not hamper but does help the operation process. Certainly, as the experiences of the surgeons accumulate, the performance of the operation will be easier, and the advances in laparoscopic instruments in the near future will also help the operation and increase the comfort of surgeons. Recently, in SILS, some more new and specialized instruments might be able to be utilized. It was reported that a combination of articulated grasper or dissector, and telescope-like endoeye might be useful to overcome the
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lack of triangulation and the clashing of instruments during single-port laparoscopic surgery [45, 46]. This allows for good dissection and traction and prevents instrument clashes within the abdomen. Furthermore, some flexible instruments might also increase freedom and alleviate the clashing of instruments. Certainly, in the near future, some industries and academic centers will explore more useful instruments, and these will promote the application of SILS in surgical procedures, including in pancreatic surgery. At present, the application of SILS in pancreatic surgery is just beginning, and to date, a total of only five cases are present in the English literature [6–9]. Certainly, for the performance of TUSI-LDP, accumulations of SILS experience for a period of time is essential in the beginning for pancreatic surgeons without extensive SILS experience, or they could team up with a SILS expert for initial operations. We began to perform SILS in 2009, and with the experiences gradually accumulating, 6 months later, we attempted the first TUSI-LDP. Although the first operation converted to conventional multi-incision surgery due to severe adhesion between the pancreatic cyst and surrounding tissues, TUSI-LDP was successfully performed in our department in the next ten cases to date. Our experience suggests that TUSI-LDP is feasible and safe, in well selected cases. In our department, the criteria for patient selection includes that the diameter of a benign lesion should be smaller than 3.5 cm (the diameter of a cystic lesion could be a little larger), and the patient has no history of abdominal operation, or contraindications for laparoscopic surgery. In addition, what we still want to highlight is that the average BMI of the patients in our study is 22.7, although our patient selection criteria does not specifically restrict this. This may be related to eating habits in China. For patients with a high BMI, careful consideration should be given before attempting TUSILDP, as a high BMI would increase the difficulty and risks of SILS, as well as the wound complication rate [44].
Conclusion Today, SILS is becoming popular, and its purpose is to cure disease in a cosmetic method with minimal invasion. Recent reports suggest that TUSI-LDP in pancreatic surgery is feasible and safe in well selected cases. TUSI-LDP could reduce injuries and contribute to an improved cosmetic effect. With the gradual accumulation of surgeons’ experience with SILS, it could be attempted in suitable cases where patients have a strong concerns about cosmetic appearance; maybe in the future, improvements in laparoscopic instruments will also render SILS more straightforward.
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Acknowledgments research funding.
This work was not supported by any outside
Disclosures The authors have no conflicts of interest or financial ties to disclose.
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