Operative indications

In a recent review of the world literature, cancer has been the indication for LPD in more than two thirds of patients, whereas cystic disease, neuroendocrine tumors, and chronic pancreatitis represent the remainder.

The complexity of resection and reconstruction and the prolonged duration of surgery mean that careful patient selection is paramount, especially early in the learning curve. Relative contraindications to LPD include patients with large tumors (>2 cm), potential vascular involvement, nondilated pancreatic or bile ducts, extension of tumor to the uncinate process that renders it in very close proximity to the superior mesenteric artery, acute pancreatitis, morbid obesity, and cardiorespiratory comorbidities. These patients are best offered open resection.

Preoperative evaluation, testing, and preparation

Patients with preoperative suspicion of vascular involvement may be further evaluated with endoscopic ultrasound (EUS) by an experienced gastroenterologist.

We prefer, whenever possible, to rely on magnetic resonance cholangiopancreatography to image the biliary tree and pancreatic duct to avoid preoperative biliary drainage unless jaundice has deepened (bilirubin >200 mmol/L or 11.7 mg/dL), because it has been shown to significantly increase the rate of postoperative complications and the need to resort to percutaneous transhepatic biliary drainage rather than endoscopic retrograde cholangiopancreatography. Insertion of a biliary stent induces inflammation and thickening of the bile duct and therefore increases operative difficulty. For similar reasons, chronic pancreatitis associated with a mass lesion within the head of the gland is best resected by open surgery.

Previous major abdominal surgery, especially within the upper abdomen (such as open cholecystectomy or laparotomy for peritonitis) is a relative contraindication to LPD. Certainly such adhesions could be divided laparoscopically, but to accomplish this the surgeon may need to either place ports in positions cumbersome for the LPD or place additional ports that could cause “crowding” and render surgery considerably more stressful. A decision could be made regarding whether such a patient is suitable for laparoscopic resection at the time of a staging laparoscopy.

The potential yield from a staging laparoscopy dictates that patients with suspected malignancy of the head of the pancreas or distal bile duct should undergo a staging laparoscopy before LPD, whereas patients with ampullary tumors and small duodenal tumors may proceed straight to resection. Laparoscopic ultrasonography may have a role to play in detecting small (<1 cm) hepatic lesions when suspected on preoperative imaging.

Surgeons contemplating LPD should have an established experience in open pancreatoduodenectomy and in advanced laparoscopic surgery, particularly in intracorporeal suturing.

Patient positioning and placement of trocars

All patients receive preoperative deep venous prophylaxis including thromboembolism-deterrent stockings and low-molecular-weight heparin (LMWH) unless epidural anesthesia is contemplated, in which case LMWH is administered after insertion of the epidural catheter and intravenous antibiotic prophylaxis. The surgery is carried out under general anesthesia, and patients receive epidural anesthesia selectively. The patient is placed in a flat Lloyd-Davies (French) position, with the surgeon standing between the patient’s legs and the assistant on the patient’s right or left according to the steps of the procedure. Most of the surgery is carried out with the patient in a 30-degree reverse Trendelenburg position to allow the colon and omentum to drop away from the upper abdomen. Surgery is most commonly conducted using a completely laparoscopic approach, although a recent review of the literature revealed that one fourth of the procedures were carried out using a hand-assist approach. The pneumoperitoneum is established and maintained at 12 to 15 mm Hg. The procedure may employ five trocars, as shown in Figure 18-1. A 30-degree laparoscope is employed routinely. The liver is retracted in a cephalad direction using an 80-mm angled Diamond-Flex retractor, which is fixed in position using a table clamp (Fast Clamp, Snowden-Pencer, San Diego, Calif.).

FIGURE 18-1 Port positioning for laparoscopic pancreatoduodenectomy.

Operative technique

Resection

Most of the steps and principles of the resection and reconstruction of the LPD are the same as those in open surgery. After an exploratory laparoscopy, the gastrocolic omentum at the antrum and distal body of the stomach is divided with the ultrasonically activated scalpel (UAS), and the lesser sac is entered. With the posterior aspect of the antrum held and retracted upward by the assistant through the patient’s leftmost lateral 5-mm port, any adhesions between the stomach and the anterior surface of the pancreas are divided. The transverse colon is then mobilized off the anterior surface of the pancreas and the second and third portions of the duodenum; early in this process is the division of the communicating vein of Henle between the middle colic and right gastroepiploic veins (Fig. 18-2), which allows the transverse colon to fall away from the head of the pancreas and facilitates exposure of the superior mesenteric vein (SMV). Also, the right gastroepiploic vessels are encountered at the inferior border of the first part of the duodenum and their division (especially that of the vein, Fig. 18-3) enhances access to the SMV; the most superficial of these, the vein, is first dissected off its confluence with the SMV and divided between locking clips (Hem-o-lok, Weck Closure Systems, Research Triangle Park, N.C.). The artery that lies in a deeper position could be similarly clipped and divided if necessary. Identification of the SMV is facilitated by following the colic vein or the right gastroepiploic vein and by gentle mobilization of the inferior border of the body of the pancreas toward the neck, where the SMV can also be encountered. The anterior surface of the SMV is dissected and followed in a cephalad direction behind the neck of the pancreas to expose the confluence with the splenic vein and to further dissect the anterior surface of the portal vein and confirm resectability (Fig. 18-4).

FIGURE 18-2 Communicating vein of Henle.

FIGURE 18-3 Right gastroepiploic vein (GEV). SMV, superior mesenteric vein.

FIGURE 18-4 The portal vein (PV) and the superior mesenteric vein were dissected to confirm resectability.

If necessary, the hepatic flexure of the colon may be taken down to enhance exposure of the duodenum, although we have not found this step always necessary. The duodenum is extensively kocherized, exposing the inferior vena cava and left renal vein (Fig. 18-5) until the territory of the superior mesenteric artery (SMA) is reached, and separating the third and, if possible, the fourth parts of the duodenum from the transverse mesocolon until the infracolic compartment is reached (Fig. 18-6). In preparation for division of the antrum, the right gastroepiploic vessels are divided between locking clips along the inferior border of the junction between the antrum and body of the stomach (Fig. 18-7), and the vessels along the lesser curvature of the stomach in the region of the incisura and the lesser omentum are also divided with the UAS. The gastric antrum is then divided with endostaplers (Fig. 18-8) after ensuring that the nasogastric and nasojejunal tubes have been advanced no further than 50 cm. To avoid oozing from the staple line that could later obscure the operative field, we tend to oversew the distal staple line for hemostasis and to control the proximal staple line with the Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, Ohio), which will be incorporated in a suture line later when the gastrojejunostomy is constructed, and to wrap it with gauze. The body of the stomach is then pushed into the left upper quadrant to facilitate exposure of the hepatic artery.

FIGURE 18-5 Kocherization of the duodenum and exposure of the inferior vena cava (IVC) and left renal vein.

FIGURE 18-6 The distal duodenum was mobilized until the infracolic compartment was reached. IVC, inferior vena cava.

FIGURE 18-7 The right gastroepiploic vessels at the junction of the body and antrum of the stomach are clipped and divided.

FIGURE 18-8 The stomach has been transected with staplers at the junction between its body and antrum.

If a pylorus-preserving pancreatoduodenectomy is planned, the posterior aspect of the antrum and the duodenal bulb are mobilized off the pancreas. Care is taken to preserve the gastroepiploic arcade along the greater curvature of the stomach. The first part of the duodenum is then divided with an endostapler.

The peritoneum over the anterior surface of the hepatoduodenal ligament is then divided from left to right until its aspect over the upper border of the Calot triangle is also divided. With the assistant holding and retracting the antrum of the stomach caudally, dissection along the left border of the hepatoduodenal ligament allows for identification of the right gastric artery, which is then clipped and divided (Fig. 18-9). This allows the antrum of the stomach to fall away from the hepatoduodenal ligament and facilitates the dissection of the gastroduodenal artery. Dissection with the Harmonic scalpel then proceeds between the lower border of the common hepatic artery and the upper border of the body of the pancreas and duodenum. Group 8a (anterior hepatic) lymph nodes could be dissected off at this stage, mobilized off the common hepatic artery from left to right, and kept attached to the upper border of the head of the pancreas or removed separately for histologic analysis. Alternatively, this group of lymph nodes could be dissected before division of the neck of the pancreas (see the accompanying DVD as well as Expert Consult). This will lead to exposure of the gastroduodenal artery, which after meticulous dissection is mobilized (Fig. 18-10A), double-clipped, and divided with scissors (Fig. 18-10B). Holding the proximal stump of the gastroduodenal artery, the surgeon can mobilize the hepatic artery further in a cephalad direction. Division of the neurolymphatics in this region exposes the anterior surface of the portal vein and the left border of the common bile duct.