10-year Experience With Laparoscopic Pancreatic Surgery by A Single Surgeon: A Challenge of Minimizing Postoperative Pancreatic Fistula

Takeyuki Misawa, MD, PhD, FACS¹, Shuichi Fujioka, MD¹, Ryota Saito, MD¹, Hiroaki Kitamura, MD¹, Takeshi Gocho, MD², Tadashi Akiba, MD, FACS¹, Katsuhiko Yanaga, MD, FACS². ¹Jikei University Kashiwa Hospital, ²The Jikei University Hospital

Aims: To demonstrate our experiences, technical refinements, and clinical results of laparoscopic pancreatectomy (LP) including distal pancreatectomy with splenectomy (DP), spleen-preserving distal pancreatectomy (SpDP), enucleation, central pancreatectomy (CP), and single-incision laparoscopic surgery (SILS).

Patients: From May 2005 to April 2015, we performed a total of 70 laparoscopic pancreatectomies (DP in 36, SpDP in 26, enucleation in 6, CP in 2). Indications were benign/low-malignant lesions including mucinous cystic neoplasm (MCN), neuroendocrine tumor (NET), intraductal papillary mucinous neoplasm (IPMN), serous cystic neoplasm, solid and pseudopapillary tumor (SPT), non-neoplastic pancreatic cyst, and splenic diseases.

Methods:  For standard multiport surgery, 4-5 trocars were used. In SILS, SILSTMPort was placed in the umbilicus for articulating instruments and a 5-mm flexible scope. In all distal pancreatectomies, the pancreas was resected using a liner stapler. In enucleation for NET, harmonic scalpel was employed for pancreatic resection. For splenic preservation, as the basic technique, both the splenic artery and vein were isolated and preserved. For 2 patients with severe adhesion between the splenic vessels and the pancreatic parenchyma, Warshaw’s technique was used. In 2 SILS (DP and SpDP, respectively), technical refinements such as gastric suspension with stitches and splenic hilum hanging maneuver with a cloth tape were applied.

Results:  There was no conversion to open surgery. The mean operation time, blood loss , and postoperative hospital stay were 272±94 min, 69±138 mL, and 11±9.1 days, respectively. Only 5 (7.1%) patients developed clinically significant pancreatic fistula (grade B: 4, C: 1). In comparison between DP and SpDP, there was no statistical difference in blood loss, operation time, postoperative hospital stay, preoperative platelet count, and tumor size. However, postoperative platelet count was significantly higher in DP (37±1.7 vs. 22±4.5 ×104/μl, p<0.0001). Postoperative pathological study revealed that two patients with preoperative diagnoses of IPMN and one with MCN had non-invasive carcinoma. Another patient with SPT was also found to have limited micro-invasive lesion within the pancreatic parenchyma, thus diagnosed as carcinoma. These three patients are now under close observation.

Conclusions: LP is a safe and optimal procedure for benign/low-malignant lesion in the pancreas. Especially, SpDP should be recommended in terms of the preventing postoperative thrombocytosis.