Fernando Rotellar, MD PhD, Fernando Pardo, MD, Alberto Benito, MD Ph D, Pablo Marti-Cruchaga, MD, Gabriel Zozaya, MD, Javier A Cienfuegos, MD PhD. University Clinic. University of Navarre. Pamplona. Spain.
Introduction: Laparoscopic pancreatic procedures have increased in recent years. However, few cases have been reported for resection of tumors in the pancreatic uncinate process using this approach. Given the anatomical location of the uncinate process, a complete mobilization of the hepatic flexure of the colon is usually done to access it. In this video, we present a hitherto undescribed laparoscopic inframesocolic approach.
Patient and method:
This is the case of a 39 years old female patient with a 16 millimeter insulinoma in the uncinate process of the pancreas. Studied for obesity (BMI: 35), a 16 millimeter hyper vascular nodule was found in the uncinate process of the pancreas. The laboratory test confirmed the suspicion of insulinoma. The patient is placed in the supine position with legs apart. The surgeon stands between the legs of the patient. A 30 degree, 5 mm optics is used, and therefore, only a twelve millimeter trocar is needed. Due to the obesity of the patient, we felt that an infra meso colic approach would be the most appropriate. After general inspection of the abdominal cavity, the first maneuver moves upwards the major omentum and the transverse colon in order to expose the mesenteric root. We can identify the duodenum through the peritoneal sheath. With the help of a hook and gentle movements, the duodenum and uncinate process of the pancreas are exposed. The duodenum is mobilized and the superior mesenteric vein identified and carefully exposed in the vicinity of the uncinate pancreas.In order to improve the exposure for the uncinectomy, a hanging maneouver of the mesenteric root will be performed with a cotton tape. The intraoperative ultrasound helps to identify the tumor, and defines the limits of the resection. A inferior pancreatico duodenal vein is dissected and carefully sectioned between clips and the uncinate process is dissected from the retropancreatic fascia. The endoGia with a reinforced green cartridge is inserted and fired. The specimen is drag into a bag and removed through the 12 millimeter orifice that does not have to be enlarged. A final inspection is performed to confirm that the duodenum maintains a normal color and no bleeding is detected. An hemostatic substance is left in the surgical field. The cotton tape is removed and the peritoneal defect closed with interrupted stitches. No drain is left.
The postoperative was uneventful and the patient was discharged on the third postoperative day. One year after the procedure, the patient has lost 35 kilograms and has a normal B M I. She remains asymptomatic and with normal blood sugar levels. No early or late surgical complications were observed.
Laparoscopic resection of the uncinate process of the pancreas is feasible and safe. The inframesocolic approach is easy to perform and achieves an optimal exposure that is improved with a hanging maneuver of the mesenteric root.
Program Number: V041