Laparoscopic Whipple Procedure with a 2-Layered Pancreatojejunostomy

ANDREW A GUMBS, MD, BRICE GAYET, MD PhD, John P Hoffman, MD. FOX CHASE CANCER CENTER

INTRODUCTION
Since the first report of laparoscopic pancreatic resections in the early 1990’s, laparoscopic resection of tumors in the pancreas have become increasingly more common in the surgical treatment of both benign and malignant tumors1. The minimally invasive approach to lesions in the head of the pancreas, however, is still only being performed in highly specialized centers2. This is principally because of concerns for safely dissecting tumors off of the superior mesenteric /portal vein (SMV/PV) and SMA, the perceived difficulty in controlling major hemorrhage via the laparoscopic approach and concerns regarding the efficacy of a laparoscopically created pancreatic anastomosis.

METHOD
We employ the laparoscopic posterior approach first described by Prof. Brice Gayet3. The main differences of this approach include the early performance of an extended Kocher maneuver and transection of the uncinate process with the ultrasonic shears. As opposed to the previously reported video of this technique, this video highlights the laparoscopic formation of a 2-layered end-to-side pancreatojejunostomy. An internal stent consisting of a 5 Fr. pediatric feeding tube is used to prevent inadvertent closure of the pancreatic duct.

RESULTS
To date 5 laparoscopic Whipple procedures using the posterior approach have been performed in the United States. Two patients had pancreatic adenocarcinoma, one of which was given neoadjuvant chemoradiation therapy, one patient had a malignant neuroendocrine tumor, one patient had a malignant tumor arising from an intraductal papillary mucinous neoplasm and a final patient had type I choledochocele involving her entire common bile duct. The average estimated blood loss was 450cc (range 200-800cc). The mean operative time was 485 minutes (range = 370-660 minutes). The length of stay averaged 11 days (range=7-14 days). One patient developed a bile leak, which responded to transhepatic biliary drainage and one patient developed a subhepatic abscess after removal of a gastrostomy tube that required percutaneous drainage on post-operative day #22. Average lymph node retrieval is 18 (range =16-29). All pancreatic margins were negative. However, one patient was found to have metastatic pancreatic cancer to the liver on final pathology in spite of a negative liver biopsy on frozen section analysis. This patient was found to have a hepatic recurrence at 12 months and is currently alive with 15 months of follow-up. All patients are currently alive with a mean follow-up of 11 months (range= 6-20 months), and the other 4 patients have no evidence of disease.

CONCLUSION
Minimally invasive techniques for laparoscopic Whipple procedures are feasible and safe. The 2-layered end-to-side laparoscopic pancreatojejunostomy has a low rate of pancreatic fistula formation and may be ideal for laparoscopically created pancreatic anastomoses. Mastery of the anatomy and laparoscopic suturing is paramount before attempting this approach with minimally invasive techniques. It should currently only be performed by surgeons with expertise in both open and laparoscopic pancreatic surgery.