Takeyuki Misawa, MD PhD, Takeshi Gocho, MD, Nobuhiro Tsutsui, MD, Ryusuke Ito, MD, Hiroaki Shiba, MD PhD, Shoichi Hirohara, MD, Shigeki Wakiyama, MD, Yuichi Ishida, MD PhD, Katsuhiko Yanaga, MD. Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
Background: Recent interest in better cosmetic outcomes has led to single- incision laparoscopic surgery (SILS) being performed in a variety of target organs. However, pancreatectomy by SILS has not yet been reported.
Objective: To demonstrate technical refinements in single incision laparoscopic distal pancreatectomy (SILS-DP) with or without splenic preservation.
Patients and Methods:
Case 1: SILS-DP with splenic preservation
The patient was a 40-year-old woman with a 35-mm-diameter cystic lesion in the tail of the pancreas. The patient was positioned in the right semilateral position with the left arm fixed over the head. A 2.5-cm intraumbilical mini-laparotomy was made to place a SILSTMPort with three 5-mm trocars as a single access site. Under pneumoperitoneum, a flexible 5-mm laparoscope and an articulating grasper were used in addition to standard laparoscopic equipment. The stomach was suspended with two 2-0 Ethibond sutures placed on the greater curvature. The ends of sutures were extracted with a laparoscopic suture passer through an extra needle hole in the skin. This technique provided excellent exposure of the pancreas after the omentum had been opened. The body to tail of the pancreas was then carefully mobilized from the splenic vessels. A 6-cm cartridge stapler was introduced to divide the pancreas. The resected specimen was extracted through the umbilical site within a retrieval bag.
Case 2: SILS-DP without splenic preservation
The patient was 53-year-old woman with 65-mm-diameter cystic lesion of the tail of the pancreas which was firmly attached to the splenic vessels. Under the same condition as in case 1, the ligamentous attachments around the spleen were divided with a 5-mm bipolar vessel sealer. A 3-mm-wide cloth tape was introduced intraperitoneally to encircle and tug the splenic hilum. Both ends of the tape were trapped and extracted with a laparoscopic suture passer through an extra needle hole in the skin. Pulling of the tape in appropriate directions provided excellent exposure of the splenic hilum; the pancreatic tail, and the splenic artery and vein. Together with the splenic vessels, the tumor and the pancreatic tail were mobilized from the retroperitoneum. The pancreatic tail was divided in the same manner as in case 1 under excellent exposure through the tug exposure technique. The fluid content of the cyst was aspirated within a retrieval bag to allow easy extraction of the specimen through the umbilical incision.
Results: Intraoperative blood loss was uncountable (?0 ml) in case 1 and 100 ml in case 2, and operative time was 240 minutes in case 1 and 225 minutes in case 2. The postoperative courses were uneventful, and the patients were discharged 7 and 5 days, respectively, after surgery. Pathological diagnoses were borderline lesion of cystadenoma and carcinoma in case 1 and epithelial cyst in case 2. Follow-up at 6 months did not reveal any complications, and the umbilical incisions were completely invisible.
Conclusions: SILS can safely be applied for distal pancreatectomy with some technical refinements, such as gastric suspension and the tug-exposure technique. The clinical, cosmetic and functional advantages require further analysis.
Program Number: V100