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  • IN 1911, Bernheim at The Johns Hopkins University performed the first
  • The lesser sac was entered by opening the gastrocolic ligament exposing the posterior wall of the stomach and pancreas.
  • At tear was noted in the pancreas between the body and the tail. There was also an significant hematoma overlying the pancreas
  • A window behind the pancreas lateral to the inferior mesenteric vein was made to the position of an endo GI stapler. The distal pancreas was retreived from the abdomen using a specimen bag.
  • The pancreas stump was secured with a running a non-absorbable suture
  • A JP drain was left in the lesser sac and covered with omentum

Transcript

  • 1. LAPAROSCOPIC PANCREATIC SURGERY GEORGE S. FERZLI, MD FACS ALPHONSE M. PECORARO, MD FACS SCOTT D. STEINBERG, MD
  • 2. QUESTION
    • What is the current role of laparoscopic surgery with regard to pancreatic disease?
  • 3. LAPAROSCOPIC PANCREATIC SURGERY
    • DIAGNOSTIC
      • TUMOR LOCALIZATION
      • TUMOR RESECTABILITY
  • 4.
    • THERAPEUTIC
      • PANCREATIC TUMORS
        • ENUCLEATION
        • DISTAL PANCREATECTOMY
        • PANCREATICODUODENECTOMY
        • PALLIATIVE SURGERY
    LAPAROSCOPIC PANCREATIC SURGERY
  • 5.
    • THERAPEUTIC
      • PANCREATITIS
        • PSEUDOCYST DRAINAGE
        • PANCREATIC DEBRIDEMENT
      • PANCREATIC TRAUMA
    LAPAROSCOPIC PANCREATIC SURGERY
  • 6.  
  • 7. Tumor Staging With Laparoscopy and Laparoscopic Ultrasonography
  • 8. “ In cases of ordinary exploratory operation for carcinoma, before having recourse to the usual large incision, the cystoscope is introduced through a very small and relatively unimportant incision, possibly made with cocaine, may reveal general metastases or a secondary nodule in the liver, thus rendering further procedures unnecessary and saving the patient a rather prolonged convalescence. BERTRAM BERNHEIM, THE JOHNS HOPKINS UNIVERSITY Bernheim B: Organoscopy: Cystoscopy of the abdominal cavity. Ann Surg 53:764-767,1911  
  • 9. HISTORY
    • 1911 Bernheim First laparoscopy for
    • pancreatic cancer in U.S.
    • 1978 Cushieri Laparoscopy for staging,
    • diagnosis, and assessment
    • of resectability in 23
    • patients with pancreatic
    • cancer
  • 10.
    • Prospective study of 88 consecutive patients
    • Pancreatic and periampullary adenocarcinoma
    • Preoperative evaluation
      • CT SCAN WITH CONTRAST 88 pts
      • MRI 20 pts
      • LAPAROSCOPY 47 pts
      • ANGIOGRAPHY 85 pts
    Preoperative Staging and Assessment of Resectability of Pancreatic Cancer Warshaw,A et al: Arch Surg 1990; 125:230-233
  • 11. RESULTS
    • Overall resectability 33/88 (38%)
    • Laparoscopy found metastatic disease when present in 22/23 patients (96%)
    • Laparoscopy found no metastatic disease in 24/24 patients (100%)
    Warshaw,A et al: Arch Surg 1990; 125:230-233
  • 12. CONCLUSIONS
    • Laparoscopy is particularly sensitive for detecting small metastases (96%)
    • This approach to pancreatic cancer allows the elimination of some operations and tailors others to individual circumstances
    Warshaw,A et al: Arch Surg 1990; 125:230-233
  • 13. The Value of Minimal Access Surgery in the Staging of Patients with Potentially Resectable Peripancreatic Malignancies
    • 115 patients- radiologically resectable
    • Extensive laparoscopy performed
      • assessment of the peritoneal cavity, liver, lesser sac, porta hepatis, duodenum, transverse mesocolon, and celiac and portal vessels
    Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  • 14. UNRESECTABILITY
    • Metastases
      • hepatic, serosal, peritoneal
    • Extrapancreatic extension
      • mesocolic involvement
    • Nodal involvement
      • celiac or portal
    Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  • 15.
    • Vascular invasion
      • celiac axis or hepatic artery
      • portal vein, SMV, SMA
    • Potential candidates for resection
      • Portal vein encroachment
      • SMV encroachment
    UNRESECTABILITY Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  • 16.
    • No intraoperative or postoperative complications related to laparoscopy
    • 67 considered resectable  61 resected
    • Laparoscopy failed to identify hepatic metastases in 5 patients and portal venous encasement in 1 patient
    RESULTS Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  • 17.
    • LAPAROSCOPY
    • Positive predictive index of 100%
    • Negative predictive index of 91%
    • Accuracy of 94%
    RESULTS Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  • 18.
    • Extended laparoscopy is accurate and safe and makes exploration unnecessary in many patients with potentially resectable peripancreatic malignancy
    CONCLUSION Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  • 19. Laparoscopic Ultrasound Enhances Standard Laparoscopy in the Staging of Pancreatic Cancer
    • Prospective evaluation of 90 patients
    • All patients had preoperative CT abdomen/pelvis and either ERCP or transabdominal sonography
    • All patients had laparoscopy and laparoscopic ultrasound
    Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
  • 20. TUMOR LOCATION
      • PANCREATIC HEAD 64 (72%)
      • PANCREATIC BODY 19 (21%)
      • PANCREATIC TAIL 3 (3%)
      • AMPULLA 4 (4%)
    Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)                                                                                         
  • 21. Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2) RESULTS ___ ___ 13 (14%) 8 (9%) EQUIVOCAL 50 (56%) 49 (54%) 41 (46%) 17 (19%) UNRESECTABLE ACTUAL LAP SONO LAP CT
  • 22. LAPAROSCOPIC ULTRASOUND
    • SENSITIVITY 100%
    • SPECIFICITY 98%
    • ACCURACY 98%
    Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
  • 23. CONCLUSION
    • The addition of laparoscopic ultrasound offers improved assessment and preoperative staging of pancreatic cancer.
    Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
  • 24. SUMMARY
    • Staging laparoscopy should be performed for all cases of pancreatic cancer prior to attempted resection
    • The addition of laparoscopic ultrasound improves assessment and preoperative staging of pancreatic cancer
  • 25. LAPAROSCOPIC WHIPPLE
  • 26. LAPAROSCOPIC PANCREATICODUODENECTOMY
    • Gagner and Pomp – 1996
    • Strasberg, Drebin, and Soper – 1997
    • Cuschieri – 1998
    • CONCLUSION:
    • THE MAGNITUDE OF THE RECONSTRUCTION MAY OUTWEIGH THE BENEFIT OF THE MINIMALLY INVASIVE APPROACH
  • 27. Palliative Laparoscopic Surgery for Unresectable Pancreatic Cancer
  • 28. Laparoscopic Gastro- and Hepaticojejunostomy for Palliation of Pancreatic Cancer
    • CASE-CONTROL STUDY
    • 14 patients – open palliation
    • 10 patients – laparoscopic palliation
    • 4 patients – diagnostic laparoscopy
    Rothlin,M et al;Surg Endosc (1999) 13:1065-1069
  • 29. RESULTS p<0.06 p<0.05 p<0.05 Rothlin,M et al;Surg Endosc (1999) 13:1065-1069 9 days 21 days HOSPITAL STAY 0% 29% MORTALITY 7% 43% MORBIDITY LAP (n=14) OPEN (n=14)
  • 30. CONCLUSION
    • Laparoscopic palliation can reduce the three major drawbacks of open bypass surgery-i.e., high morbidity, high mortality, and long hospital stay.
    Rothlin,M et al;Surg Endosc (1999) 13:1065-1069
  • 31. MISCELLANEOUS PANCREATIC NEOPLASMS
  • 32. Ultrasound Guided Laparoscopic Resection Of Pancreatic Islet Cell Tumors SPITZ, et al Surg Lap Endo and Perc Tech: Vol10, No3, 2000 Laparoscopic Resection Of Islet Cell Tumors GAGNER, et al Surgery Vol 120, 1996 Laparoscopic Resection Of Pancreatic Serous Cystadenoma SANCHEZ Surg Lap and Endo Vol 4, No 4, 1994 DESCRIPTION STUDY
  • 33. PSEUDOCYST DRAINAGE
  • 34. LAPAROSCOPIC INTERNAL DRAINAGE Cystojejunostomy L. paracolic handsewn Palanivelu Cystojejunostomy Infracolic Cushieri Cystogastrostomy Supracolic Way Cystogastrostomy Stapled Intraluminal Litwin & Ross Cystogastrostomy Transgastric Handsewn Petelin
  • 35.  
  • 36. PANCREATIC TRAUMA
  • 37. Laparoscopic Distal Pancreatectomy for Blunt Injury to the Pancreas with Splenic Preservation
    • 10 yo handle bar injury
    • CT –free fluid and distal transection of the pancreas
    • Distal pancreatectomy with splenic preservation performed
    • Reg diet POD 2
    • D/C POD 3
    Ferzli,G et al; Surg Endosc July2001
  • 38. Ferzli,G et al; Surg Endosc July2001
  • 39. Ferzli,G et al; Surg Endosc July2001
  • 40. Ferzli,G et al; Surg Endosc July2001
  • 41. Ferzli,G et al; Surg Endosc July2001
  • 42. Ferzli,G et al; Surg Endosc July2001
  • 43. Ferzli,G et al; Surg Endosc July2001
  • 44. SUMMARY
    • Laparoscopy and laparoscopic ultrasound are sensitive and specific tools for determining resectability in patients with pancreatic cancer
    • Laparoscopic techniques can be used for the treatment of benign and malignant pancreatic diseases and pancreatic trauma