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Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
Laparoscopic Pancreatic Surgery
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Laparoscopic Pancreatic Surgery

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  • IN 1911, Bernheim at The Johns Hopkins University performed the first
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    • 1. LAPAROSCOPIC PANCREATIC SURGERY George Ferzli MD, FACS
    • 2. ? <ul><li>What is the current role of laparoscopic surgery with regard to pancreatic disease? </li></ul>
    • 3. Role of laparoscopy DIAGNOSTIC <ul><ul><li>Tumor staging </li></ul></ul>THERAPEUTIC <ul><ul><li>Curative </li></ul></ul><ul><ul><li>tumors </li></ul></ul><ul><ul><li>pseudocyst </li></ul></ul><ul><ul><li>pancreatic necrosis </li></ul></ul><ul><ul><li>- trauma </li></ul></ul>Palliative
    • 4. I- Diagnostic
    • 5. “ 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”. 1911 Bernheim: First laparoscopy for pancreatic cancer in the U.S.A. Bernheim B. Organoscopy: Cystoscopy of the abdominal cavity. Ann Surg 53:764-767,1911
    • 6. <ul><li>Prospective study of 88 consecutive patients </li></ul><ul><li>Pancreatic and periampullary adenocarcinoma </li></ul><ul><li>Preoperative evaluation </li></ul><ul><ul><li>CT scan with contrast 88 pts </li></ul></ul><ul><ul><li>MRI 20 pts </li></ul></ul><ul><ul><li>Laparoscopy 47 pts </li></ul></ul><ul><ul><li>Angiography 85 pts </li></ul></ul>Preoperative Staging and Assessment of Resectability of Pancreatic Cancer Warshaw,A et al: Arch Surg 1990; 125:230-233
    • 7. Results <ul><li>Overall resectability 33/88 (38%) </li></ul><ul><li>Laparoscopy found metastatic disease when present in 22/23 patients (96%) </li></ul><ul><li>Laparoscopy found no metastatic disease in 24/24 patients (100%) </li></ul>Warshaw,A et al: Arch Surg 1990; 125:230-233
    • 8. Conclusion <ul><li>Laparoscopy is particularly sensitive for detecting small metastases (96%) </li></ul><ul><li>This approach to pancreatic cancer allows the elimination of some operations and tailors others to individual circumstances </li></ul>Warshaw,A et al: Arch Surg 1990; 125:230-233
    • 9. The Value of Minimal Access Surgery in the Staging of Patients with Potentially Resectable Peripancreatic Malignancies <ul><li>115 patients- radiologically resectable </li></ul><ul><li>Extensive laparoscopy performed </li></ul><ul><ul><li>assessment of the peritoneal cavity, liver, lesser sac, porta hepatis, duodenum, transverse mesocolon, and celiac and portal vessels </li></ul></ul>Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
    • 10. Unresectability <ul><li>Metastases </li></ul><ul><ul><li>hepatic, serosal, peritoneal </li></ul></ul><ul><li>Extrapancreatic extension </li></ul><ul><ul><li>mesocolic involvement </li></ul></ul><ul><li>Nodal involvement </li></ul><ul><ul><li>celiac or portal </li></ul></ul><ul><li>Vascular invasion </li></ul><ul><ul><li>celiac axis or hepatic artery </li></ul></ul><ul><ul><li>portal vein, SMV, SMA </li></ul></ul>Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
    • 11. <ul><li>No intraoperative or postoperative complications related to laparoscopy </li></ul><ul><li>67 considered resectable  61 resected </li></ul><ul><li>Laparoscopy failed to identify hepatic metastases in 5 patients and portal venous encasement in 1 patient </li></ul>Results Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
    • 12. <ul><li>Positive predictive index of 100% </li></ul><ul><li>Negative predictive index of 91% </li></ul><ul><li>Accuracy of 94% </li></ul>Results Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
    • 13. <ul><li>Extended laparoscopy is accurate and safe and makes exploration unnecessary in many patients with potentially resectable peripancreatic malignancy </li></ul>Conclusion Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
    • 14. Experience with staging laparoscopy in pancreatic malignancy Gastrointest Endo 1999; 49(4):498-503 <ul><li>109 patients </li></ul><ul><li>CT scan revealed metastases in 10 patients </li></ul><ul><li>Laparoscopy diagnosed metastases in 29 more patients </li></ul><ul><li>At laparotomy, 6 more patients were identified as having metastatic disease </li></ul>
    • 15. Results <ul><li>Negative predictive value was 94% </li></ul><ul><li>Positive predictive value was 88% </li></ul>
    • 16. Conclusion <ul><li>In patients with a negative CT scan for metastasis, laparoscopic identification of metastasis avoided unnecessary laparotomy in 29 of 99 (29%) patients with pancreatic cancer. Staging laparoscopy is indicated in all cases of pancreatic malignancy before laparotomy. </li></ul>
    • 17. Laparoscopic Ultrasound in the Staging of Pancreatic Cancer <ul><li>Prospective evaluation of 90 patients </li></ul><ul><li>All patients had preoperative CT abdomen/pelvis and either ERCP or transabdominal sonography </li></ul><ul><li>All patients had laparoscopy and laparoscopic ultrasound </li></ul>Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
    • 18. Tumor location <ul><li> </li></ul><ul><ul><li>Pancreatic head 64 (72%) </li></ul></ul><ul><ul><li>Pancreatic body 19 (21%) </li></ul></ul><ul><ul><li>Pancreatic tail 3 (3%) </li></ul></ul><ul><ul><li>Ampulla 4 (4%) </li></ul></ul>Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)                                                                                         
    • 19. Results Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2) ___ ___ 13 (14%) 8 (9%) EQUIVOCAL 50 (56%) 49 (54%) 41 (46%) 17 (19%) UNRESECTABLE ACTUAL LAP SONO LAP CT
    • 20. LAPAROSCOPIC ULTRASOUND <ul><li>SENSITIVITY 100% </li></ul><ul><li>SPECIFICITY 98% </li></ul><ul><li>ACCURACY 98% </li></ul>Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
    • 21. Conclusion <ul><li>The addition of laparoscopic ultrasound offers improved assessment and preoperative staging of pancreatic cancer. </li></ul>Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
    • 22. Summary <ul><li>Staging laparoscopy should be performed for all cases of pancreatic cancer prior to attempted resection </li></ul><ul><li>The addition of laparoscopic ultrasound improves assessment and preoperative staging of pancreatic cancer </li></ul>
    • 23. II- Therapeutic Laparoscopy
    • 24. 1- LAPAROSCOPIC PANCREATICODUODENECTOMY <ul><li>Gagner and Pomp – 1996 </li></ul><ul><li>Strasberg, Drebin, and Soper – 1997 </li></ul><ul><li>Cuschieri – 1998 </li></ul><ul><li>CONCLUSION: </li></ul><ul><li>THE MAGNITUDE OF THE RECONSTRUCTION MAY OUTWEIGH THE BENEFIT OF THE MINIMALLY INVASIVE APPROACH </li></ul>
    • 25. 2- MISCELLANEOUS PANCREATIC NEOPLASMS
    • 26. Videolaparoscopic Resection of Insulinomas World Journal of Surgery Vol. 26, 2002 Laparoscopic Pancreatic Resection: Single Institution Experience of 19 Patients PETERSON, et al J Am Coll Surg 193(2),2001 Ultrasound Guided Laparoscopic Resection Of Pancreatic Islet Cell Tumors SPITZ, et al Surg Lap Endo Vol 10, 2000 DESCRIPTION STUDY
    • 27.  
    • 28. 3- Management of pancreatic pseudocyst and necrotizing pancreatitis
    • 29. Laparoscopic Cholecystectomy and Acute Biliary Pancreatitis E Tang , NJ Soper , JJT Tate, W Uhl <ul><li>271 biliary pancreatitis, 22 % Ranson ≥ 3 </li></ul><ul><li>Laparoscopic cholecystectomy 86 % </li></ul><ul><li>Early operation and Ranson ≥ 3 were associated with: </li></ul><ul><li>- more technical difficulties </li></ul><ul><li>- more conversions </li></ul><ul><li>- more CBD stones </li></ul>
    • 30. Conclusions <ul><li>Past pancreatitis is a poor indicator of CBDS. IOC is indicated regardless of the risk of CBDS. </li></ul><ul><li>Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value). </li></ul><ul><li>Timing of open or laparoscopic biliary surgery depends on AP severity </li></ul>
    • 31. Urgent ERC/ES in Benign Acute Biliary Pancreatitis Neoptolemos Fan ERC Controls ERC Controls n (%) n (%) n (%) n (%) N patients 28 29 34 35 Complications - local 3 (11) 4 (14) 7 (21) 1 (3) - general 1 (4) 0 3 (9) 1 (3) Deaths 0 0 0 0
    • 32. Conclusions <ul><li>Past pancreatitis is a poor indicator of CBDS. IOC is indicated regardless of the risk of CBDS. </li></ul><ul><li>Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value). </li></ul><ul><li>Timing of open or laparoscopic biliary surgery depends on AP severity. </li></ul><ul><li>Endoscopic sphincterotomy is NOT indicated in Benign Acute Biliary Pancreatitis </li></ul>
    • 33. Surgery vs Endoscopic Sphincterotomy in Severe Cholangitis Endoscopy Surgery p Leese (non randomized) Mortality (%) 4.7 21.4 Lai (randomized) N patients 41 41 N (%) with Complications 14 (34) 27 (66) < 0.05 Deaths 4 (10) 13 (32) < 0.03
    • 34. Conclusions <ul><li>Past pancreatitis is a poor indicator of CBDS. IOC is indicated regardless of the risk of CBDS. </li></ul><ul><li>Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value). </li></ul><ul><li>Timing of open or laparoscopic biliary surgery depends on AP severity. </li></ul><ul><li>Endoscopic sphincterotomy is NOT indicated in Benign Acute Biliary Pancreatitis. </li></ul><ul><li>Endoscopic sphincterotomy is indicated in Severe Cholangitis associated with Severe ABP </li></ul>
    • 35. Pre- vs Postoperative ERCP in mild ABP Chang L,et al. Ann Surg 2000. <ul><li> ERC + (LC+IOC) (LC+IOC) + ES </li></ul><ul><li>N of patients 30 29 </li></ul><ul><li>ERC 30 7 </li></ul><ul><li>CBD stones / ES 12 (40%) / 11 8 (28%) / 7 </li></ul><ul><li>Overall stay (days) * 11.7 ± 6.1 9 ± 3.2 </li></ul><ul><li>Costs ($) * 10,210 ± 3839 8,586 ± 3520 </li></ul><ul><li>* p < 0.05 </li></ul>Savings in terms of complications and costs can be expected if preoperative ERCPs are replaced by IOC ( Erickson 1995, Sees 1997, Barwood 2002)
    • 36. Conclusions <ul><li>Past pancreatitis is a poor indicator of CBDS. IOC is indicated regardless of the risk of CBDS. </li></ul><ul><li>Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value). </li></ul><ul><li>Timing of open or laparoscopic biliary surgery depends on AP severity. </li></ul><ul><li>Endoscopic sphincterotomy is NOT indicated in Benign Acute Biliary Pancreatitis . </li></ul><ul><li>Endoscopic sphincterotomy is indicated in case of Severe Cholangitis associated with Severe ABP. </li></ul><ul><li>CBD exploration is more efficient than ERC/ES. Performing ERC after LC+IOC rather than before LC minimizes costs and morbidity  </li></ul>
    • 37. Percutaneous and Laparoscopic Management of Infected Pancreatic Necrosis. <ul><li>Gambiez 1998 - Carter 2000 - Alverdy 2000 - Horvath 2001 </li></ul><ul><li>Number of patients 38 </li></ul><ul><li>Complications Hemorrhage 4 Digestive Fistula 4 (10 % ) Pancreatic Fistula 4 (11 % ) Persisting Sepsis 5 </li></ul><ul><li>Reoperations Laparoscopic 28 Arterial embolization 2 Laparotomy 9 (24 % ) </li></ul><ul><li>Mortality 4 (11%) </li></ul>
    • 38. Local Complications (%) Associated with Surgical Management of Infected Pancreatic Necrosis <ul><li>Necrosectomy Retroper. Laparoscopy drainage lavage laparotomy Approach (95% CI) </li></ul><ul><li>N patients 256 166 134 60 38 </li></ul><ul><li>Fistulas (%) </li></ul><ul><li>- Digestive 13 6 27 27 10 (0-20) </li></ul><ul><li>- Pancreatic 16 17 17 2 11 (2-22) </li></ul><ul><li>Hemorrhage 14 8 16 13 13 (2-23) </li></ul><ul><li>Mortality 42 18 21 28 11 (2-22) </li></ul>
    • 39. Conclusions <ul><li>Past pancreatitis is a poor indicator of CBDS.IOC is indicated regardless of the risk of CBDS. </li></ul><ul><li>Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value). </li></ul><ul><li>Timing of open or laparoscopic biliary surgery depends on AP severity. </li></ul><ul><li>ES is NOT indicated in BENIGN ABP . </li></ul><ul><li>ES is indicated in case of Severe Cholangitis associated with Severe ABP. </li></ul><ul><li>CBD exploration is more efficient than ERC/ES. Performing ERC after LC+IOC rather than before LC minimizes costs and morbidity. </li></ul><ul><li>The l aparoscopic approach for necrotic collections is not a standard of care </li></ul>
    • 40. Pancreatic pseudocysts <ul><li>Non surgical techniques </li></ul><ul><ul><li>Percutaneous aspiration-drainage </li></ul></ul><ul><ul><li>Endoscopic transgastric drainage </li></ul></ul><ul><ul><li>Endoscopic transpapillary procedures </li></ul></ul><ul><li>Laparoscopic alternatives * </li></ul><ul><ul><li>Pancreatic cystogastrostomy </li></ul></ul><ul><ul><li>Pancreatic cystojejunostomy </li></ul></ul><ul><li>* Cuschieri, Gagner, Meltzer, Mouiel, Park, Way. </li></ul>
    • 41. LAPAROSCOPIC INTERNAL DRAINAGE OF PSEUDOCYSTS Cystojejunostomy L. paracolic handsewn Palanivelu Cystojejunostomy Infracolic Cushieri Cystogastrostomy Stapled Intraluminal Litwin & Ross Cystogastrostomy Transgastric Handsewn Petelin
    • 42. Therapeutic laparoscopy of the pancreas Park, A. Ann Surg 2002; 236(2):149-158 <ul><li>28 patients underwent laparoscopic pancreatic pseudocystectomy </li></ul><ul><li>a. pancreatic cyst gastrostomy via the lesser sac approach </li></ul><ul><li>b. minilaparoscopic pancreatic cyst gastrostomy </li></ul><ul><li>c. intragastric pancreatic cyst gastrostomy </li></ul><ul><li>d. pancreatic cyst jejunostomy </li></ul>
    • 43. Therapeutic laparoscopy of the pancreas <ul><li>25 patients underwent laparoscopic distal pancreatectomy </li></ul><ul><li>a. insulinoma </li></ul><ul><li>b. cystadenoma </li></ul><ul><li>c. chronic pancreatitis </li></ul><ul><li>d. simple cyst </li></ul>
    • 44.  
    • 45. 4- Pancreatic trauma
    • 46. Laparoscopic Distal Pancreatectomy for Blunt Injury to the Pancreas with Splenic Preservation <ul><li>10 yo handle bar injury </li></ul><ul><li>CT –free fluid and distal transection of the pancreas </li></ul><ul><li>Distal pancreatectomy with splenic preservation performed </li></ul><ul><li>Reg diet POD 2 </li></ul><ul><li>D/C POD 3 </li></ul>Ferzli,G et al; Surg Endosc July2001
    • 47.  
    • 48. III-Palliative Laparoscopy for Unresectable Pancreatic Cancer
    • 49. Laparoscopic Gastro- and Hepaticojejunostomy <ul><li>CASE-CONTROL STUDY </li></ul><ul><li>14 patients – open palliation </li></ul><ul><li>10 patients – laparoscopic palliation </li></ul><ul><li>4 patients – diagnostic laparoscopy </li></ul>Rothlin,M et al;Surg Endosc (1999) 13:1065-1069
    • 50. 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)
    • 51. Conclusion <ul><li>Laparoscopic palliation can reduce the three major drawbacks of open bypass surgery-i.e., high morbidity, high mortality, and long hospital stay. </li></ul>Rothlin,M et al;Surg Endosc (1999) 13:1065-1069
    • 52. SUMMARY <ul><li>Laparoscopy and laparoscopic ultrasound are sensitive and specific tools for determining resectability in patients with pancreatic cancer </li></ul><ul><li>Laparoscopic techniques can be used for the treatment of benign and malignant pancreatic diseases and pancreatic trauma </li></ul>

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