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Laparoscopic Pancreatic Surgery


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Laparoscopic Pancreatic Surgery

  2. 2. QUESTION <ul><li>What is the current role of laparoscopic surgery with regard to pancreatic disease? </li></ul>
  3. 3. LAPAROSCOPIC PANCREATIC SURGERY <ul><li>DIAGNOSTIC </li></ul><ul><ul><li>TUMOR LOCALIZATION </li></ul></ul><ul><ul><li>TUMOR RESECTABILITY </li></ul></ul>
  4. 4. <ul><li>THERAPEUTIC </li></ul><ul><ul><li>PANCREATIC TUMORS </li></ul></ul><ul><ul><ul><li>ENUCLEATION </li></ul></ul></ul><ul><ul><ul><li>DISTAL PANCREATECTOMY </li></ul></ul></ul><ul><ul><ul><li>PANCREATICODUODENECTOMY </li></ul></ul></ul><ul><ul><ul><li>PALLIATIVE SURGERY </li></ul></ul></ul>LAPAROSCOPIC PANCREATIC SURGERY
  5. 5. <ul><li>THERAPEUTIC </li></ul><ul><ul><li>PANCREATITIS </li></ul></ul><ul><ul><ul><li>PSEUDOCYST DRAINAGE </li></ul></ul></ul><ul><ul><ul><li>PANCREATIC DEBRIDEMENT </li></ul></ul></ul><ul><ul><li>PANCREATIC TRAUMA </li></ul></ul>LAPAROSCOPIC PANCREATIC SURGERY
  6. 7. Tumor Staging With Laparoscopy and Laparoscopic Ultrasonography
  7. 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  
  8. 9. HISTORY <ul><li>1911 Bernheim First laparoscopy for </li></ul><ul><li>pancreatic cancer in U.S. </li></ul><ul><li>1978 Cushieri Laparoscopy for staging, </li></ul><ul><li>diagnosis, and assessment </li></ul><ul><li>of resectability in 23 </li></ul><ul><li>patients with pancreatic </li></ul><ul><li>cancer </li></ul>
  9. 10. <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
  10. 11. 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
  11. 12. CONCLUSIONS <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
  12. 13. 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
  13. 14. 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>Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  14. 15. <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><ul><li>Potential candidates for resection </li></ul><ul><ul><li>Portal vein encroachment </li></ul></ul><ul><ul><li>SMV encroachment </li></ul></ul>UNRESECTABILITY Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  15. 16. <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
  16. 17. <ul><li>LAPAROSCOPY </li></ul><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
  17. 18. <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
  18. 19. Laparoscopic Ultrasound Enhances Standard Laparoscopy 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)
  19. 20. 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)                                                                                         
  20. 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
  21. 22. 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)
  22. 23. 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)
  23. 24. 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>
  25. 26. 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>
  26. 27. Palliative Laparoscopic Surgery for Unresectable Pancreatic Cancer
  27. 28. Laparoscopic Gastro- and Hepaticojejunostomy for Palliation of Pancreatic Cancer <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
  28. 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)
  29. 30. 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
  31. 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. 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. 37. 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
  36. 38. Ferzli,G et al; Surg Endosc July2001
  37. 39. Ferzli,G et al; Surg Endosc July2001
  38. 40. Ferzli,G et al; Surg Endosc July2001
  39. 41. Ferzli,G et al; Surg Endosc July2001
  40. 42. Ferzli,G et al; Surg Endosc July2001
  41. 43. Ferzli,G et al; Surg Endosc July2001
  42. 44. 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>