Total Laparoscopic Pancreaticoduodenectomy: A Single-Institutional Experience.

INTRODUCTION: Laparoscopic pancreaticoduodenectomy represents one of the most advanced abdominal surgical procedures; however, a standard approach is still lacking. We present our initial experience with total laparoscopic pancreaticoduodenectomy (TLPD) with a video of the technique that we have developed and the clinical as well as oncologic outcomes obtained with this technique.

METHODS: This was a retrospective review of all cases consecutively performed by two operators between January 2013 and December 2014 at The University of Colorado (Fig. 1). Fig. 1 Pathology of resected lesions via total laparoscopic pancreaticoduodenectomy (N = 30) RESULTS: Thirty patients underwent TLPD; conversion to open procedure was required in two cases (6 %). Median age at diagnosis was 63.1 years [interquartile range (IQR) 53.8-70.8]. Operative characteristics and postoperative complications are summarized in Table 1. The operative time decreased from 366 minutes (IQR 320-421) in the first 15 cases to 312 min (IQR 282-372) in the second 15 cases (r = -2.7; p = 0.047). The estimated blood loss decreased from 300 mL (IQR 300-500) in the first 15 cases to 200 mL (IQR 150-375) in the second 15 cases (r = -6.3; p = 0.314). Table 1 Operative characteristics and postoperative complications Variable N = 30 Surgical margin Negative R0 30 (100 %) Number of nodes harvested Median (range) 18 (15-22) Operative time (min) Median (range) 340 (308-377) EBL (mL) Median (range) 300 (200-400) Pancreatic fistula 15 (50 %) Pancreatic fistula grade A 8 (27 %) B 5 (17 %) C 2 (7 %) Delayed gastric emptying (DGE) 10 (33 %) DGE grade A 4 (14 %) B 5 (17 %) C 1 (3 %) Bile leak 3 (10 %) Pseudoaneurysm Hepatic artery 2 (7 %) GDA 1 (3 %) Chyle leak 1 (3 %) Surgical site infection (SSI) 6 (20 %) SSI type Superficial 2 (7 %) Deep 0 Organ space 6 (20 %) LOS (days) Median (range) 11 (8-15) Readmission (30 days) 6 (20 %) Death (90 days) 0 CONCLUSIONS: Laparoscopic pancreaticoduodenectomy is a challenging operation, which is not performed in high volume at most centers. As a new laparoscopic pancreas program, our experience shows that oncologic outcomes are acceptable in terms of margin and lymph node harvest. There is undoubtedly a steep learning curve that complicates the initial application of TLPD; however, with the techniques displayed in this video many of the early complications can be overcome. Further study to evaluate for long-term safety is needed.