This page textbook from Wolters Kluwer Health/Lippincott Williams & Wilkins is an excellent addition to the Master Techniques in Surgery series. The editors. Master Techniques in Surgery: Hepatobiliary and Pancreatic Surgery: Medicine & Health Science Books @ medical-site.info Pancreatic Surgery. Hepatobiliary and Pancreatic Surgery is part of the Master Techniques in. General Surgery Series, which presents common and advanced.
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Hepatobiliary and Pancreatic Surgery is part of the Master Techniques in Surgery Series, which presents common and advanced procedures in the major. (From. Lillemoe K, Jarnigan W, eds. Master techniques in surgery: hepatobiliary and pancreatic surgery. Philadelphia, PA: Lippincott Williams & Wilkins, ). Pancreas and Biliary Tract Pancreaticobiliary Surgery: General Considerations Lillemoe K.D., Jarnagin W.R. Master Techniques in Surgery. Hepatobiliary and Pancreatic Surgery. Файл формата pdf; размером ,09 МБ.
It was designed to reproduce the movements of the surgeon's hands positioned far away the operating table. Today only one system is available worldwide: S, Si and recently Xi. It consists of three fundamental elements: Maintaining moreover all its advantages, robotic technology shows many advantages over traditional laparoscopy: Clinical applications of robotic technology concern most surgical fields. In some cases, the robotic approach still remains almost experimental, while in some other cases, e.
In Melvin et al. Since all the pancreatic procedures are safe and feasible via a robotic approach, many authors have reported their experience and the number of patients treated is increasingly quickly. The aim of this study is to review the literature and to describe the trend of minimally invasive pancreatic surgery.
Distal pancreatectomy DP is the most commonly performed pancreatic resection using minimally invasive techniques, thanks to the absence of a reconstructive phase. Today MIDP is considered safe and feasible and several studies have shown several advantages over open surgery: The oncologic adequacy has been established too [ 8 ]. Distal pancreatectomy is indicated in the case of lesions of the pancreatic body-tail.
Selection of the patient includes: Expected advantages of the minimally invasive approach in patients with high BMI are better access in the deep abdomen, less post-operative incisional pain, faster post-operative recovery and reduced incidence of incisional hernia.
Also tumor factors need to be evaluated in the selection of patients for MIDP. In the case of malignant, bulky and locally advanced tumors and those proximal to the pancreatic neck, the indication for a minimally invasive approach is questionable: Perhaps the robotic platform with its augmented vision and motion precision can extend the indications, once an adequate learning curve is reached. Distal pancreatectomy can be performed with or without preservation of the spleen.
The incidence is reducible if vaccination against capsulated bacteria S. The second risk to be taken into consideration is post-splenectomy thrombocytosis, which may increase the thrombotic global risk of the patient. Since the number of nodes removed is necessarily lower in spleen-preserving DP, this operation is preferred and advisable only for benign disease, when lymph node removal is not as crucial.
Two techniques are described for spleen-preserving DP: Warshaw's and Kimura's. The Warshaw technique consists in the resection of the splenic artery and vein, leaving blood supply to the spleen only from short gastric vessels [ 10 ].
Kimura's preserves the spleen with its main vessels and is the most frequently applied technique [ 11 ]. Data from the literature report a spleen preserving rate superior for laparoscopic technique compared to open distal pancreatectomy ODP [ 12 ].
Moreover, some authors have reported superiority of the robotic approach over laparoscopy in order to save the spleen [ 12 , 13 ], but drawing conclusions is difficult because of the high variability of the indication between different centers. Variables to take into consideration are operating time, blood loss, conversion rate, incidence of fistula, length of hospital stay, oncologic outcomes, re-operation, morbidity, mortality and costs.
In different series, operating time is reported as longer [ 14 — 17 ], similar [ 18 — 25 ] or shorter [ 26 — 28 ] compared with the open approach: Reported operating time for RDP is — min in major series [ 12 , 13 , 32 — 36 ]. It is one of the most important results of the advances in surgical techniques, vascular sealing devices and endomechanical staplers that have increasingly augmented the safety of minimally invasive pancreatic resections.
Some authors have reported a significant reduction in conversion rate associated with the robotic approach [ 32 , 37 ]. Conversion to open surgery implies greater intraoperative blood loss [ 18 , 21 , 38 ] and longer operating time [ 26 , 28 ]. Reasons for conversion include high BMI, adhesions, large and proximal lesions and intraoperative bleeding.
Pancreatic fistula after a DP is due to a later and incomplete closure of the pancreatic duct system after the resection of the parenchyma.
Ranges are so large because different centers adopt different definitions and classifications of fistula, despite an international definition and classification being available the International Study Group on Pancreatic Fistula, ISGPF [ 40 ].
Moreover, some series report the entire incidence, while others report only clinically relevant cases requiring interventions. A large meta-analysis also demonstrated that different treatment of the stump stapler, suture or nothing is not associated with variation of incidence of pancreatic fistula [ 41 ].
Patients undergoing MIDP tend to have a smaller lesion and rarely a malignant lesion, due to a pre-selection bias. Long-term results in terms of oncologic adequacy of minimally invasive technique for malignancy are not yet available.
Costs are one of the most debated aspects of MIDP, in particular for RDP, which requires a large initial investment and high maintenance costs too. Only a few articles analyze and compare costs, and the conclusions are not in agreement. Waters et al.
Kang et al. It is difficult to compare costs of MIDP between different health systems, but in general a robotic procedure is considered more expensive than conventional open and laparoscopy. In summary, MIDP up to now is considered safe and feasible. LDP has become the operation of choice for distal pancreatic lesions, except for bulky, locally advanced and proximal tumors.
When indicated, the minimally invasive approach has better outcomes. Experience with RDP is quickly growing worldwide, but possible advantages are still under debate. Pancreatoduodenectomy is considered one of the most challenging and complex operations in abdominal surgery, due to the necessity of very delicate manipulation during resection considering the uncinate process, portal vein and mesenteric vessels and very laborious reconstruction considering biliary anastomoses and pancreatic anastomoses.
This is the reason for the extremely low diffusion of a minimally invasive approach, including among pancreatic centers. So, since the demonstration of its feasibility by Gagner et al. Only 4 authors [ 50 — 53 ] have compared their experience between MIPD and open pancreatoduodenectomy OPD ; among them only two described a total laparoscopic technique.
In this scenario the well-known technical advantages of the robotic platform were expected to be very useful in order to popularize the MIPD; this mirrors the experience with minimally invasive prostatectomy: In fact, since the first small series [ 7 ] of robotic PD, the number of treated patients has slowly been increasing, although the experience is still in the hands of a few very skilled surgeons and only one series includes more than cases [ 54 ].
Pancreatoduodenectomy is the surgical treatment of periampullary, duodenal and pancreatic head lesions. The earliest series [ 3 , 39 ] of MIPD included patients with benign or low-grade malignant lesions, in the absence of local invasion of major vessels. So neuroendocrine tumors, cystic lesions and tumors of Vater's ampulla are ideal surgical candidates for MIPD.
Patients affected by obesity, cardiac and pulmonary comorbidity are not excluded by traditional open PD. Experience with these patients operated via a minimally invasive approach is still too limited to establish a conclusion, but some surgeons state that it may have the most benefit.
Since the beginning, two techniques have been described for MIPD: The first consists of resection and anastomosis performed totally laparoscopically; in contrast, in the hybrid technique the reconstructive phase is performed through a small incision which is also used for specimen extraction. With the advent of the robotic system the authors described different approaches: Independently of the technique, LPD and RPD are now accepted as safe operations, with morbidity and mortality similar to the traditional open surgery.
The main reasons for conversion are bleeding mostly from the portal vein , difficult dissection, adhesions and tumor infiltration of local vascular structures [ 51 , 53 , 58 ]. In addition, there is tremendous bias in patient selection, since malignant, large and locally advanced tumors and morbidly obese patients are frequently excluded, so the results may appear in favor of MIPD over OPD. Robotic series are still small: Several studies demonstrate a reduction in blood loss and a trend towards reduced length of hospital stay vs.
In a meta-analysis on RPD vs. Since the major indications for PD are periampullary and pancreatic head cancers, the oncologic outcome of the resection is one of the key points of the success of different approaches.
Comparison of results is once again compromised by enormous selection bias; nevertheless, negative margins are achieved in most LPD series [ 64 — 66 ], with an adequate number of lymph nodes harvested [ 50 , 53 ]. Only one paper in the literature compares the mean costs of RPD vs. Even though these results are encouraging, it is important to observe that they are obtained by only a few very skilled minimally invasive surgeons and, as such, cannot be considered a standard of care, including for high volume pancreatic centers.
Given that in experienced centers the results of pancreatoduodenectomy via the open traditional approach are excellent, it may be hard to justify the increased operative time, efforts and resource utilization for MIPD. Major indications of total pancreatectomy TP are the tumor involving most of or the entire gland e.
In selected patients laparoscopy with or without robotic assistance proved advantageous, although experience with MITP is still confined to small series [ 54 , 70 — 73 ].
Total pancreatectomy with auto-transplant of islet cells has been described in patients with chronic pancreatitis [ 74 , 75 ]. In a series of 5 robotic total pancreatectomies RTPs by Zureikat et al. Advantages of robotic RTP vs.
Eleven patients underwent RTP for benign 1 or malignant disease and were compared to 11 patients with similar indications but without the availability of the robotic system at the time of scheduled surgery. The length of hospital stay was similar between the two groups, but all the parameters evaluating the recovery were advantageous for RTP. Enucleation is characterized by the maximal preservation of pancreatic parenchyma, the absence of dissection and reconstruction, low blood loss, but a high incidence of pancreatic fistula.
Preoperative imaging and intraoperative ultrasound assessment are crucial in ensuring that the tumor can be resected with negative resection margins and leaving the main pancreatic duct intact [ 3 , 77 ]. Length of stay is about 6—9 days [ 77 , 79 ], shorter than the days of open series.
Zureikat et al. Middle pancreatectomy is a rare but interesting procedure, indicated in cases of benign or low-grade malignant tumors located in the pancreatic neck or proximal body, where the surgical purpose is to achieve a radical removal preserving full exocrine and endocrine pancreatic function [ 80 ].
The minimally invasive approach for this procedure has not been widely described in the literature, and there are only a few reports available on laparoscopic and robotic MP. The approach described by Kang was hybrid for 3 patients out of 5 laparoscopic resection and robotic reconstruction , with pancreaticogastrostomy preferred over pancreaticojejunostomy.
Giulianotti et al. The mean operative time was min, and the mean length of hospital stay was 9 days for patients with no complications and 27 days for patients complicated by a grade B according to ISGPF pancreatic fistula. There were no conversions and the mortality was nil. During the last 20 years the history of pancreatic surgery has undergone a revolution thanks to the introduction and diffusion of minimally invasive surgery.
Traditionally the laparoscopic approach was limited to distal pancreatectomies and enucleations; conversely, laparoscopic pancreaticoduodenectomy never gained wide diffusion because of the very challenging reconstructive phase. The introduction of the robotic platform more than 10 years ago elicited an increased interest in minimally invasive pancreatic surgery.
The main advantages of the robot are the restoration of eye-hand coordination, enhanced 3D vision, augmented precision in movements and improved ergonomics. The robot eventually allows one to perform a procedure more similar to open surgery but via a minimally invasive approach. Laparoscopy is accepted as a gold standard approach for small tumors of the pancreatic body-tail thanks to its many advantages: The robot can obtain similar outcomes, but clear advantages over the traditional laparoscopic approach are difficult to demonstrate.
On the other hand, robotic surgery is commonly criticized for the costs involved. Randomized clinical trials are not available in the literature, while comparative studies are contradictory and compromised by strong bias in patient selection and data analysis. Surgery of the pancreatic head is very challenging with the laparoscopic and robotic approach too. The learning curve with this procedure is very long, so even though results are encouraging, a large and extensive diffusion is still far away.
Young patients with benign or low-grade malignant pancreatic lesions are perhaps the most suitable candidates for this type of surgery. National Center for Biotechnology Information , U.
Wideochir Inne Tech Maloinwazyjne. Published online Jul 7. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Address for correspondence: Rossi, Piazzale L. Scuro, 10, , Verona, Italy.
This article has been cited by other articles in PMC. Abstract During the past 20 years the application of a minimally invasive approach to pancreatic surgery has progressively increased. Introduction Pancreatic surgery is one of the most challenging and complex fields in general surgery, due to the deep position of the organ inside the abdominal cavity and its close proximity to major vasculature; so the application of a minimally invasive laparoscopic and robotic approach to pancreatic resections came late and slowly when compared to most abdominal operations.
Minimally invasive distal pancreatectomy MIDP with or without splenectomy Distal pancreatectomy DP is the most commonly performed pancreatic resection using minimally invasive techniques, thanks to the absence of a reconstructive phase. Indications Distal pancreatectomy is indicated in the case of lesions of the pancreatic body-tail. Technique Distal pancreatectomy can be performed with or without preservation of the spleen.
Outcomes Variables to take into consideration are operating time, blood loss, conversion rate, incidence of fistula, length of hospital stay, oncologic outcomes, re-operation, morbidity, mortality and costs.
Minimally invasive pancreaticoduodenectomy MIPD Pancreatoduodenectomy is considered one of the most challenging and complex operations in abdominal surgery, due to the necessity of very delicate manipulation during resection considering the uncinate process, portal vein and mesenteric vessels and very laborious reconstruction considering biliary anastomoses and pancreatic anastomoses.
Indications Pancreatoduodenectomy is the surgical treatment of periampullary, duodenal and pancreatic head lesions. Minimally invasive total pancreatectomy MITP Major indications of total pancreatectomy TP are the tumor involving most of or the entire gland e. Middle pancreatectomy MP Middle pancreatectomy is a rare but interesting procedure, indicated in cases of benign or low-grade malignant tumors located in the pancreatic neck or proximal body, where the surgical purpose is to achieve a radical removal preserving full exocrine and endocrine pancreatic function [ 80 ].
Conclusions During the last 20 years the history of pancreatic surgery has undergone a revolution thanks to the introduction and diffusion of minimally invasive surgery. Conflict of interest The authors declare no conflict of interest.
References 1. Gagner M, Pomp A.
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