Minimally invasive pancreaticoduodenectomy

Introduction

Since its initial description by Codevilla in 1898, through the first procedure performed by Kauch in 1909 and the two-stage procedure described by Whipple in 1935, the pancreaticoduodenectomy (PD) technique has evolved significantly over the last decades to become a common and safe procedure in pancreatobiliary surgery (see Chapters 62 and 117A ). Currently, PD is executed routinely with low morbidity and mortality rates when performed in experienced high-volume centers.

As in many other fields of surgery, minimally invasive approaches have revolutionized gastrointestinal and hepato-pancreato-biliary (HPB) operations (see Chapter 127A ). The overall advantages of minimally invasive surgery include less pain, less use of pain medications, less blood loss, fewer wound complications, shorter length of stay, and earlier recovery, among others. Currently, minimally invasive distal pancreatectomy (laparoscopic or robotic) has become widely used for pancreatic body and tail tumors (see Chapter 117B ). Yet, given the complexity of PD (see Chapter 117A ) and the steep learning curve for laparoscopic and robotic approaches, the adoption of these minimally invasive techniques has been slow for complex HPB surgery. Another aggravating factor for its implementation has been the cost associated with acquiring equipment for minimally invasive surgery, including the robotic system platform.

Laparoscopic PD was initially used by Gagne and Pomp in 1994, and the first robotic PD was performed by Giulanotti in 2001, and since then minimally invasive PD (MIPD) use has steadily increased across the globe. The increased use of minimally invasive techniques has highlighted the potential advantages of laparoscopic and robotic pancreas surgery and motivated a critical review of the current relevant data by experts in the field. The review was an international multi-institutional effort that resulted in recently published evidence-based guidelines for minimally invasive pancreatic resection that were endorsed by the most relevant international societies of HPB surgery.

The aim of this chapter is to describe indications, patient selection, technique, and outcomes associated with MIPD. This chapter will cover the basic aspects of the laparoscopic approach but will focus on robotic MIPD given the trend of modern minimally invasive techniques, the rapid growth of robotic programs globally, and the expertise of our group.

Indications

Current indications for MIPD are similar to those of the open approach (see Chapters 62 and 117A ) and include any periampullary tumor, including pancreatic adenocarcinoma (see Chapters 59 , 61 , and 62 ), pancreatic neuroendocrine tumors (see Chapter 65 ), distal common bile duct cancer (see Chapter 47 ), duodenal masses (see Chapter 63 ), and ampullary tumors (see Chapter 62 ), among others. Depending on the surgeon’s expertise, there are just a few absolute contraindications for the minimally invasive approach.

Our group and others have reported using robotic PD in patients with borderline and locally advanced tumors where portal vein resections and repair are needed (see Chapters 62 , 117A , and 122 ). ^, For surgeons at the early stages of their learning curve, we do not recommend the use of minimally invasive approaches when major vascular resections are anticipated. To assess these and other anatomic considerations, high-quality preoperative imaging is paramount to determine mesenteric vessel involvement before proceeding with MIPD (see Chapter 17 ). Specifically, we recommend a multiphasic computed tomography scan or magnetic resonance imaging during an early arterial and portal vein phase. For patients with locally advanced tumors where superior mesenteric artery or hepatic artery resection and reconstruction is anticipated, we recommend the open technique (see Chapter 117A ). Another potential contraindication includes patients who are unable to undergo pneumoperitoneum due to CO ₂ -retaining conditions. Previous upper abdominal operations, a high body mass index, and multiple comorbidities are not considered absolute contraindications. Yet adequate patient selection is highly encouraged in every case. A high level of minimally invasive technical skills should not replace critical clinical acumen and surgical planning. At our institution, all pancreas and periampullary tumors are discussed preoperatively in a multidisciplinary fashion that includes the opinions of specialized HPB surgeons.