Applied Anatomy And Clinic Study On Laparoscopic Pancreatic Surgery

Objective and SignificanceSince Frence doctor Mouret implemented successfully laparoscopic cholecystectomy firstly in 1987, laparoscopy have been canonized by surgeons, and been enjoyed by patients, because laparosopic technique has many advantages such as little trauma, gentle interferece and an accelerated recovery. Todays laparosopic technique have been applied into general surgery, liver and gall surgery, urine surgery, and so on. especially in the fields of general surgery, all of traditional open operations were attempted successfully through laparoscopy. Whereas laparoscopic pancreatic surgery develop more slowly, for pancreas anatomy is especial, In order to develop laparoscopic pancreatic surgery, we fulfilled a series of applied anatomy and clinical study on it. Firstly, we explored the operational pathway and anatomic landmarks of retroperitoneal laparoscopic distal pancreatic surgery. Secondly, we provided the anatomic findings of superior mesenteric vessels for laparoscopic pancreatoduodenectomy (LPD). Thirdly, we summarized anatomic connections among splenic artery, splenic vein and distal pancreas, and put forward operation points about distal pancreatectomy with spleen preserving through preserving splenic vessel. Fourly, we explored the clinical application of laparoscopic distal pancreatectomy(LDP) for cystic tumor in the body or tail of the pancreas.Materials and Methods 1. The retroperitoneal space were studied in 10 cases of abdominal specimen fixed by 10% filmaline liquid and in 2 cases of fresh (=24h) cadavers, and the latter we also simulated retroperitoneal laparoscopic distal pancreas's separating.2. Superior mesenteric vessels were studied in 10 cases of abdominal specimen fixed by 10% filmaline liquid and in 2 cases of fresh(=24h) cadavers, and then we also simulated undergoing LPD.3. Anatomic connections among splenic artery, aplenic vein and distal pancreas were studied in 20 cases of pancreas-spleen organ cluster, meanwhile we reveiwed related literature.4. From Feb. 2003 to Apr. 2006, 5 cases with cystic tumor in the distal region of the pancreas were treated by LDP in our department. The mean age was 32. 8(rang: 27-43)years.Results1. Anterior pararenal space were anatomied fully. We succeeded in retroperitoneal laparoscopic distal pancreas's separating.2. (1) The mean length of superior mesenteric vein(SMV) before the third part of duodenum, along with uncinate process of pancreas head, behind cervix of pancreas and over pancreas were (3.80±0.72)cm, (1.76±0.25)cm, (3.81±0.64)cm and(4.73±1.31)cm, respectively. (2) There are six types of right gastroepiploic vein's flowing into SMV. (3) Superior mesenteric artery(SMA) originated from abdominal aorta at an average distance of (1.12±0.15)cm from coeliac trunk. The mean caliber and length of superior mesenteric artery were (0.69±0.03)cm and (3.97±0.54)cm, respectively. There are five types of inferior pancreaoduodenal artery and the first jejunal artery's originating from SMA.3. Splenic artery and splenic vein are enwrapped by sheath. Splenic artery rides on splenic vein. Distal pancreas swings from splenic vessel. 4. All of the operations were completed successfully using laparoscopic procedure, with an average operation time of 258(rang: 95-430)min and a mean intraoperative blood loss of 140(rang: 50-300)ml. Histopathological diagnosis is 4 cases pancreatic myxedema and 1 case pancreatic serous cystoma. There was one minor pancreatic leak, which resolved conservatively. The median postoperative hospitalization was 6.8(rang: 5-17)days.Conclusions1. Retroperitoneal laparoscopic distal pancreatic surgery is safe and feasible through anterior pararenal space, which is larger enough to operate in pancreas and where there are good anatomic landmarks.2. (1)Right gastroepiploic vein is a good landmark for seeking superior mesenteric vein during laparoscopic pancreatoduodenectomy. (2)To dissect superior mesenteric vein and artery should be undergone through left and right trocar respectively. (3)It is feasible to seek and to dissect superior mesenteric vessels during laparoscopic pancreatoduodenectomy if making use of amplification effect of laparoscopy and spliting effect of ultrasonic dissector.3. Operational points of distal pancreatectomy with spleen preserving through preserving splenic vessel are: (1)Separating distal pancreas from splenic vessel, it is correct to regard splenic vessel as a integer; (2)We should separate distal pancreas from splenic vessel along clearance between splenic vein and distal pancreas; (3) Whether form proximal to distal or from distal to proximal separating pancreas from splenic vessel should be based on splenic vessel anatomic types.4. LDP for distal pancreatic cystic tumor is feasible, the procedure appears to be safe, and it is acccompanied by an accelerated recovery...