Anatomic Basis And Clinical Applications Of Laparoscopic Pancreatic Resection

Objective:In recent years,laparoscopy has been widely used in many areas of surgery, however,laparoscopic pancreatic resection is still regarded as a complicated and high-risk operation.This study focused on the following objects:1.Based on the observation of the laparoscopic pancreatic anatomy,this study aimed to design the optimal approaches for laparoscopic pancreatic surgery according to the lesions with different localization.2.Through summarizing the experiences of laparoscopic pancreatic resection,this study aimed to discuss the key techniques and the prevention of complications for laparoscopic pancreatic resection.3.To discuss the diagnosis and treatment of insulinoma and to evaluate the efficacy and safety of laparoscopic insulinoma resections through a retrospectively comparing study with the laparotomic procedure.Methods:1.9 patients with normal body mass index were enrolled into the study which proposed to laparoscopic pancreatic surgery.During the laparoscopic operations, the whole pancreas were explored and the pancreatic anatomic structure and adjacent relationship were detected.And some important anatomic signs which play important roles in the pancreatic resections were tried to be identified. Furthermore,5 videos of laparoscopic left nephrectomy through posterior peritoneum were analyzed,and the pancreatic anatomic structure and adjacent relationship were observed through the posterior peritoneum.Finally,according to the above research,we tried to design the eligible laparoscopic approaches for the lesions with different localization in the pancreas.2.Then,with utilizing the designed laparoscopic approaches,47 cases,17 males and 30 females,underwent laparoscopic pancreatic resections in our hospital. Preoperative diagnosis included 33 cases of insulinoma,3 cases of pancreatic cystadenoma,1 case of pancreatic cystadenocarcinoma,2 cases of pseudocyst(1 case combined with hepatic cystic lesion),3 cases of true cyst,4 cases of nonfunctional islet cell tumor and 1 case of solid pseudo-papillary neoplasm.3.The medical records of 89 patients with insulinomas which underwent surgical treatment during Jan 1993 to Dec 2008 in our hospital were analyzed retrospectively,and the related index were compared between the laparoscopic and laparotomic groups.Results:1.The whole pancreas could be explored successfully under laparoscopy,some important anatomic structures of pancreas,such as the superior mesenteric vein,the gastroduodenal artery and the uncinate process of pancreas,could be identified successfully.From the videos of laparoscopic left nephrectomy through posterior peritoneum,the pancreas tail and adjacent structure also could be observed clearly. And according to the different localization and surgical plan,4 corresponding laparoscopic approaches were designed.2.During Mar 2003 to Feb 2009,47 cases of laparoscopic pancreatic resections were completed with the application of the designed laparoscopic approaches.The operations were successfully completed in 45 cases,the procedures included 37 cases of total laparoscopic resections and 8 cases of converting to open resections. We failed in the other 2 cases because the pancreatic lesions could not be identified during the operation.The success rate of the whole operations was 95.7%(45/47 ), for laparoscopic approach was 78.7%(37/47),the conversion rate was 17.0% (8/47 ).The mean operative time was 240±140.8 min(range:90-960 ),the mean blood loss was 184.0±310.5 ml(range:20-1500 ).Severe complications occurred in 7 cases postoperatively,including 2 cases of bleeding,1 case of drainage tube prolapse accidently and 4 cases of type C pancreatic fistula(1 case combined with biliary leak).All of these complications were healed by conservative treatments.3.There was no significant differences in success rate,operation time,blood loss, complication rate between the laparoscopic and open groups.And the laparoscopic group seemed to have less invasion and taster recovery than the open approach.Conclusions:1.According to the pancreatic anatomy and the preoperative image,the optimal laparoscopic approaches could be designed successfully.Through those laparoscopic approaches,laparoscopic pancreatic resection could be completed smoothly.2.Utilizing designed laparoscopic approaches,we could complete some difficult pancreatic resection,such as pancreaticoduodenectomy and distal pancreatectomy, and the technique of laparoscopic pancreatic resection could be simplified.This study suggests that,with selected patients,laparoscopic pancreatic resection is feasible and sate for the patients with presumed benign lesions and some early malignancies of pancreas.3.Laparoscopic insulinoma resection has the same clinic efficacy as open approach, and it has less invasion and faster recovery.So it is worthwhile to be further extended in clinic.