Various retraction techniques for laparoscopic pancreaticoduodenectomy.

The laparoscopic pancreaticoduodenectomy (LPD), introduced by Gagner and Pomp in 1994, is typically done in high-volume centers due to its technical demands. Our methods aim to provide effective traction, enabling efficient surgery despite limited staffing. A retrospective analysis of 29 patients undergoing LPD by a single surgeon between September 2021 and December 2022 showed promising outcomes: median intraoperative bleeding of 425 mL, operation time of 505 minutes, and postoperative hospital stay of 10 days. With only one case requiring open conversion, our external retraction techniques demonstrate efficacy in overcoming challenges associated with manpower constraints, highlighting potential utility for surgeons in similar settings. We share LPD external retraction techniques and outcomes.

Robotic central pancreatectomy: a surgical technique.

Robotic central pancreatectomy has not been widely performed because of its rare indications, technical difficulties, and concern about the high complication rate. We reviewed six robotic central pancreatectomy cases between May 2016 and June 2021 at a single institution. This multimedia article aims to introduce our technique of robotic central pancreatectomy with perioperative and follow-up outcomes. All patients experienced biochemical leakage of postoperative pancreatic fistula, except in one with a grade B pancreatic fistula, which resulted in a pseudocyst formation and was successfully managed by endoscopic internal drainage. All patients achieved completely negative resection margins. There was no new-onset diabetes mellitus or recurrence during the median follow-up period of 13.5 months (range, 10-74 months). With an acceptable complication rate and the preservation of pancreatic function, robotic central pancreatectomy could be a good surgical option for patients with benign and borderline malignant tumors of the pancreatic neck or proximal body.

Laparoscopic pancreaticoduodenectomy and laparoscopic pancreaticoduodenectomy with robotic reconstruction: single-surgeon experience and technical notes.

Purpose: Despite the increasing number of robotic pancreaticoduodenectomies, laparoscopic pancreaticoduodenectomy (LPD) and LPD with robotic reconstruction (LPD-RR) are still valuable surgical options for minimally invasive pancreaticoduodenectomy (MIPD). This study introduces the surgical techniques, tips, and outcomes of our experience with LPD and LPD-RR. Methods: Between March 2014 and July 2021, 122 and 48 patients underwent LPD and LPD-RR respectively, at CHA Bundang Medical Center in Korea. The operative settings, procedures, and trocar placements were identical in both approaches; however, different trocars were used. We introduced our techniques of retraction methods for Kocherization and uncinate process dissection, pancreatic reconstruction, pancreatic division, and protection using the round ligament. The perioperative surgical outcomes of LPD and LPD-RR were compared. Results: Baseline demographics of patients in the LPD and LPD-RR groups were comparable, but the LPD group had older age (65.5 ± 11.6 years vs. 60.0 ± 14.1 years, p = 0.009) and lesser preoperative chemotherapy (15.6% vs. 35.4%, p = 0.008). The proportion of malignant disease was similar (LPD group, 86.1% vs. LPD-RR group, 83.3%; p = 0.759). Perioperative outcomes were also comparable, including operative time, estimated blood loss, clinically relevant postoperative pancreatic fistula (LPD group, 9.0% vs. LPD-RR group, 10.4%; p = 0.684), and major postoperative complication rates (LPD group, 14.8% vs. LPD-RR group, 6.2%; p = 0.082). Conclusion: Both LPD and LPR-RR can be safely performed by experienced surgeons with acceptable surgical outcomes. Further investigations are required to evaluate the objective benefits of robotic surgical systems in MIPD and establish widely acceptable standardized MIPD techniques.

Self-traction Method for Uncinate Process Dissection During Laparoscopic Pancreaticoduodenectomy.

BACKGROUND: Dissection of the uncinate process is one of the most challenging procedures in laparoscopic pancreaticoduodenectomy and is also oncologically important to secure the retroperitoneal resection margin. In this study, we introduced a traction method that could provide stable lateral traction of the uncinate process to elevate it to allow better visualization of the retroperitoneal resection margin between the uncinate process and the superior mesenteric artery. METHODS: The pancreatic head and duodenal unit were encircled using a 25-cm-long nylon tape and an elastic rubber band was used to tract it. The elastic power of the rubber band induces gradual automatic self-traction that allows the surgeon to proceed with the dissection without any other manipulation. With the help of this traction method, both of the operator's hands were free from the traction. RESULTS: This video demonstrated the setting for the application of our self-traction method and how it can be used to achieve a proper operative field during uncinate process dissection. CONCLUSION: This simple traction method could allow better exposure of the operative field and provide a stable operative environment.

Easily Applicable Single-incision Laparoscopic Appendectomy Using Straightforward Instrumental Alignment and Conventional Laparoscopic Instruments.

BACKGROUND: Laparoscopic appendectomy is one of the most frequently performed operations. As such, single-incision laparoscopic appendectomy (SILA) is indicated as a feasible and safe procedure comparable to conventional laparoscopic appendectomy (CLA). However, novice surgeons face challenges in performing SILA, because the role of the surgeon's hands is reversed. We introduce an easily applicable technique of SILA by adapting the alignment of CLA. METHODS: A series of 61 consecutive patients underwent SILA between January 2019 and December 2019 by 4 surgeons at Bundang CHA Medical Center. Acute appendicitis was diagnosed preoperatively by abdomino-pelvis computed tomography or ultrasonography. During the operation, a 3-channel Glove port was used with conventional laparoscopic instruments. RESULTS: The study participants consisted of 32 males and 29 females, with a mean age of 26.8 years (range, 4 to 66 y). The mean body mass index was 20.79 kg/m2 (range, 11.89 to 27.04 kg/m2). The mean operation time was 37.5±17.0 minutes. There was only 1 case of conversion with 1 additional port. Eight patients (13.1%) experienced postoperative complications defined by Dindo-Clavien-Strasberg classification: grade 1 wound complication in 7 patients and grade 2 postoperative bowel obstruction in 1 patient. The mean postoperative hospital stay was 2.5±1.3 days. CONCLUSION: Alignment of the instruments during CLA was successfully implemented into a SILA. Our new, easily applicable SILA technique will decrease the learning curve for novice surgeons in performing single-incision laparoscopic surgery.

Hybrid Laparoscopic and Robotic Hepatopancreaticoduodenectomy for Cholangiocarcinoma.

INTRODUCTION: Combined hepatic resection and pancreaticoduodenectomy is the treatment of choice for patient with extensive horizontal-spreading cholangiocarcinoma involving both the perihilar bile duct and the intrapancreatic distal bile duct.1-3 This surgical procedure is extremely complex, and incurs a high risk of postoperative morbidity and mortality.4 However, in recent years, this complicated high-risk operation can be safely performed in well-selected patients.5 However, as we know, none of these operations have been reported as minimally invasive surgery. PATIENT AND METHODS: A 73-year-old female presented with jaundice and was diagnosed with cholangiocarcinoma. The preoperative image studies revealed a 4.3-cm-long diffuse, infiltrative cholangiocarcinoma from the hilar bile duct to the intrapancreatic bile duct without major vascular invasion. The patient was scheduled to undergo left hepatectomy with caudate lobectomy and pancreaticoduodenectomy to obtain a free resection margin. In order to maximize the efficiency of each surgical modality, we designed a hybrid method of laparoscopic resection and robotic reconstruction for this complicated surgery with a long operation time. A 12-mm port was placed at the subxiphoid area, which was utilized for laparoscopic CUSA during the liver resection. Three 12-mm ports around the umbilicus and an 8-mm robotic port at the right flank were placed. In the resection phase, pancreaticoduodenectomy was performed first, followed by hilar dissection and liver resection in en bloc manner. Here, a hanging maneuver was helpful for the complete resection of the caudate lobe in environment with the large specimen attached. In reconstruction phase, the right flank 8-mm port and the left side 12-mm port (using the double docking technique) were used for docking of two robotic working arms. RESULTS: The total operation time was 510 min, and the estimated blood loss was 350 mL without transfusion. The patient's postoperative recovery was smooth, except for a mild fever due to cystitis, and she was discharged on the 16th postoperative day. Permanent pathologic examination revealed a disease-free proximal bile duct margin, but a metastasis was discovered in one regional lymph node metastasis from 18 retrieved lymph nodes. The patient is receiving adjuvant gemcitabine chemotherapy and regular surveillance. We performed two consecutive cases and the perioperative outcomes were summarized in the attached video. CONCLUSION: Hepatopancreaticoduodenectomy has a long operative time, involves complicated anatomical structures and difficulty of R0 resection, and it is a remaining frontier of minimally invasive surgery. However, we expect that highly selected patients can carefully undergo minimally invasive surgery if the advantages of the currently available surgical methods are well utilized.

Inverted Meckel's diverticulum: Two case reports and a review of the literature.

Gastrointestinal surgeons seldom encounter inverted Meckel's diverticulum in their clinical practice. We describe two cases of inverted Meckel's diverticulum. If the patient has a disease-related complication such as intussusception, as with our first case, it can be easily detected. However, if the patient has subacute or chronic symptoms, as with our second case, the diagnosis might be delayed. Regardless of the disease-related complication, intussusception of inverted Meckel's diverticulum can be easily managed with laparoscopic single-port surgery.