Table Of ContentC R
ASE EPORT
Single Incision Laparoscopic Pancreas Resection for
Pancreatic Metastasis of Renal Cell Carcinoma
Umut Barbaros, Aziz Su¨mer, MD, Tugrul Demirel, MD, Nazlı Karakullukc¸u, MD, Burc¸in Batman, MD,
Yalın ˙Içscan, MD, Gu¨lay Sarıc¸am, MD, Ku¨rçsat Serin, MD, Wei-Liang Loh, Ahmet Dinc¸c¸ag˘,
Selc¸uk Mercan
ABSTRACT Key Words: Single incision, Pancreas, Resection.
Background:Transumbilicalsingleincisionlaparoscopic
surgery(SILS)offersexcellentcosmeticresultsandmaybe
associated with decreased postoperative pain, reduced
INTRODUCTION
needforanalgesia,andthusacceleratedrecovery.Herein,
we report the first transumbilical single incision laparo-
Pancreatic surgery is an extremely challenging field,
scopic pancreatectomy case in a patient who had renal
and the management of pancreatic diseases continues
cell cancer metastasis on her pancreatic corpus and tail.
to evolve. The application of laparoscopic surgery for
Methods: A 59-year-old female who had metastatic le- the treatment of pancreatic diseases is only recently
sions on her pancreas underwent laparoscopic subtotal gainingwidespreadpopularity,owing,innosmallpart,
pancreatectomy through a 2-cm umbilical incision. to the retroperitoneal location of the pancreas. Studies
involving small numbers of patients suggest that it is as
Results: Single incision pancreatectomy was performed safe as open surgery, with the additional advantages of
withaspecialport(SILSport)andarticulatedequipment. a shorter hospital stay and a faster return to normal
The procedure lasted 330 minutes. Estimated blood loss activity.1 Although the laparoscopic approach de-
was100mL.Noperioperativecomplicationsoccurred.The creases surgical morbidity, it still requires 3 to 4 inci-
patient was discharged on the seventh postoperative day sions each at least 1cm to 2cm in length. In addition,
with a low-volume (20mL/day) pancreatic fistula that each working trocar has morbidity risks of bleeding,
ceased spontaneously. Pathology result of the specimen hernia, visceral organ damage, or all of these, and
was renal cell cancer metastases. incrementally decreases cosmesis.2,3 Improvement of a
new minimally invasive technique called “single inci-
Conclusion: This is the first reported SILS pancreatec-
sionlaparoscopicsurgery”(SILS),whichislessinvasive
tomy case, demonstrating that even advanced surgical
than standard multiport laparoscopy, is a challenging
procedurescanbeperformedusingtheSILStechniquein
idea. SILS has several unique difficulties for the laparo-
well-experienced centers. Transumbilical single incision
scopic surgeon. First, triangulation and retraction are
laparoscopic pancreatectomy is feasible and can be per-
significantly limited. The introduction of a camera and
formed safely in experienced centers. SILS may improve
several instruments parallel to each other results in
cosmetic results and allow accelerated recovery for pa-
decreased range of motion and ‘‘clashing” of instru-
tients even with malignancy requiring advanced laparo-
ments. This decreased freedom of motion increases the
scopic interventions.
technical complexity of the operation and results in a
significant learning curve for performing SILS. Critics
also mention the need for new and specialized instru-
IstanbulUniversity,IstanbulFacultyofMedicine,DepartmentofGeneralSurgery,
Istanbul, Turkey (Drs Barbaros, Karakullukc¸u, Batman, I˙çscan, Sarıc¸am, Serin, mentation, thereby increasing the cost of the opera-
Dinc¸c¸ag˘,Mercan). tion.4 We are the team that performed the first SILS
VanUniversityof100thYear,DepartmentofGeneralSurgery,Van,Turkey(Dr splenectomy,andwenowpresentthefirstSILSsubtotal
Su¨mer).
pancreatectomy case.
GaziantepStateHospitalofSehitKemal,DepartmentofGeneralSurgery,Gazi-
antep,Turkey(DrDemirel).
CASE REPORT
NationalUniversityofSingapore,FacultyofMedicine,Singapore(DrLoh).
Addresscorrespondenceto:UmutBarbaros,IstanbulUniversity,IstanbulFacultyof A 59-year-old woman was admitted to our clinic for ab-
Medicine, Department of General Surgery, C¸apa, Istanbul, Turkey, GSM:
dominal pain. In her medical history, she had previously
00905423425115,E-mail:[email protected]
undergone a left radical nephrectomy for clear cell renal
DOI:10.4293/108680810X12924466008448
cancer 11 years earlier. Laboratory tests were totally nor-
©2010byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. malincludingthetumormarkersCEAandCA19-9.Ultra-
566 JSLS(2010)14:566–570
sonography (US) revealed 2 hypodense lesions in the
corpus and the tail of the pancreas. A computerized to-
mography (CT) scan of the abdomen revealed 2 hyper-
vascular lesions, 30mm x 22mm in the body and 15mm x
14mm in the tail of the pancreas (Figure 1). In addition,
positron emission tomography also revealed pancreatic
involvement, increasing the suspicion of malignancy in
the pancreas. Because splenectomy would be added to
pancreas resection, the patient was vaccinated against
pneumococci (Pneumovax 23, Boehringer) 2 weeks be-
foretheoperation,andreceived1gofsulbactam/ampicil-
lin intravenously as a preoperative prophylaxis. The pa-
tient was informed about the details of the surgical
procedure, and informed consent was obtained.
Surgical Technique
ThepatientwasplacedinasupineandreverseTrendelen-
Figure1.Computedtomographicviewofpancreaticlesions.
burg position (30 degree) with open legs. The surgeon
stood between the legs; the first assistant was on the left
sideofthepatientwiththemonitorplacedonthepatient’s
cranial side. With the patient under general anesthesia, a
completely transumbilical 2-cm skin incision was per-
formed. A special SILS port having 4 working channels
was placed through this abdominal incision of the umbi-
licus. Pneumoperitoneum was applied through this port.
After the maintenance of 12mm Hg CO pneumoperito-
2
neum, the three 5-mm cannulas were inserted inside this
special SILS port (Figure 2). We used a rigid 30-degree,
5-mm laparoscope, and 2 standard rigid but articulating
5-mm laparoscopic instruments for all SILS procedures.
Once the laparoscope, grasper, and dissector were
placed, the overall procedures were similar to the proce-
duresperformedina5-portlaparoscopicpancreatectomy.
The most difficult part of this technique was that the
workinginstrumentswerecrossingeachotherandroticu- Figure2.SpecialSILSportwithroticulatedinstruments.
lated.The5-mmtelescopeisintroducedunderbothofthe
workinginstrumentsandsometimesoverthem,changing
according to the surgical step of the procedure. After less We prepared the loop by using polypropylene suture
invasive entry into the abdomen, nothing different from covered with a plastic tube of IV serum set to prevent a
the multi-trocar laparoscopic pancreatectomy technique possible stomach injury. Two tips of this suture were
was performed. During all these steps, at least one of the taken out of the abdominal cavity with a suture passer
pieces of equipment, roticulated grasper and dissector, placed under the xiphoid process. During the entire pro-
was used. Following a diagnostic laparoscopy, the lesser cedure, stomach retraction was provided with this tensed
sacwasenteredbydividingthegastrocolicligamentusing loop Prolene securing the stomach. The “medial-to-lat-
the advanced LigaSure probe (Valleylab, Boulder, CO, eral”techniquefortumorsinthebodyandproximaltailof
USA). The whole pancreatic body and tail were exposed, the pancreas was the chosen method. The peritoneal
and the 2-cm lesion on the corpus was defined. Before lining along the inferior edge of the pancreas was dis-
startingpancreaticdissection,weplacedaloopencircling sected at the point where transection of the pancreas
the stomach corpus by crossing the lesser curvature and would be carried. An adequate window was created; a
greater curvature for preoperative continuous retraction. roticulated grasper was passed around the body of the
JSLS(2010)14:566–570 567
SingleIncisionLaparoscopicPancreasResectionforPancreaticMetastasisofRenalCellCarcinoma,BarbarosUetal.
Figure3.Pancreaticmassandsplenicveinview.
Figure5.Postoperativeviewofumbilicalincision.
freed.Oncethedistalpancreaswasmobilized,thestapled
closure of the proximal pancreatic stump was reinforced
with fibrin glue. The splenic part of the specimen was
retrievedusingtheEndo-Catch15(USSurgicalCorp,Nor-
walk, CT, USA) by morcellation, and then, the pancreatic
partofthespecimenwasdeliveredthroughtheumbilical
port site as an intact piece. A closed suction drain was
placed in the lesser sac. The umbilical site was sutured
with 0 polypropylene, and the skin was closed with a
stapler (Figure 5).
Figure4.Removedpancreas.
Postoperative Period
gland. The splenic vein was identified and ligated with
The patient started oral intake at the sixth postoperative
LigaSure at this level (Figure 3). One of the 5-mm trocar
hour. She had a low-volume (20mL/day) pancreatic fis-
sitesonaSimportdevicewasreplacedbya15-mmtrocar
tula, for 35 days that ceased spontaneously with only a
tobeabletointroducealinearstapler.Thepancreaswas
drain. She was discharged on the seventh postoperative
then transected by using two 45-mm Endo-GIA staplers
daywithherdrain.Pathologyresultsrevealedthe2fociof
(USSurgicalCorp,Norwalk,CT,USA)(Figure4).Dissec-
clear cell type renal cell cancer metastases in pancreatic
tion of the pancreas from the pancreatic bed was started
tissue. Surgical margins were clear 1.5cm away from the
after ligation of the splenic artery near the celiac trunk.
tumor.Duringthe2-monthfollow-up,wedidnotidentify
Dissection was carried out in a medial-to-lateral fashion
any complications from the surgical procedure.
from the tail towards the hilum of the spleen. Retroperi-
toneal dissection took time because of dense fibrosis of
DISCUSSION
theregioncausedbyapreviousleftnephrectomy.Inthis
manner, the distal portion of the pancreas containing the The laparoscopy revolution in the early 1990s changed
tumorwasremovedtogetherwithsplenicvesselsandthe standard procedures in the treatment of human dis-
spleen itself and its retroperitoneal attachments and thus eases. Surgeons aimed at limiting the number of ab-
568 JSLS(2010)14:566–570
dominal incisions (as in SILS) or eliminating them com- struments and the laparoscope is common. SILS has a
pletely (as in natural orifice transluminal endoscopic uniquelearningcurve,principallyinnavigatingtheinstru-
surgery [NOTES]).5 The first attempts at single-incision ments within a limited range of motion and it requires
laparoscopic cholecystectomy were performed by Na- significant coordination between the surgeon and the
varra et al (1997) and Piskun & Rajpal (1999). A single camera holder. The surgeon also has to be adapted to
incisionwasmadethroughtheumbilicusandtwotrocars counterintuitive movements due to frequent crossing of
orportswereinsertedthroughtheopeningwithabridge theinstrumentshaftsatthepointofentryintotheabdom-
of fascia (soft connective tissue) between them.6,7 In ad- inal cavity. Other than nephrectomy, prostatectomy, gas-
dition, recent reports3,4 of single incision donor nephrec- trojejunostomy,sigmoidectomy,adrenalectomy,andsple-
tomies and other urologic applications have been de- nectomy have also been successfully performed.9–11 A
scribed,aswellassingleincisionsleevegastrectomiesfor randomized controlled trial not only to document safety
morbid obesity.8 SILS poses unique challenges for the and feasibility but also patient satisfaction, postoperative
laparoscopic surgeon. First, triangulation and retraction pain, and cosmesis should be performed to clarify the
aresignificantlylimited.Theintroductionofacameraand feasibility of the technique. Application of SILS in solid
several instruments parallel to each other results in de- organ surgery like nephrectomy and splenectomy can be
creased range of motion and “clashing” of instruments. accomplished. After gaining sufficient experience in SILS
Thisdecreasedfreedomofmotionincreasesthetechnical splenectomy, we decided to perform SILS pancreatec-
complexity of the operation and results in a significant tomy. Herein, we describe a single incision pancreatec-
learning curve for performing SILS. tomyperformedinapreviouslynephrectomizedrenalcell
cancer patient. To our knowledge, this is the first SILS
Laparoscopic distal pancreatectomy is an acceptable treat-
pancreatectomycasereportedintheliterature.Single-port
mentoptionformostbenignandindolenttumorslocatedin
or single incision laparoscopy, even with flexible instru-
thebodyortail of the gland, but the current techniques
mentation, is technically more challenging than straight
describetransectionofthepancreasattheregionofthe
laparoscopy.
body regardless of the actual location of the tumor.
The advantage of a more proximal transection is that Performed by expert hands, SILS pancreatectomy is
the splenic vessels have not branched considerably at equally as efficacious as conventional laparoscopic
this point, and there is theoretically a lower risk of hem- pancreatectomy without compromising surgical stan-
orrhagefromsmallsplenicbranches.Thedisadvantageof dardsofcare.Althoughpancreassurgeryitselfisarisky
such a proximal transection, however, is that for very and difficult procedure, SILS pancreatectomy may offer
distal lesions, a large amount of normal pancreatic tissue a subjective cosmetic advantage. Validated patient-out-
must be sacrificed.10 In this case, due to 2 suspected comedataarerequiredtomoreobjectivelyaddressthis
tumoral foci, we performed a subtotal pancreas resection in- final comment. Prospective comparison between SILS
cludingsplenectomy.Althoughthispatienthadpreviouslyun- and conventional laparoscopic procedures is sine qua
dergoneanephrectomy,wewereabletoperformaSILSpan- nontomoreclearlydefinethecertainbenefitsofsingle
createctomy. This may mean that technically a surgical incision surgery. This report can only declare that even
procedurecouldbeeasierandshorterinundocases. pancreas resection together with splenectomy could be
performed technically in well-experienced tertiary re-
Today, single incision is becoming popular and serves
ferral centers. However, a question like “Should it be
both for the less minimally invasive procedure wishes
applied?”isanothertopicofdebatethatcouldbesolved
ofsurgeonsandthemorecosmesisrequestsofpatients.
after evaluation of long-term results of SILS cases.
As clinical experience with SILS increases, it is impera-
tive that we critically evaluate 3 important questions:
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