Laparoscopic pancreaticoduodenectomy (LPD) was first described by Gagner and Pomp in 1994. However, due to the inherent technical challenges of laparoscopy and the requirement for advanced laparoscopic skills, LPD has predominantly been performed by a handful of experienced surgeons in high-volume centers. In low-volume centers, the lack of skilled surgical teams further complicates the adoption of LPD. Additionally, there is ongoing debate regarding the safety of LPD. Nevertheless, accumulating evidence supporting its oncological safety and the increasing experience of many surgeons have extended the reach of LPD. To address adjacent challenges such as understaffing, we have devised various retraction techniques for LPD to ensure stable traction during surgery.

In this article, we present our retraction tips for LPD and report surgical outcomes performed by a single surgeon.

Patients and methods

We conducted a retrospective review of medical records for a total of 29 patients who underwent LPD performed by a single surgeon at CHA Bundang Medical Center, CHA University College of Medicine, between September 2021 and December 2022. Among these patients, there was only one case that required open conversion due to tumor abutment to the posterior dorsal jejunal vein. The median age of the patients was 65 years, and 72.4% were male. Demographic information and pathologic diagnoses are provided in Table 1.

Table 1 . Demographics and pathologic diagnosis.

Characteristic	Data
No. of patients	29
Age (yr)	65 (41–80)
Sex, male:female	21 (72.4):8 (27.6)
Body mass index (kg/m2)	24.1 (18.5–30.2)
ASA PS classification
I	1 (3.4)
II	25 (86.2)
III	3 (10.3)
Diagnosis
CBD cancera)	14 (48.1)
Pancreas cancer	3 (10.3)
Pancreas NET	1 (3.4)
IPMN	1 (3.4)
AoV tumorb)	8 (27.6)
Duodenum GIST	2 (6.9)

Values are presented as number only, median (range), or number (%)..

ASA, American Society of Anesthesiologists; PS, physical status; CBD, common bile duct; NET, neuroendocrine tumor; IPMN, intraductal papillary mucinous neoplasm; AoV, ampulla of vater; GIST, gastrointestinal stromal tumor..

^a)One patient was hilar cholangiocarcinoma (Bismuth type 1), the others were distal CBD cancer. ^b)Two patients were AoV adenoma, the others were cancer..

Contraindications to LPD included the following: (1) poor general health assessed by an American Society of Anesthesiologists physical status classification of >III, (2) uncertainty about the safety of surgical margins concerning the proximity to major arterial structures, pancreatic resection margin, and upper bile duct margin, (3) locally advanced malignancy with invasion of other organs, and (4) risk of tumor rupture during the procedure.

Definitions

Postoperative complications were graded using the Clavien-Dindo classification system. Specifically, postoperative pancreatic fistula (POPF), delayed gastric emptying, and postpancreatectomy hemorrhage were graded using guidelines from the International Study Group of Pancreatic Surgery. The size of pancreatic duct was measured at the cut surface of the remnant pancreas during the operation, and these data were recorded in an operative note.

Surgical techniques (Supplementary Video 1)

Operative setting

The patient was positioned in a 20° to 30° reverse Trendelenburg position with approximately 15° right elevation. Three 12-mm and two 5-mm trocars were used (Fig. 1). The operator and scopist stood on the left side of the patient. Firstly, exploration was conducted to confirm the presence of metastases.

Figure 1. Port placement. (A) The camera port was located at the umbilicus and two 12-mm (red circles) and two 5-mm trocars were placed on the sub-xiphoid and right abdomen (blue circles), respectively. (B) An assistant surgeon worked through the left side 5-mm trocar, if needed.

Omentectomy

During omentectomy, the retraction of stomach toward the cranial side was required. External fixation with Penrose drain was used for stabilization (Fig. 2), and partial omentectomy was performed using ultrasonic shears.

Figure 2. External fixation with a Penrose drain. (A) The patient`s stomach was retracted toward the cranial side. (B) Instruments were secured using a Penrose drain.

Colon mobilization and Kocher maneuver

Full mobilization of the right colon, including hepatic flexure, to expose the duodenum and pancreatic head, facilitates kocherization and also helps identification of the relationship of the middle colic and gastroepiploic vein with the superior mesenteric vein (SMV). Therefore, proper pulling of the right colon caudally will greatly improve the exposure of the duodenum, pancreatic head, and gastrocolic trunk.

After mobilization of the colon at the hepatic flexure area, external retraction downward was applied using an ENDOLOOP (Ethicon US) to expose the surgical field, thereby facilitating dissection (Fig. 3).

Figure 3. External retraction with ENDOLOOP (Ethicon US). (A) After colon mobilization, the colon was retracted downward using ENDOLOOP. (B) The loop was externally fixed via the camera port.

Division of the distal bowel

After kocherization, duodenum, pancreatic head, and uncinate process were dissected from the retroperitoneum. Once the jejunum was completely released from Treitz ligament, it was pulled out to the patient’s right side through the detached Treitz ligament. Subsequently, additional retraction was necessary from the opposite side of the initial one, and the jejunum was then divided (Fig. 4).

Figure 4. Cross-retraction of Jejunum. (A) After the ligament of Treitz was completely dissected, cross-retraction was performed for adequate transection. (B) Instruments were held in place using a Penrose drain for continuous retraction.

Lifting the liver

After detachment of the gallbladder, the remaining plate was secured using a barbed suture toward the cranial side to lift the liver for surgical field (Fig. 5) [1]. The advantage of using a barbed suture is that it can be fixed without the need for any additional ties, making it applicable in various situations.

Figure 5. Liver lifting. The remnant gallbladder bed was fixed upward using a barbed suture to elevate the liver.

Uncinate process dissection

After performing the pancreatic transection with ultrasonic shears, the pancreatic neck was externally retracted using a rubber band (Fig. 6). To anchor the rubber band to the pancreas, a barbed suture was utilized. Additionally, the pancreatic head and duodenal unit were encircled using 25 cm-long nylon tape, with a rubber band twisted into the nylon tape for further fixation [2]. It is worth noting that this method can also be employed instead of using a barbed suture. Adequate traction of the duodenum and pancreatic head complex during the uncinate process dissection frees the surgeon’s hand from traction, allowing for a fine dissection and the ability to respond appropriately to sudden bleeding.

Figure 6. External pancreas retraction. The pancreatic head was encircled with nylon tape, and a rubber band was twisted into the nylon tape for additional fixation. External retraction was then performed.

During the process of completely separating the specimen, the scopist gently retracted the superior mesenteric vein and the portal vein medially using a snake retractor (Fig. 7).

Figure 7. Snake retractor. While separating the specimen, gently retracting the superior mesenteric vein and the portal vein medially using a snake retractor proved to be helpful

Reconstruction phase

After completing the resection, end-to-side pancreaticojejunostomy was performed using the modified Blumgart technique with a short silicone stent. Before anastomosis, a drain tube was placed under the anastomosis site to prevent potential damage from inserting the drain after the anastomosis.

Subsequently, hepaticojejunostomy was carried out using end-to-side duct-to-mucosa anastomosis. In some cases, a barbed string was utilized, as it enables appropriate tension for suturing without requiring assistance. However, it is crucial to exercise caution when pulling the barbed string to avoid iatrogenic anastomosis-site stricture.

Duodenojejunostomy or gastrojejunostomy was routinely performed on the extracorporeal side via the mini-laparotomy wound.

We attempted a total of 30 cases of LPD, with only one case requiring open conversion due to a high risk of major bleeding caused by tumor abutment to the posterior dorsal jejunal vein. Pure LPD was successfully performed in 29 cases (Table 1).

The median operation time was 505 minutes (range, 350–675 minutes). The median intraoperative bleeding was 420 mL (range, 110–1,350 mL). The overall POPF rate was 55.2% (16 cases), but all cases of POPF were biochemical leakage, and there were no clinically relevant POPF cases. One patient experienced pulmonary thromboembolism (grade II), and two patients required percutaneous drainage for interstitial fluid collection (grade IIIa). Additionally, one patient experienced postpancreatectomy hemorrhage from the gastroduodenal artery and required intervention (grade IIIa). Delayed gastric emptying occurred in three cases (Table 2).

Table 2 . Perioperative outcomes (n = 29).

Variable	Data
Operative time (min)	505 (350–675)
Estimated blood loss (mL)	420 (110–1,350)
Size of duct (mm)
Pancreatic duct	2 (1.5–9)
Bile duct	10 (5–20)
Sips of water day	2 (1–3)
Postoperative hospital stay (day)	10 (8–25)
Drain removal day	8 (4–12)
Postoperative complicationa)
I	17b) (BL, 16; CL, 1)
II
IIIa	4 (PPH, 1; PT, 1; PFC, 2)
IIIb
IV
Delayed gastric emptyingc)	3
Open conversion (%)	1 (3.3)
Major postoperative complication	0 (0)
Postoperative 90 days mortality	0 (0)

Values are presented as median (range) or number (%)..

BL, biochemical leakage; CL, chyle leakage; PPH, postpancreatec­tomy hemorrhage; PT, pulmonary thromboembolism; PFC, perihpatic fluid collection..

^a)Clavien-Dindo classification. ^b)Postoperative pancreatic fistula (gradings of new 2016 International Study Group of Pancreatic Surgery [IFGPS] definition). ^c)Grade A of 2007 IFGPS definition..

The median postoperative hospital stay was 10 days (range, 8–25 days). There were no postoperative mortalities within the 90-day postoperative period.

There have been numerous studies, including randomized controlled trials comparing LPD and open pancreaticoduodenectomy [3-5]. The LEOPARD-2 trial failed to demonstrate the safety of LPD compared to open pancreaticoduodenectomy. However, other studies have shown that LPD is a safe and feasible procedure, especially in high-volume centers.

In other words, LPD requires significant experience and skill with the assistance of a skilled surgical team for stable surgery. For this reason, LPD is considered a challenging surgery to attempt, particularly in smaller hospitals. Even in high-volume centers, the surgical results during a surgeon’s learning curve may not be satisfactory.[6] Moreover, Nagakawa et al. [7] have advocated that more than 30 cases are required for LPD to become stable.

Minimally invasive surgery has become the prevailing trend, prompting surgeons in many centers to attempt LPD. Various papers sharing experiences for achieving stable surgery continue to be published to aid in the procedure [8,9] Furthermore, in Korea, there is a research society where individuals interested in minimally invasive pancreas surgery gather to share their experiences and insights (Korean Study Group on Minimally invasive Pancreatic Surgery, http://kmips.or.kr/). This article also introduced retraction techniques for stable LPD and presented the outcomes.

An essential aspect of LPD is appropriate case selection. For instance, if the cancer is located close to a major blood vessel or if securing space is challenging due to previous surgical adhesions, the likelihood of conversion to open surgery increases. Therefore, the international expert consensus at the first Summit on Minimally Invasive Pancreatico-Biliary-Surgery recommended careful case selection [10].

Our retraction techniques may not always be advantageous. Additional traction processes can extend the operation time and pose a risk of iatrogenic injury to organs or vessels. Nevertheless, even in smaller hospitals with limited manpower, initiating LPD can be facilitated by the methods we have introduced. Additionally, utilizing Penrose or rubber bands with appropriate tension can help minimize the iatrogenic unnecessary damage.

While more experience is still needed, the various retraction methods are expected to be helpful when performing LPD in hospitals with limited manpower, such as small or medium-sized hospitals.

In high-volume centers with a skilled surgical team, LPD is considered the preferred choice. Nevertheless, our study demonstrates that various innovative skills and ideas can serve as effective alternatives to having an experienced surgical assistant. Our research shows that, with the application of external retraction techniques, 29 cases of pure and safe LPD were successfully performed, with only one case requiring open conversion. These external retraction methods proved beneficial in overcoming hurdles related to insufficient manpower.

Ethical statements

This study was approved by the Institutional Review Board of CHA Bundang Medical Center, CHA University in Seongnam, Korea (No. 2023-02-026), and was conducted according to the ethical standards of each institutional committee on human experimentation, the Declaration of Helsinki. The need for patient consent was waived because anonymized data was collected and analyzed.

Author contributions:

Conceptualization, Methodology: KHK, SJY

Data curation: all authors

Investigation: KHK, EHC, SJY

Writing–original draft: All authros

Writing–review & editing: All authros

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Data availability

The data presented in this study are available on request from the corresponding author.

Supplementary materials

Supplementary materials can be found via https://doi.org/10.7602/jmis.2024.27.2.118.