Operative Techniques in

General Surgery

Preface

t is a rare opportunity to thank someone in a “virtual” from the endeavor. Indeed, with each volume pub-
I world that harbors some 1,000 witnesses. So it is that I
want to publicly thank my co-editor, my mentor, my
lished (20, to date), he has informed me each time that,
“I really learned a lot from this issue. This is good
colleague, and my close friend, Jonathan A. van Heerden, stuff!” He is indeed a life long learner. He has never lost
in front of all of you, our readers of this journal Jon holds his desire to improve. JvH carries enough “swagger” to
so dear. Many of you realize that on December 31, 2003, be confident, but he harbors the insight to understand
the real editor of Operative Techniques in General Surgery that being a surgeon is a humbling profession. As he so
retired from active clinical practice. After more than 32 often says, “Surgery is a fickle mistress!”
years as a staff consultant at the Mayo Clinic in Rochester, While Jon is far from perfect, his meticulous care of
Minnesota, “JvH” leaves an extraordinary legacy of surgi- patients is legendary at Mayo. Whether personally calling
cal excellence: the blood lab to find out the serum calcium level on one of
● 28,000 operations performed as the leader of a larger his postop parathyroid patients (n ⫽ 2738), or re-check-
surgical team. ing the quality of ␣-blockade in a patient with an adrenal
● 350 residents trained in the nuances of General Sur- tumor (n ⫽ 431), or staying home (in lieu of presenting at
gery. a national meeting!) to be with a patient with a pulmo-
● 32 years of medical students learning shoulder-to- nary embolism following a distal pancreatectomy, Jon
shoulder with a master. kept the needs of the patient first and foremost in mind.
● 500 peer-reviewed publications that stimulated the Although he is an extraordinarily complex and talented
betterment of patient care. individual, he boils down simply to a very select set of
● 300 succinct, logical, and educational presentations. core traits: work hard, play hard, be fair, love your neigh-
I find it a bit ironic to be thanking Jon in this highly bor. I wish it was everyone’s mantra.
technical volume of Operative Techniques in General As we look to the future of surgery, our species will
Surgery—the “old guy” hasn’t performed a single lapa- need to replace men like Jon van Heerden, Keith Kelly,
roscopic procedure described herewith! Not one! The Norman Thompson, and John Farndon; women like
irony fades, however, when you see him up close and Anna Ledgerwood, Monica Morrow, and Mary McGrath.
personal as I do on a daily basis. Dr. van Heerden pores Surgery will become ever more competitive, more “mini-
over each manuscript, making grammatical, punctua- mally-invasive,” more financially challenged, and ever
tion, and spelling changes that someone else could, and more based on evidence. We will collectively need to be
should, easily do. He alters the order of drawings to life long learners. Although I am saddened by the depar-
bring across a more logical presentation of the proce- ture of my esteemed and trusted colleague, reading this
dure described. JvH queries not only the author or issue of Operative Techniques in General Surgery is uplift-
guest editor, but even the artist, when the words or ing. The future of surgery is now, and it rests in the
illustrations fail to meet his lofty standards. He hands capable hands of the Nat Sopers, Demetrius Litwins, and
me an ink-covered draft on Monday mornings that Kevin Conlons. . .the Michel Gagners, Nancy Perriers
attest to his off-hours indulgence in perfecting our and Mike Sarrs. . .
product. And, most importantly, he absorbs and learns It has been a pleasure to work together with Jon for the
last decade— operating and caring for patients, training res-
idents and students, and, especially, developing this fledg-
© 2004 Elsevier Inc. All rights reserved.
1524-153X/04/0601-0001$30.00/0 ling journal into a platform for advancements in our field.
doi:10.1053/j.optechgensurg.2004.01.009 Thank you! I wish Jon the greatest of joys in retirement, but

Operative Techniques in General Surgery, Vol 6, No 1 (March), 2004: pp 1-2 1

2 David R. Farley

will expect his ongoing best effort over the last four this knowledge in the manner of Jonathan A. van Heer-
issues. Life long learning does not stop at retirement! den—for the betterment of patients. “This is good
You (JvH)have so much else left to learn and do! So do stuff!”
the rest of us! Devour this excellent treatise on laparo-
scopic procedures provided by Nat Soper and his col- David R. Farley, MD
lection of minimally invasive gurus. May all of us use Editor

“I prefer to be remembered for what I have done

for others not for what others have done for me.”
Thomas Jefferson
Introduction

Nathaniel J. Soper, MD, FACS

Guest Editor

his volume of Operative Techniques in General Surgery tric resection, which is slowly assuming greater impor-
T is devoted to articles dealing with laparoscopic sur-
gery of the upper abdomen. Authors recognized interna-
tance in the management of patients with benign and
malignant diseases of the stomach. Dr. Poulin discusses
tionally as experts in the field share with the readership issues relevant to laparoscopic splenectomy, including
their approach to the laparoscopic management of vari- technical tips and the potential applications of hand-as-
ous disease entities and conditions. The articles are well sisted surgery.
researched and beautifully illustrated, especially in re- Two articles deal with a relatively underutilized area of
gards to the technical aspects of the operations them- laparoscopic surgery: surgery of the pancreas. Laparo-
selves. scopic pancreatic surgery is still considered to be a tour de
Two of the articles in this volume deal with laparo- force by many surgeons, and only small series of these
scopic approaches to patients with intra-abdominal ma- procedures have been reported in the literature. Dr.
lignancy. Dr. Conlon discusses the issues involved in, and
Litwin describes various techniques for performing drain-
the technique for, laparoscopic staging of upper abdomi-
age of pancreatic pseudocysts. Dr. Strasberg discusses the
nal cancer. If the patient is found to have a neoplasm not
indications for laparoscopic distal pancreatectomy and
amenable to surgical resection, Dr. Eubanks describes
illustrates his operative technique.
laparoscopic methods for performing palliative bypass
procedures. Both laparoscopic staging and laparoscopic It has been my pleasure to organize this mini-sympo-
palliation have the potential to limit the morbidity and sium of the current status of laparoscopic surgery. The
minimize time in hospital for those patients with unre- editors-in-chief streamlined the process for me, and the
sectable cancers. artist for the series is a master at communicating the
The algorithm for treating esophageal achalasia has abstract thoughts of surgeons into clear reproductions of
changed markedly over the past few years, largely as a the anatomy. Finally, I must publicly acknowledge my
result of the success of laparoscopic Heller myotomy, debt of gratitude to the authors who kindly agreed to
which Dr. Patti describes and illustrates. Dr. Brunt covers participate and share their extensive knowledge with the
the topic of laparoscopic, and laparoscopic-assisted gas- readers. I know well that it is often easy to agree to con-
tribute a scholarly article, but a different matter entirely to
do it well and in a timely fashion.
© 2004 Elsevier Inc. All rights reserved.
1524-153X/04/0601-0002$30.00/0
Nathaniel J. Soper, MD, FACS
doi:10.1053/j.optechgensurg.2004.01.001 Guest Editor

Operative Techniques in General Surgery, Vol 6, No 1 (March), 2004: p 3 3

Staging of Intra-Abdominal Malignancy
Kevin C. Conlon, MD, FACS, and Sean M. Johnston, MD, FRCSI (gen)

n current clinical practice, management strategies for 1. Multiple previous upper abdominal operations
I intra-abdominal malignancies have become increas-
ingly sophisticated. As a result, it is critically important
2. Ongoing intra-abdominal sepsis
3. Pregnancy
that disease staging be accurate and effective. Despite the The following equipment is considered necessary for
many preoperative radiological staging modalities avail- laparoscopic staging:
able such as computerized tomographic scanning (CT), 1. 30 degree angled laparoscope either 10 mm or 5 mm
magnetic resonance imaging (MRI), and positron emis- in diameter
sion tomography (PET), there often exists a small but 2. 5 mm laparoscopic instruments including
significant margin of error between preoperative diagno- a. Maryland dissector
sis and surgical findings at laparotomy. Since the mid- b. Blunt tip dissecting forceps
1990s a significant amount of data has been produced to c. Cup-Biopsy forceps
suggest, that the use of laparoscopy and laparoscopic ul- d. Atraumatic grasping forceps
trasound in the staging of intra-abdominal malignancies e. Liver retractor
has the ability to reduce this margin of error and have a f. Scissors
positive impact on overall management.1-4 3. 5 mm or 10 mm suction device
The aim of laparoscopic staging is to mimic open ex- 4. A laparoscopic ultrasound probe is optional (see
ploration while avoiding unnecessary intervention, and below)
allowing for quicker administration of adjuvant therapies
if required. Laparoscopic staging should be viewed as OPERATIVE TECHNIQUE
complementary and not as a replacement for other mo- In general, for intra-abdominal staging the patient is po-
dalities such as CT and MRI. With respect to intra-ab- sitioned supine on the operating table. A warming blanket
dominal malignancies, such as gastric, pancreaticobiliary is placed underneath the patient who is secured appropri-
and hepatic, recent data has suggested a continued role ately to the table with pressure points appropriately pad-
for laparoscopic staging in the assessment of patients with ded.
these diseases. Laparoscopy is performed under general anesthesia us-
Laparoscopy and laparoscopic ultrasound is now com- ing a multiport technique. An open technique for place-
monly utilized in these malignancies to assess: ment of the initial trocar usually in the infra-umbilical
1. Resectability area is preferred. However, for patients with a history of a
2. Staging of locally advanced disease before chemora- prior laparotomy an open cut-down in either the right or
diation left upper quadrant may be performed. This is particu-
3. Diagnosis and histological conformation of radio- larly useful in patients with hepatic disease who have had
logically suspected metastatic disease a prior open colectomy. A Verres needle can also be used
As with laparoscopy for benign disease there are few to obtain initial pneumoperitoneum. If using such a tech-
absolute contra-indications for the procedure apart from nique in patients with a history of prior abdominal sur-
the patient who is deemed unfit for general anesthesia or gery, care is required to avoid visceral injury. In these
has an ongoing bleeding diathesis. The main relative con- cases in particular, it is our preference to use an open
traindications to laparoscopic staging for upper gastroin- technique allowing the peritoneum to be opened under
testinal malignancy include: direct vision. A blunt port is inserted and secured in place
with two stay sutures. Pneumoperitoneum is achieved
with CO2 gas. Initial insufflation should be at low flow
From the Department of Surgery, The Adelaide and Meath Hospital, Incorpo- rates until peritoneal entry is confirmed. An intraperito-
rating the National Children’s Hospital, Dublin; and the University of Dublin
Trinity College Dublin, Dublin, Ireland.
neal pressure of 10 to 12 mmHg is considered optimal for
Address reprint requests to Kevin C. Conlon, MD, FACS, Chair of Surgery, the examination. Occasionally in elderly patients a lower
Professorial Surgical Unit, The Adelaide and Meath Hospital, Tallaght, Dublin 24 maximum pressure will be set. A 30° telescope is inserted
Ireland. and an initial examination of the peritoneal cavity per-
© 2004 Elsevier Inc. All rights reserved.
1524-153X/04/0601-0003$30.00/0 formed. Additional trocars are then inserted. The size and
doi:10.1053/j.optechgensurg.2004.01.002 actual position of these trocars is determined by the site of

4 Operative Techniques in General Surgery, Vol 6, No 1 (March), 2004: pp 4-12

Staging of Intra-Abdominal Malignancy 5
left upper quadrant allowing for assessment of the liga-
ment of Treitz, proximal jejunum, and transverse meso-
colon as demonstrated in Fig 5.
Following examination of the mesenteric root and the
ligament of Treitz, the patient is returned to the supine
position. For patients with gastric or pancreatic lesions,
attention is turned to the gastro-hepatic omentum. The
left lateral segment of the liver is elevated by use of a
retractor inserted through the left upper quadrant port.
Operating instruments are inserted via the right upper
quadrant ports and the gastro-hepatic omentum is incised
allowing entry into the lesser sac (Fig 6). If present, an
aberrant left hepatic artery should be identified and pre-
served. The caudate lobe of the liver is clearly seen; fur-
ther posteriorly lies the inferior vena cava. The neck and
body of the pancreas and posterior gastric wall can also be
inspected. Often adhesions between the stomach and
pancreas require division to facilitate this part of the ex-
amination. By elevating the stomach the “gastric pillar”
can clearly be appreciated as shown in Fig 6. This pillar
contains the left gastric artery and vein. By following this

1 Port position for Pancreatic and Gastric Cancer staging (10

mm subumbilical blunt camera port, 10 mm port in the right
upper quadrant placed laterally). This port is utilized for liver
retraction and for insertion of the laparoscopic ultrasound.
Additional, 5 mm ports are placed in the left upper quadrant
midclavicular line and in the right upper quadrant as demon-
strated.

the tumor and the initial examination findings. In gen-

eral, ports are placed along the planned open incision line
as shown in Figs 1 and 2.
After the initial visual examination, a detailed exami-
nation of the abdominal cavity is performed which mim-
ics that performed during open exploration. The princi-
ple of this examination is to identify and biopsy any overt
metastatic disease within the peritoneal cavity as shown
in Fig 3A,B.
Following initial inspection, the patient is tilted ap-
proximately 10° head up. Examination of the liver begins
with the anterior aspect of the left lateral segment (seg-
ments 2 and 3) as shown in Fig 4A,B.
Despite the absence of tactile sensation “indirect” pal-
pation of the liver surface can be achieved by using two
instruments as shown in Fig 4A. The blunt suction device
2 Port placement for staging Hepatic malignancy. Metastatic
colorectal disease to the liver is the commonest indication for
is particularly useful for compressing liver tissue. Small laparoscopic staging of liver tumors in the United States. As
metastases can be detected in this manner. these patients in general have had prior open surgery a right
On completion of the liver examination, the patient is subcostal cut down is the preferred means of access to the
placed in approximately 10° Trendelenberg position. The peritoneal cavity. Additional ports are inserted along the line of
omentum and transverse colon are elevated toward the incision as shown.
6 Conlon and Johnston

10-mm port. In general, we prefer to use the lateral port in

the right upper quadrant. This allows for excellent exam-
ination of the liver (Fig 8), hepatoduodenal ligament
(Figs 9 and 10), stomach and pancreas. To examine the
stomach, 500 mL of warmed saline is inserted into the
stomach. The resultant distention facilitates examination
of the anterior and posterior walls. The liver is examined
sequentially with particular attention paid to the areas not
seen on the standard laparoscopic examination. Suspi-
cious lesions can be biopsied either by fine needle aspira-
tion (FNA) or with a percutaneously inserted Tru-cut
needle. Duplex scanning is useful to enable identification
of vessels particularly in the hepato-duodenal ligament
and around the pancreas (Fig 10). The relationship of the
primary tumor to the surrounding vessels can be deter-
mined.

3 (A) Peritoneal metastases (blue arrow). Biopsy of suspi-

cious peritoneal lesion (blue arrow). (B) Note also ascitic fluid
present at hepatic flexure (red arrow).

structure down the celiac axis is appreciated and any

suspicious nodal tissue can be biopsied. The hepatic ar-
tery is also identified and followed to the hepato-duode-
nal ligament. Again, any suspicious nodal tissue can be
biopsied if required.
In the case of both gastric and pancreatic cancer it is
our practice to perform peritoneal lavage for cytologi-
cal analysis. In general, specimens are taken at the start
of the laparoscopic examination to avoid potential con-
tamination from tumor manipulation or dissection. Be-
tween 200 mL and 400 mL of saline is placed into the
peritoneal cavity. The abdomen is gently agitated be-
fore aspiration. In pancreatic cases samples are taken
from the right and left upper quadrants (Fig 7). An
additional sample is taken from the pelvis in patients 4 (A) Examination of the left lateral hepatic sector (segments
with gastric cancer as this has been shown to increase 2 and 3). (B) Examination of inferior aspect of the right hepatic
the diagnostic yield. lobe. GB ⫽ gallbladder, HDL ⫽ hepatoduodenal ligament,
If available, laparoscopic ultrasonography (LUS) can TC ⫽ Transverse colon. A metastastic lesion can be seen lateral
be performed at this stage. The probe can be inserted via a to the hepatoduodenal ligament.
Staging of Intra-Abdominal Malignancy 7

5 The transverse colon has been elevated caudally revealing the mesenteric root and ligament of Trietz.

6 Examination of the lesser sac.

8 Conlon and Johnston

7 Sites for aspiration cytology (pancreas 1, 2, gastric 1, 2, 3).

8 Laparoscopic ultrasound of the

Liver. A 10 mm linear array laparo-
scopic ultrasound probe is placed
over the surface of the live in similar
fashion to the initial palpation de-
scribed in Fig 4A,B.
Staging of Intra-Abdominal Malignancy 9

9 LUS assessment of hepato-duo-

denal ligament and pancreas.

10 LUS image (reversed image) of the

hepatoduodenal ligament showing a dis-
tended common bile duct (red arrow),
cystic duct (blue arrow), portal vein (yel-
low arrow) and abnormal right hepatic ar-
tery (purple arrow).
10 Conlon and Johnston

RESULTS the diaphragm were not visualized by LUS. In common

with other published reports, EUS in this study remained
No randomized control trials exist to assess the utility of the best modality for identifying early tumors compared
laparoscopic staging for gastrointestinal malignancy. How- with CT or LUS (64%, 38%, and 57%).
ever, recent published data can be used to suggest possible The identification of occult nodal disease remains
benefits and define the limitation for the modality. problematic. CT has a reported accuracy of 25% to 70%.
With respect to EUS Wakelin and co-workers report an
Gastric Cancer overall accuracy rate of EUS in nodal staging for proximal
or EG junction tumors of 72%. If nontraversable tumors
Traditionally, the majority of patients with gastric cancer are excluded this increases by approximately 10%. Simi-
underwent some form of operative procedure. However, lar results have been reported for LUS with accuracy rates
recent experience has suggested that those patients with of 60% to 90% reported. LUS can also direct biopsy of
metastatic disease at presentation do not require a gas- suspicious nodes, which improves the utility of the mo-
trectomy for palliation. Laparoscopic staging can identify dality.
patients with subradiological disease allowing them to
avoid laparotomy and proceed to systemic therapies.
The issue of subradiological disease has been addressed
Pancreatic Cancer
by a number of authors.5-7 Gross and co-workers, re- Patients with pancreatic cancer have potentially the most
ported that laparoscopy identified metastatic disease in to benefit from accurate staging. As with gastric cancer
57% of patients that had a prelaparoscopic staging status the notion that all patients require an operative procedure
of M0. In an early study, Possik noted in a series of 360 for palliation no longer is true. Our understanding of the
patients who underwent laparoscopic staging an accuracy natural history of the disease coupled with improvement
of 89% and 96%, respectively, for the detection of perito- in endoscopic and laparoscopic palliative techniques
neal and hepatic metastases. More recently Stell8 and oth- means that effective palliation does not require an open
ers reported a prospective study evaluating the efficacy of operation. Proponents of laparoscopic staging suggest
laparoscopy, US, and CT in the staging of gastric cancer. that in combination with contrast-enhanced CT and/or
Laparoscopy had an accuracy rate of 99% for the detec- MRI laparoscopic staging can prevent needless open sur-
tion of hepatic metastases compared with 76% and 79% gery for those who would not benefit while not preclud-
for CT and US, respectively. The sensitivity for laparos- ing resection for appropriate candidates.
copy was 96% versus 37% and 53% for US and CT. With An early report from the Memorial Sloan-Kettering
regard to the diagnosis of peritoneal metastases, the accu- Cancer Center experience with laparoscopic staging of
racy rate was 94% for laparoscopy, 84% for US and 81% peri-pancreatic malignancy cited an improvement in re-
for CT. D’Ugo and co-workers prospectively assessed the sectability from 50% based on CT scanning alone, to over
diagnostic accuracy of laparoscopy compared with CT 90% when staging laparoscopy was added.12 While recent
and US in 100 patients. Laparoscopy demonstrated 21 improvements in CT technique, better patient selection
unsuspected metastases (21%) in 100 patients with M0 and refinements in surgical technique have reduced the
disease. Laparoscopy demonstrated 100% accuracy for M benefit somewhat, the added value of laparoscopic stag-
staging with an over all TMN staging accuracy of 72% ing remains between 15% to 20% for patients with adeno-
compared with 38% for US/CT.9 A recent study by Leh- carcinoma of the pancreas. The utility of laparoscopic
nert10 and colleagues looked at 120 consecutive patients ultrasound remains unclear. Early work suggested that
with gastric cancer. There were 15 patients who under- combined with multiport laparoscopic staging the added
went laparoscopy because of an inconclusive preopera- value was less than 10%. However, Vollemer and co-
tive diagnosis regarding liver metastases, peritoneal workers have recently reported an improvement in resec-
metastases, or local infiltration. In 6/15 patients uncon- tion rates using LUS (84% with lap staging vs. 58% with-
firmed liver or peritoneal metastases were identified and out).13 Further data are required before the true utility of
laparotomy prevented. this modality is understood.
Walkelin and co-workers11 examined 36 patients with With respect to other pancreatic tumors such as neu-
adenocarcinoma of the proximal stomach or esophageal roendocrine tumors, intraductal papillary mucinous neo-
junction who were considered to have potentially resect- plasm, and cystadenocarcinoma, the data are sparse for
able localized disease. Preoperative evaluation included laparoscopic staging. Hockwald14 and co-workers exam-
contrast-enhanced CT, EUS, and laparoscopy with LUS. ined a group of patients with islet cell tumors and found a
Locally advanced (T3/T4) tumors were accurately identi- high incidence of occult metastases at laparoscopy. CT
fied by CT in 94% of cases while EUS and LUS accurately followed by laparoscopy was significantly more sensitive
identified tumor in 88% and 83%, respectively, in those than CT alone in predicting resectability (93% vs. 50%).
tumors that could be traversed by the endoscope (14/16) CT failed in particular to identify low volume hepatic
and were below the diaphragm (10/12). Tumors above disease. The predictive value for resectability was also
Staging of Intra-Abdominal Malignancy 11
much higher for CT in combination with laparoscopy CT. The added yield of LUS was approximately 10% over
than for CT alone (95% vs. 74%). CT in detecting hepatic lesions. In a heterogenous patient
Patients with distal bile duct tumors also appear to population with malignant liver disease from the United
benefit from laparoscopic staging both in terms of deter- Kingdom, Hartley and co-workers demonstrated that LUS
mining respectability and avoiding unnecessary sur- was equivalent to MRI in determining resectability.22
gery.15 In contrast those patients with known duodenal Vascular involvement or extensive biliary involvement
or ampullary tumors gain little added value from laparos- despite the use of LUS, however, proved difficult to eval-
copy as the incidence of occult disease is low and overall uate. This benefit was more apparent in primary hepatic
resectability rates high. tumors compared with metastatic tumors.

Hepatic Disease SUMMARY

Regarding the issue of colorectal metastases to the liver, Laparoscopy is no longer a tool of limited use and now has
Rahusan16 studied the role of LUS in patients who were widespread indications within surgical oncological prac-
considered by preoperative imaging studies to have re- tice. It now has proven benefit in the detection and stag-
sectable disease. Laparoscopy determined that 13% of ing of gastrointestinal malignancies, saving a small but
patients had previously occult disease that precluded re- significant number of patients with unresectable disease
section. The added value of LUS in this study was 12%. from unnecessary laparotomy. In selected patients com-
The addition of LUS to the staging armamentarium ap- bined with state of the art radiological modalities, it ap-
peared to increase resectability rates from 46% to 71% pears safe and cost-efficient.
thus sparing approximately one-third of patients an un-
necessary open procedure. Similar results were reported
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Overall, laparoscopy predicted unresectablity in 68% of Eur J Radiol 41:161-167, 2002
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12 Conlon and Johnston

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Palliative Bypass Procedures
Sandhya Lagoo-Deenadayalan, MD, PhD, and W. Steve Eubanks, MD

uring the past decade, there has been an increasing scopic biliary bypass procedures show no difference in
D trend towards minimally invasive procedures in the
palliation of inoperable cancer. Progress in advanced
morbidity and length of hospital stay. This may be be-
cause of the fact that laparoscopic procedures are associ-
laparoscopic procedures has made laparoscopic bypass ated with a decreased incidence of postoperative ileus and
procedures feasible and safe. Laparoscopic procedures an earlier return to work. Initial hospital days may be
have the advantage of decreased postoperative pain, de- longer in the surgical group, but overall hospital days are
creased need for postoperative analgesics, earlier return similar in both groups when one takes into consideration
to routine activities, and improved cosmesis. These pro- re-admissions for stent placement and delayed complica-
cedures are indicated in patients with nonresectable am- tions of stent placement. While stenting is the only option
pullary carcinoma, cholangiocarcinoma, pancreatic can- in patients who are a very high operative risk, surgical
cer, or with metastases causing extrinsic compression of bypass is the procedure of choice in otherwise healthy
extrahepatic bile ducts. patients with a life expectancy of greater than 4 months.
Surgical biliary bypass is also the procedure of choice in
BILIARY BYPASS PROCEDURES patients who are symptomatic from duodenal obstruction
or in those in whom this is anticipated.
Indications
The incidence of pancreatic cancer is increasing and Selection of Candidates and Workup
fewer than 20% of pancreatic cancers are resectable for Patients with proven inoperable pancreatic cancer are
cure. The remaining 80% of patients are plagued by symp- candidates for biliary bypass. Preoperative evaluation re-
toms of pain, jaundice, itching, and occasionally vomiting quires liver function tests, the use of computerized
because of duodenal obstruction. Jaundice and itching tomography (CT) of the abdomen, ultrasound for evi-
can be alleviated by biliary drainage. Nonoperative pro- dence of gallstones, and endoscopic cholangiopancreato-
cedures include radiological or endoscopic stent place- gram (ERCP) or magnetic resonance cholangiopancre-
ment. While advances in endoscopic technology, includ- atography (MRCP). The introduction of dynamic spiral
ing the expanding wall stents, have yielded excellent CT has led to easier identification of patients with
results, problems of bacterial biofilm resulting in in- nonresectable disease. Patients with a previous cholecys-
creased episodes of infection and resulting cholangitis are tectomy, tumor involvement of the hepatocystic duct
worrisome. Additionally, stent obstruction secondary to junction, or hilar obstruction are not eligible for chole-
deposition of calcium bilirubinate continues to be prob- cystojejunostomy. Preoperative ERCP helps estimate the
lematic. potential role of laparoscopic cholecystojejunostomy for
Biliary bypass procedures add to the quality of life of palliation of patients with malignant obstructive jaun-
the patient and increase survival time by 2 to 5 months. dice. The presence of gallbladder or cystic duct filling is
Resolution of symptoms is critical in affecting quality of critical. Only those patients with patent hepatocystic
life, as patients can remain free of jaundice and pruritus, junctions and having biliary obstruction more than 1 cm
until the time of death. This is in contrast to episodes of from the cyst duct takeoff are candidates for laparoscopic
recurrent jaundice and repeated cholangitis associated cholecystoenterostomy.
with clogged stents or stents encroached upon by tumor. Biliary bypass procedures include cholecystojejunos-
Laparoscopic cholecystojejunostomy was first de- tomy and choledochojejunostomy. Cholecystojejunos-
scribed in 1992. Studies comparing stenting with laparo- tomy is technically feasible and yields good results. Cho-
ledochojejunostomy is technically more challenging than
cholecystojejunostomy and requires considerable laparo-
From the Department of Surgery, Duke University Medical Center, Durham,
NC. scopic skill.
Address reprint requests to: Sandhya Lagoo-Deenadayalan, MD, PhD, Rm
3454, Box 3110, Duke University North, Duke University Medical Center,
Durham, NC 27710. Preoperative Care
© 2004 Elsevier Inc. All rights reserved.
1524-153X/04/0601-0004$30.00/0 The patient is adequately hydrated and given preopera-
doi:10.1053/j.optechgensurg.2004.01.003 tive antibiotics. Prophylactic measures are taken to pre-

Operative Techniques in General Surgery, Vol 6, No 1 (March), 2004: pp 13-22 13

14 Lagoo-Deenadayalan and Eubanks

vent deep vein thrombosis. A nasogastric tube and a uri- be encountered in a normal caliber duct. The technical
nary catheter are inserted. Maintenance of adequate fluid demands of this procedure are such that very few sur-
status and monitoring of urine output are critical to pro- geons perceive that the benefits of a laparoscopic ap-
tect against renal failure, which is common in these pa- proach outweight the risks of potential leak or the nega-
tients following operative intervention. tive aspects of a longer and more tedious operation.
Port placement is similar to that described for a laparo-
SURGICAL TECHNIQUE scopic cholecystojejunostomy (see Fig 1A).
The proximal aspect of the divided jejunum is then
Choledochojejunostomy attached to the distal limb of the jejunum in a Roux-en-Y,
Laparoscopic choledochojejunostomy is a rarely per- side-to-side fashion and the anastomosis is created with a
formed procedure. Access to the common bile duct is single deployment of the endoscopic stapling device (see
patients with biliary obstruction from pancreatic cancer Fig 2B). The remaining enterotomy is closed with inter-
can be quite difficult. One fortunate sequelae of this sad rupted or continuous sutures. Each anastomosis is care-
situation is that the bile duct is usually quite dilated and, fully examined to ensure that there is no evidence of
therefore, easier to use for a bypass procedure than would leakage and that secure hemostasis has been achieved.
 Cholecystojejunostomy

1 (A) Port placement for laparoscopic

biliary and gastric bypass procedures.
The umbilical port is inserted using the
Hasson technique. After establishing a
pneumoperitoneum with carbon diox-
ide, a 5-mm port is inserted in the mid-
line in the subxyphoid region. A 5-mm
port is inserted in the right subcostal re-
gion in the anterior axillary line and a
12-mm port is placed in the right mid-
abdomen near the anterior axillary line.
An optional fifth port (usually 5 mm)
may be placed in the left subcostal region
if additional retraction is required. A
360-degree evaluation of the abdomen is
carried out. If evidence of tumor exten-
sion beyond the pancreatic head or into
the duodenum is detected, a gastrojeju-
nostomy may be added to the planned
cholecystojejunostomy. (B) Approxima-
tion of a loop of jejunum to the fundus
of the gallbladder. The ligament of Treitz
is identified and a loop of small bowel
with sufficiently long mesentery is
brought in an antecolic fashion to the
fundus of the gallbladder. It is critical
that both the fundus of the gallbladder
and the loop of jejunum are secured to
the gallbladder with one or two stay su-
tures. Using scissors and cautery, and en-
terotomy is created on the anti-mesen-
teric surface of the jejunum. An opening
is made on the fundus of the gallbladder
in a similar fashion. Stabilization of the
fundus of the gallbladder and the jeju-
num with nontraumatic graspers may be
required.
16 Lagoo-Deenadayalan and Eubanks

1 (C) Insertion of the endo-

scopic stapler into the lumen of
the jejunum and gallbladder. The
endoscopic stapler is then inserted
into the abdominal cavity through
the 12-mm port. One limb of the
stapler is inserted into the gallblad-
der and the other end into the jeju-
num. After closing the stapler, the
site is inspected to verify correct
positioning and to rule out inclu-
sion of adjacent structures. The
stapler is then deployed. Upon re-
moval of the stapler, the anastomo-
sis is inspected for hemostasis and
to verify an intact anastomosis. (D)
Closure of the enterotomy with a
stapler. The two ends of the enter-
otomy are grasped and the enterot-
omy closed transversely with a sta-
pler. Alternatively, the enterotomy
may be closed with a hand-sewn
technique.
Palliative Bypass Procedures 17

2 (A) Exposure of the distal common bile duct. The performance of a minimally invasive choledochojejunostomy is accom-
plished by mobilizing the adventitial covering of the distal common bile duct. The anatomy is clearly identified.
18 Lagoo-Deenadayalan and Eubanks

2 (B) Mobilization of the distal limb of the divided small bowel and approximation with the common bile duct; sutured
choledochojejunostomy; stapled enteroenterostomy. Attention is then turned to the ligament of Treitz where the small bowel is run
distally for approximately 40 to 60 cm. A segment of small bowel is then selected for division by an endoscopic stapling device. The
mesentery is also divided so as to allow the distal limb of the divided small bowel to reach the common bile duct without tension.
This limb may be brought in an antecolic or retrocolic fashion and placed adjacent to the common bile duct. A tension-free
anastomosis is essential. An enterotomy is created in the distal limb of the jejunum along the staple line and a matching
choledochotomy is created. (C) Sutured anastomosis: choledochojejunostomy. The anastomosis is then performed with either
running or interrupted sutures. The basic principles of anastomotic creation must be retained despite the technical difficulties
associated with the laparoscopic performance of this procedure. The tissue must be viable and retain an adequate vascular supply,
and the anastomosis accomplished in a tension-free manner.
Palliative Bypass Procedures 19

Gastric Bypass debate as to the need for prophylactic gastrojejunostomy

in patients who have symptoms of only biliary obstruc-
Gastric bypass is indicated for duodenal obstruction sec-
tion.
ondary to disease process. Although Wolfer and Cour-
voisier had performed gastrojejunostomies in the early
Laparoscopic Gastrojejunostomy
1880s, the surgeon most commonly associated with the
procedure is Billroth, who in 1885 performed a gastric A nasogastric tube and a urinary catheter are placed after
resection for a pyloric tumor with subsequent side-to-side induction of general anesthesia. Decompressing the
gastrojejunostomy (Billroth II). The Billroth I procedure stomach and urinary bladder minimize the chance of in-
consists of an end-to-end anastomosis of the stomach to jury to these organs during port placement. A 10-mm port
the duodenum following distal gastric resection. Anasto- is placed at the umbilicus using the open Hassan method.
mosis can be performed using stapling devices or can be The abdominal cavity is insufflated with CO2 to obtain a
hand-sewn. Stapling techniques use an endoscopic linear peritoneal pressure of 15 mm Hg. A 30-degree laparo-
cutting stapler or a circular stapler. Suturing techniques scope is introduced through the umbilical port and a
require laparoscopic skills with suturing and intracorpo- 360-degree evaluation of the abdominal cavity is per-
real knot tying. formed. This allows recognition and biopsy of peritoneal
implants and hepatic metastases not detected by preoper-
ative imaging studies. The decision is then made regard-
Indications for Gastrojejunostomy ing resectability of the disease. If only palliative interven-
This procedure is indicated in patients with symptoms tion is indicated, the remaining ports are inserted under
secondary to compression of the duodenum causing gas- direct vision. These include 12-mm and 5-mm ports be-
tric outlet obstruction. Diseases include advanced gastric, ing placed in the right subcostal region. The ports are at
duodenal, ampullary, and pancreatic cancers. While least 5 cm apart and equidistant from the anticipated area
symptoms of duodenal obstruction such as vomiting and of gastrojejunostomy. Another 5-mm port is placed in the
nausea are treated with gastrojejunostomy, there remains left subcostal region if needed (see Fig 1A).
20 Lagoo-Deenadayalan and Eubanks

3 (A) Anchoring sutures through the gastric and jejunal walls. An upper jejunal loop is identified approximately 40 to 60 cm
distal to the ligament of Treitz. After ascertaining that the segment can reach the anterior surface of the stomach without tension and
without twisting of the mesentery, it is held against the gastric wall in an isoperistaltic fashion. Straight (Keith) needles are passed
through the abdominal wall and through seromuscular layers of the stomach and jejunum and then again out through the
abdominal wall. Another suture is passed in a similar fashion at least 6 to 8 cm from the first suture on the gastric and jejunal wall.
This allows for an adequate gastrojejunostomy at the site of the stay sutures. The sutures are retracted upward so as to allow easy
access to the site of the gastrojejunostomy.
Palliative Bypass Procedures 21

3 (B) Stapled gastrojejunal

anastomosis. The gastrotomy and
jejunotomy are made using electro-
cautery and the tip of the endos-
hears. The endoscopic stapler is
then inserted through the 12-mm
port. The 30-mm stapler is used;
the broader limb is threaded
through the gastrotomy while the
narrower limb is inserted through
the jejunotomy. The stapler is de-
ployed. Two or three cartridges are
sequentially used to obtain a 60 to
90 mm length of gastrojejunal
anastomosis. (C) Closure of enter-
otomy with sutures. After inspect-
ing the anastomosis for hemostasis,
the enterotomy is closed with su-
tures. We use 2-0 Surgidac or an
Endostitch device to close the ente-
rotomy in either a running or inter-
rupted fashion.
22 Lagoo-Deenadayalan and Eubanks

POSTOPERATIVE CARE Studies performed in our laboratory, as well as those

performed in other institutions, have failed to demon-
Following cholecystojejunostomy or choledochojejunos-
strate a benefit of robotic assisted choledochojejunos-
tomy, a nasogastric tube is maintained overnight. Prophy-
tomy over laparoscopic hands-on approaches. It is antic-
lactic measures are taken to prevent deep vein thrombosis
ipated that future generations of surgical robots will make
or gastritis. The patient is started on clear liquids and the
this operation technically easier and feasible for a larger
diet advanced as tolerated. Length of stay is approxi-
number of surgeons.
mately 2 to 4 days. Following gastric bypass procedures,
the nasogastric tube is left in place longer to protect the
gastrojejunal anastomosis. It is removed after return of REFERENCES
bowel function. The patient is then started on a clear 1. Cuschieri A, Berci G: Laparoscopic Management of Pancreatic
liquid diet and advanced as tolerated. Similarly, prophy- Cancer. Laparoscopic Biliary Surgery. Oxford, Blackwell Scientific
lactic measures are instituted to protect against deep vein Publications, 1992, pp 170-182
thrombosis and stress ulcers. 2. Nordback IH, Cameron JL: Periampullary Cancer, in Cameron JL
(ed): Current Surgical Therapy, 4th ed. St. Louis, Mosby-Year
Book, Inc., 1992, pp 441-448
EXPECTED RESULTS 3. Wu JS, Centers DS, Eubanks WS: Open versus laparoscopic pal-
The main disadvantage of cholecystojejunostomy is the liative procedures for unresectable periampullary tumors. South
tendency to fail either early because of persistent jaundice Med J 87:S129, 1994
4. Tarnasky PR, England RE, Lail LM, et al: Cystic duct patency in
or late because of recurrent jaundice or cholangitis. Ap-
malignant obstructive jaundice. Ann Surg 221:265-271, 1995
proximately 25% of patients undergoing this procedure 5. Rhodes M, Nathanson L, Fielding G: Laparoscopic biliary and
experience failure to palliate the jaundice at some point gastric bypass: A useful adjunct in the treatment of carcinoma of
following the procedure. Laparoscopic gastrojejunos- the pancreas. Gut 36:778-780, 1995
tomy for palliation of unresectable disease can achieve 6. Schob OM, Schmid RA, Morimoto AK, et al: Laparoscopic
excellent results. Only 20% of patients with unresectable Roux-en-Y choledochojejunostomy. Am J Surg 173:312-319,
1997
pancreatic cancer develop duodenal obstruction in the 7. Casaccia M, Diviacco P, Molinello P, et al: Laparoscopic gastroje-
course of their illness. In these patients, gastric bypass junostomy in the palliation of pancreatic cancer: reflections on the
procedures can add significantly to the quality of life. preliminary results. Surg Laparosc Endosc 8:331-334, 1998
Studies indicate that there is no increase in morbidity and 8. Chekan EG, Clark L, Wu J, et al: Laparoscopic biliary and enteric
mortality in patients undergoing prophylactic gastrojeju- bypass. Semin Surg Oncol 16:313-320, 1999
9. Park A, Schwartz R, Tandan V, et al: Laparoscopic pancreatic
nostomy above the rate that is encountered with biliary
surgery. Am J Surg 177:158-163, 1999
bypass alone. 10. Othmar MS, Rothlin MA, Schlumpf R: Laparoscopic biliary by-
Robotic surgery holds the promise of facilitating pro- pass, in Zucker K (ed): Surgical Laparoscopy (2nd ed). Philadel-
cedures such as laparoscopic choledochojejunostomy. phia, Lippincott Williams & Wilkins, 2001, pp 201-209
Heller Myotomy
Maria V. Gorodner, MD, Carlos Galvani, MD, and Marco G. Patti, MD

uring the 1970s and 1980s, it was generally accepted malignancy. In addition, it is important to know if a pa-
D by the medical community that pneumatic dilation
was the primary form of treatment of esophageal achala-
tient has been previously treated with intrasphincteric
injection of botulinum toxin, as fibrosis may develop at
sia, so that surgery was relegated to a supporting role for the level of the gastroesophageal junction. The conse-
the failures of pneumatic dilation. As a consequence, even quent loss of anatomic planes makes the operation more
in tertiary care centers the experience was limited to one difficult and the results less predictable.
or two cases per year, mostly for patients who had dys- All patients who are candidates for a laparoscopic
phagia after multiple dilatations, or for those who suf- Heller myotomy should undergo the following preopera-
fered a perforation at the time of a dilation. The applica- tive evaluation.
tion of minimally invasive surgery to the treatment of
esophageal achalasia has delivered an unexpected change Barium Swallow
in the treatment algorithm of this disease, whereby today
In patients with achalasia it often shows distal esophageal
a laparoscopic Heller myotomy is considered by most
narrowing. It also provides important information about
gastroenterologists and surgeons the primary treatment
the diameter and shape (straight versus sigmoid) of the
modality, reserving pneumatic dilation to the few failures
esophagus.1
of this operation (Fig 1). This shift in practice is because
of the following factors1-11: (1) minimally invasive sur-
gery replicates the excellent results of open surgery with Endoscopy
relief of dysphagia in 85% to 95% of patients; (2) mini- It should be done in all patients to rule out a benign or
mally invasive surgery is associated with a shorter hospi- malignant stricture of the distal esophagus, as well as to
tal stay, minimal postoperative discomfort and a rapid identify any gastric and duodenal pathology.2
recovery time; and (3) it has become clear that the results
of the other forms of treatment for achalasia (botulinum Esophageal Manometry
toxin and pneumatic dilation) are clearly inferior to those
of surgery and may complicate subsequent operative ther- Esophageal peristalsis is always absent. The lower esoph-
apy. As a consequence, during the last decade we have ageal sphincter is hypertensive in about 50% of patients,
witnessed an increase in the number of patients referred
each year for operation, from one or two patients per year
in the 1970s and 1980s to 15 to 25 patients per year
during the last 5 years. In addition, about 70% of patients
we operate today have never been treated before.

PREOPERATIVE EVALUATION
Patients are questioned regarding the presence of dyspha-
gia, regurgitation, chest pain, and heartburn. Because
most patients with achalasia are able to maintain their
weight, a history of major weight loss in an elderly patient
(⬎60 years of age) who has been symptomatic for a short
period of time (⬍1 year) should raise the suspicion of a

From the Laparoscopic Surgery, University of California, San Francisco, San

Francisco, CA and Center for the Study of Gastrointestinal Motility and Secretion,
University of California, San Francisco, San Francisco, CA.
Address reprint requests to Marco G. Patti, MD, University of California, San
Francisco, 533 Parnassus Avenue, Room U-122, San Francisco, CA 94143-0788.
© 2004 Elsevier Inc. All rights reserved.
1524-153X/04/0601-0005$30.00/0 1 Treatment algorithm of esophageal achalasia before and
doi:10.1053/j.optechgensurg.2004.01.006 after the introduction of minimally invasive surgery.

Operative Techniques in General Surgery, Vol 6, No 1 (March), 2004: pp 23-28 23

24 Gorodner et al

and usually fails to relax appropriately in response to

swallowing.9

Ambulatory pH Monitoring
This test should be performed preoperatively in patients
who have undergone previous treatment to determine if
abnormal reflux is already present. In addition, it should
be repeated after the procedure even in asymptomatic
patients, as heartburn is present in only 40% of patients
who develop abnormal reflux postoperatively.9

Laparoscopic Heller Myotomy and

Dor Fundoplication

3 Placement of the trocars. Five trocars are used for the

operation. Trocar #1 is placed in the midline, 14 cm caudad to
the xiphoid process. It is used for the 30° scope. Trocar # 2 is
placed in the left mid clavicular line at the same level with the
camera. It is used for inserting a Babcock clamp and instru-
ments to divide the short gastric vessels. Trocar # 3 is placed in
the right mid clavicular line at the same level as the previous 2
trocars. It is used for the insertion of a retractor to lift the left
lateral segment of the liver and expose the gastroesophageal
junction. Trocars # 4 and #5 are placed under the right and left
costal margins, respectively, so that their axes form an angle of
about 120°. These ports are used for the dissecting and suturing
instruments. The electrocautery used to perform the myotomy
is inserted through trocar #5.

Dissection of the Lower Esophagus and

Gastroesophageal Junction
The operation is started at the level of the caudate lobe of
the liver by dividing the gastrohepatic ligament. The right
crus of the diaphragm is identified and separated from the
esophagus by blunt dissection. The peritoneum and phre-
2 Positioning of the patient on the operating room table. noesophageal membrane overlying the esophagus are
After induction of general anesthesia with a single lumen endo- transected. The left pillar of the crus is separated by blunt
tracheal tube, the patient is positioned supine on the operating dissection from the esophagus. The dissection is contin-
table over a beanbag, which is securely fixed to the table. The ued in the posterior mediastinum, lateral and anterior, to
lower part of the beanbag is used to create a saddle under the
expose 6 cm to 7 cm of the esophagus. Because an anterior
patient’s perineum to avoid sliding during the operation when a
fundoplication is performed after completion of the my-
steep reverse Trendelenburg position is used. The legs are ex-
tended on stirrups, with the knees flexed only 20° or 30°. otomy, no posterior dissection is necessary. During this
Compression stockings are routinely used. An orogastric tube early part of the dissection it is important to identify and
and a urinary catheter are inserted before the operation and are preserve the posterior and anterior vagal divisions. The
usually removed at the end of the procedure. The surgeon short gastric vessels are divided starting from a point
stands in between the patient’s legs, while the assistants stand midway along the greater curvature of the stomach, all the
on the right and left side of the table. way to the angle of His (Fig 4).
Heller Myotomy 25

4 Heller myotomy. The fat

pad is removed to expose the
gastroesophageal junction. A
Babcock clamp is then ap-
plied over the junction, and
traction is applied downward
and to the patient’s left to ex-
pose the right side of the
esophageal wall. The myot-
omy is performed using the
hook cautery in the 11
o’clock position. We do reach
the submucosal plane in one
point, usually about 3 cm
above the gastroesophageal
junction. Subsequently, the
myotomy is extended up-
ward for about 5 cm and
downward onto the gastric
wall for about 2 cm. Early in a
surgeon’s experience with
this procedure it is useful to
perform intraoperative en-
doscopy to identify the
squamo-columnar junction.
After 10 or 15 procedures it
becomes easier to identify the
transition between esopha-
geal and gastric musculature,
and endoscopy can be
avoided. If bleeding from the
cut muscle edges occurs, it is
important to avoid using the
cautery as it can cause dam-
age to the esophageal mucosa
with a delayed perforation.
Gentle pressure with a
sponge usually controls the
bleeding. In some patients
previously treated with in-
trasphincteric injection of
botulinum toxin, fibrosis can
develop at the level of the
gastroesophageal junction
with loss of the normal ana-
tomic planes. In these cir-
cumstances, creating the my-
otomy can be very difficult
and there is an increased risk
of a mucosal perforation. If a
perforation is suspected, wa-
ter is instilled into the upper
abdomen, and air is insuf-
flated through the orogastric
tube. Once the esophageal
perforation is identified, it
can be closed with fine (5-0)
absorbable sutures.
26 Gorodner et al

Dor Fundoplication vantage of keeping the edges of the myotomy separated

and avoiding recurrent dysphagia, an anterior fundopli-
A posterior 220° fundoplication can be used instead of a cation avoids the posterior dissection, it covers the ex-
Dor fundoplication to prevent gastroesophageal reflux.3 posed esophageal mucosa, and it has been shown to be an
While a posterior fundoplication has the theoretical ad- effective antireflux operation.

5 The Dor fundoplication is an an-

terior 180° fundoplication. It is con-
structed by using two rows of sutures.
The first row of sutures is on the left,
and comprises three stitches. The up-
permost stitch is triangular, and in-
corporates the gastric fundus, the left
side of the esophageal wall (avoiding
the anterior vagus nerve) and the left
pillar of the crus.

6 The second and the third

stitches incorporate the esophageal
and the gastric wall only.
Heller Myotomy 27

7 The stomach is then

folded over the exposed
mucosa so that the greater
curvature of the stomach
lies next to the right pillar
of the crus. The upper-
most stitch is triangular
and includes the gastric
fundus, the right side of
the esophageal wall and
the right pillar of the crus.

8 The second and the

third stitches are placed
between the greater curva-
ture of the stomach and
the right side of the esoph-
ageal wall. Finally, two or
three additional stitches
are placed between the
gastric fundus and the rim
of the esophageal hiatus
(without incorporating
the esophageal wall) to
take any tension away
from the right row of su-
tures.
28 Gorodner et al

Table 1. Laparoscopic Heller Myotomy and Dor Fundoplication REFERENCES

1. Patti MG, Pellegrini CA, Horgan S, et al: Minimally invasive sur-
Author (year) Patients, no. Excellent/Good Results, %
gery for achalasia. An 8 year experience with 168 patients. Ann
Jamieson (2001) 82 90 Surg 587:230, 1999
Finley (2001) 91 91 2. Moonka R, Patti MG, Feo CV, et al: Clinical presentation and
Zaninotto (2001) 142 98
Patti (2003) 124 94
evaluation of malignant pseudoachalasia. J Gastrointest Surg
Total 439 93 456:3, 1999
3. Champion JK, Delisle N, Hunt T: Laparoscopic esophagomyo-
tomy with posterior partial fundoplication for primary esophageal
motility disorders. Surg Endosc 746:14, 2000
4. Watson DI, Liu JF, Devitt PG, et al: Outcome of laparoscopic
anterior 180-degree partial fundoplication for gastroesophageal
POSTOPERATIVE COURSE reflux disease. J Gastrointest Surg 486:4, 2000
5. Zaninotto G, Costantini M, Molena D, et al: Treatment of esoph-
The orogastric tube is removed at the end of the proce- ageal achalasia with laparoscopic Helle myotomy and Dor partial
dure. A barium swallow is obtained only if a perforation is anterior fundoplication: Prospective evaluation of 100 consecu-
suspected. Patients are fed the morning of the first post- tive patients. J Gastrointest Surg 282:4, 2000
operative day and are instructed to avoid meat or bread 6. Ackroyd R, Watson DI, Devitt PG, et al: Laparoscopic cardiomyo-
tomy and anterior partial fundoplication for achalasia. Surg En-
for 2 weeks. About 70% of patients are discharged within dosc 683:15, 2001
23 hours, and 90% of patients are discharged within 48 7. Finley RJ, Clifton JC, Stewart KC, et al: Laparoscopic Heller my-
hours. Most patients resume their regular activity within otomy improves esophageal emptying and the symptoms of acha-
2 weeks. lasia. Arch Surg 892:136, 2001
8. Patti MG, Arcerito M, Feo CV, et al: An analysis of operations for
gastroesophageal reflux disease: Identifying the important techni-
OUTCOME EVALUATION cal elements. Arch Surg 600:133, 2001
9. Patti MG, Diener U, Molena D: Esophageal achalasia: Preoperative
Table 1 shows the results of the four largest series from assessment and postoperative follow-up. J Gastrointest Surg 11:5,
centers around the world where this technique is 2001
used.6,7,10,11 Overall, excellent or good results are consis- 10. Zaninotto G, Costantini M, Portale G, et al: Etiology, diagnosis
and treatment of failures after laparoscopic Heller myotomy for
tently obtained in more than 90% of patients, confirming
achalasia. Ann Surg 186:235, 2002
that a laparoscopic Heller myotomy should be considered 11. Patti MG, Fisichella PM, Perretta S, et al: Impact of minimally
today the primary form of treatment for esophageal acha- invasive surgery on the treatment of esophageal achalasia. A de-
lasia. cade of change. J Am Coll Surg 196:698, 2003
Laparoscopic Partial Gastrectomy
L. Michael Brunt, MD

aparoscopic gastric resection was first reported in section that can usually be performed laparoscopically.
L 1992 by Goh1 who performed a distal gastrectomy
with Billroth II reconstruction in a patient with a chronic
Patients with gastric outlet obstruction from benign
peptic stricture at the pylorus are appropriate for lapa-
gastric ulcer. The first laparoscopic gastrectomy for can- roscopic antrectomy. Vagotomy may also be performed
cer was performed by Azagra in 1993.2 Since then, lapa- laparoscopcially if indicated. A laparoscopic approach
roscopic techniques have been used in a variety of gastric is more challenging in the setting of emergent indica-
resection procedures and are being increasingly em- tions for complications of ulcer disease and is mainly
ployed in patients with benign gastric lesions and, in limited to peritoneal washout and omental patch clo-
some centers, in patients with early gastric cancer as well. sure of perforated duodenal ulcer.
The adaptation of gastric resection techniques has The most common benign gastric tumors for which
evolved slowly, however, for a number of reasons. These gastric resection is indicated are gastrointestinal stro-
include the lower frequency of indications for gastric sur- mal tumors (GIST) and carcinoid tumors. Other gastric
gery, the increased technical difficulty of performing gas- lesions that may require excision either for diagnosis or
tric resection and re-anastomosis laparoscopically, and treatment are leiomyomas, large polyps, and pancreatic
because of potential concerns in patients with gastric ma- rests which may mimic a neoplasm. Gastric stromal
lignancies. However, as the numbers of surgeons trained tumors are submucoal tumors that arise between the
in laparoscopic gastric bypass techniques for obesity in- muscularis propria and muscularis mucosa of the
creases, many of these limitations will be overcome. A stomach and appear to originate in the interstitial cells
variety of laparoscopic approaches to gastric resection of Cajal. These tumors most often come to attention
have been described including totally laparoscopic,3,4 because of underlying mucosal ulceration that leads to
laparoscopic-assisted,5,6 and combined laparoscopic and gastrointestinal bleeding but they may also be discov-
endoluminal procedures.7,8 ered incidentally during upper gastrointestinal (GI)
In this chapter, the conditions in which laparoscopic endoscopy or computed tomography (CT). The treat-
gastric resection may be considered will be reviewed and ment is local excision with negative margins that can,
the diagnostic evaluation of these patients will be dis- in most cases, be accomplished with a wedge resection.
cussed. The techniques for performing laparoscopic Bill- Most gastric stromal tumors are small and are appro-
roth I or II gastric resection and anastomosis and gastric priate for laparoscopic removal. Laparoscopic excision
wedge resections will be presented in detail. of tumors ⬎5 cm is controversial because of the in-
creased likelihood of malignancy and potential diffi-
INDICATIONS culty with tumor manipulation. GISTs that occur in the
distal antrum or prepyloric region often require antrec-
The potential indications for a laparoscopic approach
tomy for removal. Lesions at or near the gastroesoph-
to gastric resection are listed in Table 1. A laparoscopic
ageal junction are potentially more difficult to manage
approach should be considered as an option for any
but may be excised locally provided there is not lumi-
patient with benign disease that requires gastric resec-
tion. Benign peptic ulcer disease has become a much
less common indication for surgery over the last decade
because of improved medical and endoscopic therapy,
Table 1. Potential Indications for Laparoscopic Gastric
including treatment of Helicobacter pylori. Nonheal- Resection
ing gastric ulcer remains an indication for surgical re-
Peptic ulcer disease
Nonhealing gastric ulcer
Gastric outlet obstruction from pyloric or duodenal stricture
From the Department of Surgery and Institute for Minimally Invasive Surgery Benign gastric tumors
Washington University School of Medicine, St. Louis, MO. Gastric stromal tumors
Address reprint requests to L. Michael Brunt, MD, Department of Surgery, Gastric carcinoids
Washington University School of Medicine, 660 South Euclid Avenue, Campus Miscellaneous gastric lesions
-Pancreatic rests
Box 8109, St. Louis, MO 63110.
-Large polyps
© 2004 Elsevier Inc. All rights reserved.
-Leiomyoma
1524-153X/04/0601-0006$30.00/0 Early gastric cancer
doi:10.1053/j.optechgensurg.2004.01.007

Operative Techniques in General Surgery, Vol 6, No 1 (March), 2004: pp 29-41 29

30 L. Michael Brunt

nal compromise. Gastric carcinoids may also be re- radiography may be useful in selected cases to define the
sected laparoscopically in selected cases. Suspicion of anatomy before operation but is not routinely indicated.
lymph node metastases or other signs of malignancy is CT should be used to stage patients with potential malig-
an indication for an open resection. Patients with gas- nancies, including larger gastric stromal tumors and car-
tric carcinoids that arise in the setting of hypergastrine- cinoids. CT may also be indicated in patients with appar-
mia should undergo concomitant antrectomy to re- ent benign peptic strictures to exclude the presence of an
move the source of increased gastrin production. extrinsic mass. Endoscopic ultrasound may be helpful in
The role of laparoscopic resection in patients with gastric cases of early gastric cancer to determine the depth of
cancer is controversial. Several groups have recently re- penetration of the stomach and to assess for associated
ported series of patients undergoing laparoscopic resection lymphadenopathy.
in early (T1 or T2) gastric cancer with favorable results.9-11
Tumors were limited to the mucosa or submucosa and had OPERATIVE TECHNIQUE
no evidence of suspicious lymphadenopathy. D1 lymphad-
enectomy has also been performed laparoscopically in some
reports.9,10 Prospective, randomized trials are needed to de-
termine whether a laparoscopic approach is oncologically
safe and beneficial in this setting.
Relative contraindications to laparoscopic gastric re-
section include extensive prior upper abdominal surgery
and previous gastric resection. Absolute contraindica-
tions include locally advanced (T4) gastric cancer, sus-
pected lymph node metastases, and general contraindica-
tions to laparoscopy and pneumoperitoneum.

DIAGNOSTIC EVALUATION
Upper gastrointestinal endoscopy with biopsy is the pre-
ferred method of diagnosis in patients with suspected
gastric or peptic pathology and should be a prerequisite in
all patients before gastric resection. It is especially impor-
tant that the lesion be localized accurately preoperatively,
particularly in regard to its location relative to the gastro-
esophageal junction, lesser curvature of the stomach, and
pylorus because of the greater difficulty in managing le- 1 Preoperative evaluation. Upper gastrointestinal endos-
sions in those locations. Endoscopic tattooing of the copy shows the typical appearance for a gastrointestinal stro-
stomach with India ink may facilitate intraoperative lapa- mal tumor. The lesion is located submucosally and has a small,
roscopic localization of smaller lesions. Barium contrast punctuate, centrally located ulcer.
Laparoscopic Partial Gastrectomy 31

2 Positioning for laparoscopic gastric resection is the same as that for Nissen fundoplication. The patient is supine on a bean bag
mattress with the legs secured on spreader bars. The surgeon usually stands to the patient’s left and the first assistant is on the
opposite side. Alternatively, the surgeon may stand at the foot of the table between the legs. The operating table may be placed in
reverse Trendelenberg or rolled side to side to facilitate exposure and gravity retraction of adjacent organs.
32 L. Michael Brunt

3 Initial access to the peritoneal cavity is usually performed at the umbilicus with an open insertion technique. Potential sites
for port placement include the umbilicus, the right and left subcostal regions, and the right and left mid-abdomen. The location of
the port sites may vary according to the nature of the gastric resection to be performed. Lesions in the fundus may require placement
of an epigastric port for easier access to the upper abdomen similar to a Nissen fundoplication (figure inset) whereas lower port
placement is desirable for antral lesions. All ports may be 5 mm in size initially; any of these ports can eventually be up sized to 12
mm to accommodate the linear stapler. Instrumentation, in addition to standard laparoscopic instruments, should include
atraumatic and Babcock graspers, an ultrasonic coagulator, and endoscopic linear cutter staplers. An angled 30° laparoscope
facilitates different viewing angles and is routinely used.
Laparoscopic Partial Gastrectomy 33

4 After placement of the laparo-

scopic ports, the peritoneal cavity
and liver surfaces should be in-
spected for associated pathology.
Any suspicious lesions should be bi-
opsied and analyzed by frozen sec-
tioning. A retractor is inserted via
the right subcostal port to elevate
the left lateral segment of the liver.
The greater curvature is elevated
with a Babcock grasper and counter-
traction is placed on the omentum.
The initial step in the dissection is to
divide the gastrocolic omentum to
mobilize the greater curvature of the
stomach and gain access to the lesser
sac. Division of the gastrocolic
omentum is facilitated by the use of
the ultrasonic shears, although some
surgeons prefer to use electrocau-
tery in conjunction with endoscopic
clips for larger vessels. The dissec-
tion is carried just proximal to the
planned site of division of the stom-
ach.

5 The stomach is elevated and

posterior attachments are divided
to expose the pancreas and duode-
num. The dissection is then contin-
ued onto the duodenum 1 to 2 cm
distal to the pylorus. The gastroepi-
ploic vessels near the pylorus and
duodenum may be divided at this
point either with the ultrasonic co-
agulator or with clips. Clips should
not be placed adjacent to the duo-
denum if possible because they
may interfere with subsequent de-
ployment of a gastrointestinal sta-
pler. The right gastroepiploic ar-
tery may also bleed if not well
sealed.
34 L. Michael Brunt

6 The gastrohepatic omentum is

divided in the avascular plane be-
tween the liver and the lesser curva-
ture vessels and the nerves of Later-
jet. The dissection is carried down to
the pylorus and the right gastric ar-
tery is divided, usually with clips.
The vessels along the lesser curva-
ture can be divided laparoscopically
at this point or this can be done once
the stomach is exteriorized if a laparo-
scopic-assisted technique is planned.

7 For antrectomy with Billroth I

gastrojejunostomy, the author’s
preference is to use a laparoscopic-
assisted technique rather than a to-
tally laparoscopic one as the latter
approach is technically challenging
and time consuming. Selection of
patients for Billroth I reconstruction
requires that the duodenum be soft
and pliable and that the duodenum
and the gastric remnant come to-
gether easily and without any ten-
sion. After the stomach has been
mobilized laparoscopically, a small
5-cm open upper midline abdominal
incision is created and the stomach
is exteriorized.
Laparoscopic Partial Gastrectomy 35

8 (A) A linear stapler is used to transect the

proximal stomach. For antrectomy, the resection
should extend along a line perpendicular to the
axis of the stomach from the lesser curvature just
proximal to the crow’s foot of the vagus nerve
over to the greater curvature. The gastroepiploic
arcade along the greater curvature is divided and
the stomach is at this point ready for transection.
The duodenum is then divided with a linear cut-
ter stapler 1 to 2 cm distal to the pylorus and the
specimen is removed. (B) The gastroduodenal
anastomosis can be sutured but the author’s pref-
erence is to staple it. A circular stapler is inserted
via an anterior gastrotomy after sizing the duode-
num. In most cases a 25-mm diameter stapler is
appropriate. A pursestring suture of 2 to 0 mono-
filament Prolene suture is placed in the duode-
num. The anvil portion of the stapler head is in-
serted into the duodenum and the pursestring
suture is tied down. The stapler head is then at-
tached to the anvil and the stapler is closed and
fired to create the anastomosis near the greater
curvature side of the stomach. The stapler is then
removed, the anastomosis is inspected for bleed-
ing, and the stapler is inspected for complete rings
of tissue. The anterior gastrotomy is then closed
either with sutures or a gastrointestinal stapler.
Once the anastomosis has been completed, the
stomach and duodenum are returned to the peri-
toneal cavity and the midline fascia is closed. The
abdomen is reinflated with CO2 and the dissec-
tion site is irrigated and inspected for hemostasis.
The abdomen is then evacuated of CO2 and the
fascia at all 10 mm or larger port sites is closed
with absorbable 0-gauge braided suture. The gas-
troduodenostomy can also be performed totally
laparoscopically using a circular stapler. The cir-
cular stapler is inserted directly into the abdomen
by removing the 12-mm port and enlarging the
site somewhat. A pretied loop suture (Endoloop)
is first placed around the post on the stapler anvil
to facilitate its handling and the anvil is then in-
serted into the abdomen. The duodenal purse-
string suture is next sewn laparoscopically and
the anvil is inserted in the duodenum. The tech-
nique for placement of the stapler through the
anterior stomach and creation of the anastomosis
is the same as shown above for the laparoscopic-
assisted technique. The benefits of a total laparo-
scopic approach versus laparoscopic-assisted
technique in this setting have not been evaluated.
36 L. Michael Brunt

9 Antrectomy and Billroth II gastroje-

junostomy may be performed in a totally
laparoscopic fashion. After the stomach
has been mobilized and the vessels di-
vided, the stomach is then transected
proximally with a 45 or 60 mm endo-
scopic GIA stapler which is usually in-
serted through the subcostal port site. A
12-mm port suffices for the 45-mm sta-
pler but the 60-mm device requires a
15-mm port. Multiple applications of the
stapler may be required to complete the
transection. Bleeding points along the
staple line may be cauterized lightly or,
preferably, oversewn with absorbable se-
romuscular inverting sutures. The duo-
denum is then transected just distal to
the pylorus with the endoscopic linear
cutting stapler. Alternatively, the duode-
num can be transected before dividing
the proximal stomach. The duodenal sta-
ple line should be oversewn if there is any
concern about the closure. The resected
stomach is then placed in an entrapment
bag and moved to the side so that it can
removed after the anastomosis has been
completed.
Laparoscopic Partial Gastrectomy 37

10 The gastrojejunostomy may be constructed in either in an antecolic or retrocolic fashion but the retrocolic position is
generally preferred. Once the distal stomach has been removed, the transverse colon is elevated to expose the proximal jejunum and
the ligament of Treitz. This step is facilitated by placing the patient in Trendelenberg position. A window is created in the transverse
mesocolon through which the jejunal loop will be brought up to the stomach. A site on the jejunum approximately 15 cm distal to
the ligament of Treitz is brought through this window in the mesocolon and positioned alongside the posterior aspect of the
stomach. The loop should be long enough to reach the stomach without tension but should not be so long as to increase the risk of
an afferent loop syndrome. It may be helpful to mark the planned anastomotic site on the jejunum before it is brought up to the
stomach. Two to three anchoring sutures are placed between the jejunum and stomach to line up the anastomosis. Enterotomies are
then created in the stomach and jejunum using the ultrasonic shears. An endoscopic 45-mm stapler is then inserted into the two
limbs and is fired as shown. The stapler should be rotated back and forth to be sure that the stomach and jejunum are aligned
properly before firing. The stapler is then removed and the staple line is inspected for bleeding.
38 L. Michael Brunt

11 The enterotomy created to place the stapler is closed in two layers using first a full thickness running inner layer of 2-0 Vicryl
tied intracorporeally followed by a second seromuscular layer of interrupted 2-0 Vicryl sutures placed extracorporeally. Alterna-
tively, it can be closed with a GIA stapler. Although stapling may be faster, the current laparoscopic GIA staplers are not designed
specifically for enterotomy closure, thereby incorporating relatively more tissue in the closure that could potentially resulting in
greater luminal compromise. Once the anastomosis is completed, it is brought down to the opening in the transverse mesocolon.
The mesenteric defect is then closed around the stomach and jejunum with interrupted absorbable sutures to prevent herniation at
this site. The resected stomach is then removed at one of the 12-mm port sites after enlarging the incision somewhat.
Laparoscopic Partial Gastrectomy 39

12 The technique for laparoscopic gastric wedge resection of benign gastric lesions varies depending on the size of the lesion
and its location. Lesions in the fundus of the stomach are ideally suited for wedge resection as shown above. The greater curvature
of the stomach has been completely mobilized by dividing the gastrosplenic ligament and short gastric vessels. The lesion is elevated
with a Babcock grasper by grasping adjacent normal stomach. If the lesion is difficult to grasp or elevate, sutures may be placed in
the gastric wall adjacent to it. These sutures can then be used for traction to facilitate placement of the stapler. An endoscopic linear
cutting stapler is then placed below the lesion to obtain a margin of normal tissue of 1 cm or greater. More than one stapler
application may be necessary. The gastric staple line may need to be inverted with interrupted or running absorbable suture if there
is bleeding from it. For lesions in the antrum or those near the gastroesophageal junction, intraoperative gastroscopy may be
important to visualize application of the stapler so that the gastric or gastroesophageal lumen is not compromised. Gastroscopy may
also be used intraoperatively to localize smaller lesions. Once the specimen is free, it is placed in an entrapment bag and removed
at the conclusion of the procedure. It should be examined by the pathologist to ensure negative gross resection margins. An
alternative technique for posteriorly located lesions, especially those that protrude into the gastric lumen, is excision via an anterior
gastrotomy. Although not shown here, the anterior stomach is opened over the lesion with the ultrasonic shears. The lesion is
identified, elevated and excised with a linear cutting stapler using the same techniques and principles as described above.

POSTOPERATIVE MANAGEMENT of an oral diet is also individualized according to patient

condition and the procedure performed. After gastric
Postoperatively, patients are admitted to a regular nursing wedge resection, clear liquids can usually be started on
unit. Inpatient care is similar to that for open gastric the second postoperative day and the diet is advanced as
surgery and should include intravenous fluids, nothing tolerated. A more conservative approach to resumption of
by mouth, and pain medications. The use of a nasogastric feedings is often taken after distal gastrectomy and re-
tube is individualized according to the clinical situation anastomosis, starting clear liquids on postoperative day 3
and surgeon preference. If a nasogastric tube is employed, or 4 and advancing as tolerated. Some groups advocate
it can usually be removed the morning of the first postop- obtaining radiographic studies to evaluate for leaks before
erative day provided the output is not high. Resumption feeding. Most patients can be discharged to home by the
40 L. Michael Brunt

Table 2. Series of Laparoscopic Resection of Gastric Stromal Tumors

Operative Time Resumption of Length of Stay
Series N (min) Conversions Oral Intake (days) (days)

Buyske 199712 7 132 2 (28%)* — 5.0

Hepworth 200013 9 — 2 (22%) 1 3
Basso 200015 9 75-120 0 2 4
Choi 2000†16 32 — 1 (3.1%) 2.9-3.5** 5.9-7.1
Matthews 200017 21 169 0 — 3.8
†
Some patients in series had other gastric tumors, including polyps, lipomas, lymphoma, and other lesions.
*Includes one patient converted to a laparoscopic-assisted resection
**Resumption of diet and length of stay varied by type of procedure-wedge versus intragastric resection.

3rd or 4th postoperative day after gastric wedge resection. from 3 to 5 days. Complication rates have been under
The length of stay is more variable after antrectomy and 10% with few major complications.
depends on the time to resumption of a regular diet. No prospective randomized trials of laparoscopic ver-
Following discharge, patients can begin normal light ac- sus open gastric resection have been performed. Mat-
tivities according to comfort level and are usually able to thews and associates17 retrospectively compared out-
resume unrestricted activities within 7 to 10 days of sur- comes in 33 patients with gastric stromal tumors
gery. A follow-up office visit is scheduled for 2 to 3 weeks. undergoing either laparoscopic (N ⫽ 21) or open resec-
tion (N ⫽ 12). Fifteen patients (71%) in the laparoscopic
PRELIMINARY RESULTS AND OUTCOMES group underwent wedge resections. No differences were
Removal of gastric stromal tumors and other benign gas- seen in operative times, blood loss, and complications
tric lesions has been the most accepted indication for between the two groups, but patients in the laparoscopic
laparoscopic gastric resection. Wedge resection has been group had a shorter length of hospital stay. Two patients
the most commonly employed technique but partial gas- in the laparoscopic group were re-resected laparoscopi-
trectomy has also been used for larger lesions. Transgas- cally early postoperatively because of close resection mar-
tric resection of posterior wall lesions has been advocated gins. Tumor recurrence developed in one patient in each
by some groups.12-14 A totally intragastric mini-laparo- group. Reyes and co-workers18 reported results of a ret-
scopic approach has recently been reported for resection rospective case-matched analysis of laparoscopic versus
of submucosal lesions near the gastroesophageal junc- open gastrectomy in 36 patients. Of the 18 patients in
tion.7 In this approach, 2 mm ports were placed into the each group, two-thirds had a malignant diagnosis. Most
stomach under laparoscopic vision and the gastric lesions procedures were gastric resections with Billroth II recon-
were then enucleated under endoscopic guidance with a struction. Laparoscopic resection was associated with
gastroscope. longer operative times but less blood loss, fewer transfu-
Several groups have reported results in small series as sions, faster resumption of an oral diet, and a shortened
listed in Table 2.12,13,15-17 Operative times have been in length of stay. Nasogastric tubes were used postopera-
the 2 to 2.5 hour range and conversion rates to an open tively in 61% of patients in the laparoscopic group com-
procedure have ranged from 0% to 28%. The primary pared with 94% in the open group.
reasons for conversion have been large tumor size, con- Several groups have recently reported their experience
cerns regarding resection margins, and technical prob- in patients undergoing laparoscopic gastrectomy for gas-
lems. Resumption of an oral diet was reported between 1 tric adenocarcinoma. A summary of the major series and
and 3 days and postoperative length of stay has ranged results are given in Table 3.9,10,19-22 The largest experi-

Table 3. Major Series of Laparoscopic Gastrectomy for Gastric Cancer

Operative Time Resumption of
Series N (min) Oral Diet (days) Complications Recurrences Follow-Up
9
Azagra 1999 13 240 5 1 (7.7%) 3 (23%) 27.5mo
Adachi 200019 49 246 5 4 (8%) 0 6 mo
Weber 200322 12 262 3.3 — †
18 mo
Fujiwara 200310 43 225 — 7 (16%) 1 (2.3%) 37 mo
Shimizu 200321 100* 330 6.2 12 (12%) — —
Noshiro 200320 76 327 5.1 9 (13%) — —

*Includes 15 patients who had gastric lesions other than adenocarcinoma.

†
There were 9 of 12 patients alive at 18 months follow-up.
Laparoscopic Partial Gastrectomy 41
ence has come from Japan where screening programs patients with gastric adenocarcinoma is controversial.
detect large numbers of patients with early gastric cancer. Prospective, randomized trials are needed to determine
The laparoscopic approach has been generally limited to whether a laparoscopic approach in this setting has ad-
patients with cancers confined to the mucosa or submu- vantages over open gastrectomy and if it is oncologically
cosa, which should have a low likelihood of lymph node safe.
metastases. However, patients with more advanced can-
cers have also been resected laparoscopically by some REFERENCES
groups.9,22 A laparoscopic-assisted technique in which 1. Goh P, Tekant Y, Kum CK, et al: Totally intra-abdominal laparo-
resection, anastomosis, and specimen extraction were scopic Billroth II gastrectomy. Surg Endosc 6:160, 1992
performed via a 5 cm upper midline mini-laparotomy was 2. Azagra JS, Goergen M: Laparoscopic total gastrectomy, in Meinero
used in most of these series. M, Melotti G, Mouret PH (eds): Laparoscopic Surgery. Masson,
Milano, 1995, pp 289-296
The rate of conversion to open gastrectomy ranged 3. Fowler DL, White SA: Laparoscopic gastrectomy: Five cases. Surg
from 2% to 25% and was highest in the series in which all Laparoscop Endosc 6:98-101, 1996
cases were done in a totally laparoscopic fashion.22 Obe- 4. Goh P, Tekant Y, Isaac J, et al: The technique of laparoscopic
sity appears to increase the technical difficulty of the Billroth II gastrectomy. Surg Laparoscop Endosc 2:258-260, 1992
procedure and the conversion risk.20 Operative times for 5. Kitano S, Iso Y, Moriyama M, et al: Laparoscopy-assisted Billroth I
gastrectomy. Surg Laparoscop Endosc 4:146-148, 1994
laparoscopic gastrectomy have been longer than those
6. Naitoh T, Gagner M: Laparoscopically assisted gastric surgery
typically reported for open resection. Other outcome using Dexterity Pneumo Sleeve. Surg Endosc 11:830-833, 1997
measures have been favorable with resumption of an oral 7. Heniford BT, Arca MJ, Walsh RM: The mini-laparoscopic intra-
diet within three to five days and low complication rates. gastric resection of a gastroesophageal stromal tumor: A novel
Of potential concern is that anastomotic leaks were re- approach. Surg Laparoscop Endosc Perc Tech 10:82-85, 2000
corded in 12% and 14% of cases, respectively in two of 8. Taniguchi E, Kamiike W, Yamanishi H, et al: Laparoscopic intra-
gastric surgery for gastric leiomyoma. Surg Endosc 11:287-289,
these reports despite an open anastomotic technique.10,21 1997
Potential explanations for these high leak rates were ten- 9. Azagra JS, Goergen M, De Simone P, et al: Minimally invasive
sion on the anastomosis because of failure to mobilize the surgery for gastric cancer. Surg Endosc 13:351-357, 1999
duodenum adequately, duodenal stump devasculariza- 10. Fujiwara M, Kodera Y, Kasai Y, et al: Laparoscopy-assisted distal
tion, duodenal injury from the coagulating shears, and gastrectomy with systemic lymph node dissection for early gastric
carcinoma: A review of 43 cases. J Am Coll Surg 196:75-81, 1993
surgical inexperience with the technique.
11. Ohgami M, Otani Y, Kumai K, et al: Curative laparoscopic surgery
Outcomes of laparoscopic versus open gastric resection for early gastric cancer: Five years experience. World J Surg 23:
for malignancy have been compared in two nonrandom- 187-192; discussion 192-183, 1999
ized, cohort matched studies.19,22 Compared with open 12. Buyske J, McDonald M, Fernandez C, et al: Minimally invasive
gastrectomy, the laparoscopic approach was associated management of low-grade and benign gastric tumors. Surg Endosc
with longer operative times but resulted in less operative 11:1084-1087, 1997
13. Hepworth CC, Menzies D, Motson RW: Minimally invasive sur-
blood loss, decreased pain, a faster return of gastrointes- gery for posterior gastric stromal tumors. Surg Endosc 14:349-
tinal function, and a shortened hospitalization. Resump- 353, 2000
tion of an oral diet was earlier for the laparoscopic group 14. Watson DI, Game PA, Devitt PG: Laparoscopic resection of benign
in one study but not significantly different in the other. tumors of the posterior gastric wall. Surg Endosc 10:540-541,
Surgical margins, number of lymph nodes harvested, and 1996
15. Basso N, Rosato P, De Leo A, et al: Laparoscopic treatment of
recurrence rates were similar for the laparoscopic and
gastric stromal tumors. Surg Endosc 14:524-526, 2000
open procedures. However, the number of patients is too 16. Choi YB, Oh ST: Laparoscopy in the management of gastric sub-
small and the length of follow-up too short for a mean- mucosal tumors. Surg Endosc 14:741-745, 2000
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open resection of gastric stromal tumors. Surg Endosc 16:803-
807, 2002
CONCLUSIONS 18. Reyes CD, Weber KJ, Gagner M, et al: Laparoscopic vs open
Laparoscopic gastric resectional procedures are being in- gastrectomy. Surg Endosc 15:928-931, 2001
creasingly utilized in patients with gastrointestinal stro- 19. Adachi Y, Shiraishi N, Shiromizu A, et al: Laparoscopy-assisted
Billroth I gastrectomy compared with conventional open gastrec-
mal tumors and other small, benign gastric lesions. Most tomy. Arch Surg 135:806-810, 2000
of these lesions can be removed using a laparoscopic 20. Noshiro h, Shimizu S, Nagai E, et al: Laparoscopy-assisted gastrec-
wedge resection technique. Preliminary results suggest tomy for early gastric cancer. Is it beneficial for patients of heavier
that in expert hands this approach is safe and achieves weight? Ann Surg 238:680-685, 2003
results comparable to that for open gastric resection with 21. Shimizu S, Noshiro H, Nagai E, et al: Laparoscopic gastric surgery
in a Japanese institution: Analysis of the initial 100 procedures.
a shortened hospitalization. The relative merits of a to-
J Am Coll Surg 197:372-378, 2003
tally laparoscopic versus laparoscopic-assisted approach 22. Weber KJ, Reyes CD, Gagner M, et al: Comparison of laparoscopic
to antrectomy and other gastrectomy procedures remain and open gastrectomy for malignant disease. Surg Endosc 17:968-
to be established. The role of laparoscopic resection in 971, 2003
Laparoscopic Splenectomy
Eric C. Poulin, MD, MSc, FRCSC, Christopher M. Schlachta, MD, FRCSC, and
Joseph Mamazza, MD, FRCSC

ost laparoscopic surgeons would agree that one of strategic plan that includes an initial assessment of the
M the least stated features of minimally invasive sur-
gery is that it has brought anatomy back to the forefront of
anatomy, appropriate port placement once the patient
position has been chosen, an early search for accessory
the craft of surgery. The optical resolution and magnifi- splenic tissue, opening of the asplenic tent, reviewing
cation offered by the endoscopic equipment has permit- options as to an anterior, posterior, or mixed approach to
ted the proper identification and appreciation of fine an- the hilum, and finally securing and extracting the spleen.
atomical detail often overlooked in open surgery.
Simplification of difficult advanced laparoscopic surgery THE INITIAL ANATOMICAL ASSESSMENT
is often driven by the appreciation of subtle anatomy. Because of the many variations in anatomy, it is a mistake
Nowhere is this more evident than in laparoscopic sple- for surgeons to assume that the conduct of laparoscopic
nectomy. Detailed knowledge of splenic anatomy to avoid splenectomy will be the same in every patient. Early ob-
potential complications and serious intraoperative mis- servation of the anatomical clues available at the initial
haps is essential to the successful performance of laparo- assessment will help determine the operative strategy
scopic splenectomy. (Table 1).
Successful laparoscopic splenectomy should follow a Whereas most anatomy texts imply that the splenic
artery is constant in its course and branches, the classic
essay of Michels demonstrates the fact that each spleen
From the Center for Minimally Invasive Surgery, St. Michael’s Hospital, Uni- has its own peculiar pattern of terminal artery branches.
versity of Toronto, Toronto, Canada.
The splenic branches exhibit so many variations in num-
Address reprint requests to Eric C. Poulin, MD, Chair, Department of Surgery,
University of Ottawa, The Ottawa Hospital, Box 175, 501 Smyth Road, Ottawa, ber, length, size, and origin that no two spleens have the
Ontario K1H 8L6, Canada. same anatomy. Michels divides splenic artery topography
© 2004 Elsevier Inc. All rights reserved.
into two types: distributed and bundled (magistral). He
1524-153X/04/0601-0007$30.00/0
doi:10.1053/j.optechgensurg.2004.01.004 reports that the distributed type is found in 70% of dis-

Table 1. Using Anatomical Clues to Determine Operative Strategy

General
1. No two spleens have the same anatomy
2. The size of the spleen can influence operative strategy
3. The size of the spleen does not determine the number of entering arteries
4. The presence of notches and tubercles correlates with a greater number of entering arteries
5. Determining how much (%) of the hilar surface of the spleen is penetrated by vessels determines the type of blood supply and gives a good
clue to operative strategy
Splenic blood supply
1. The splenic artery usually arises from the celiac artery, but can also come from the aorta, the superior mesenteric, the middle colic, the left
gastric, and other arteries. The splenic artery tends to be more tortuous with age
2. The patterns of splenic blood supply fall into two types: the distributed type (70%) and the magistral or bundled type (30%)
3. The arteries outside the spleen are divided in first, second, and third terminal divisions, and collaterals
4. There is no collateral circulation within the spleen (terminal blood supply)
5. However, transverse anastomoses exist between the splenic artery branches
6. Veins are usually posterior to arteries except at the ultimate division level inside the spleen
Accessory spleens
1. The search for accessory spleens should be performed early in the operation, as most are easier to find and remove at that time
2. Finding and removing accessory splenic tissue is crucial is some hematological disorders, such as ITP
3. Most accessory spleens are situated close to the hilum of the spleen and the tail of the pancreas
Suspensory ligaments of the spleen
1. The gastrosplenic ligament contains short gastric and gastroepiploic vessels
2. The lienorenal ligament contains the hilar vessels and the tail of the pancreas
3. The other suspensory ligaments of the spleen are avascular except in portal hypertension and in myeloproliferative disorders
The tails of the pancreas
1. The tail of the pancreas lies within 1 cm of the splenic hilum in 73% of patients
2. The tail of the pancreas is in direct contact with the spleen in 30% of patients

42 Operative Techniques in General Surgery, Vol 6, No 1 (March), 2004: pp 42-54

Laparoscopic Splenectomy 43

1 Distributed type of vascularization.

AO ⫽ aorta, PM ⫽ pancreatic magna. By
definition, the splenic trunk is short, and
many long branches (6-12) enter over
three-fourths (75%) of the medial surface
of the spleen. The branches originate be-
tween 3 to 13 cm from the hilum. Outside
the spleen, the arteries also present fre-
quent transverse anastomoses with each
other which, according to Testud, arise at a
90° angle between the involved arteries, as
with most collaterals. This means that the
application of hemostatic clips or the em-
bolization of coils occluding a branch of
the splenic artery before such an anastomo-
sis may fail to devascularize the corre-
sponding splenic segment.1,2,15 (“The
anatomical basis for laparoscopic splenec-
tomy”—Reprinted from: Can J Surg
36:484-488, 1993, by permission of the
publisher. © 1993 Canadian Medical Asso-
ciation.)

2 Bundled (magistral) type of vascu-

larization. AO ⫽ aorta, PM ⫽ pancreatic
magna. The bundle type is characterized
by the presence of a long main splenic
artery that divides into short terminal
branches near the hilum. In this type, the
splenic branches enter over only a fourth
to a third (25-33%) of the medial surface
of the spleen. These branches are large,
few (3-4) originate 3.5 cm on average
from the spleen, and reach the center of
the organ as a compact bundle.1,15 (“The
anatomical basis for laparoscopic sple-
nectomy”—Reprinted from: Can J Surg
36:484-488, 1993, by permission of the
publisher. © 1993 Canadian Medical As-
sociation.)
44 Poulin et al

3 General scheme of splenic artery branches. * ⫽ present in only 20% of cases. The splenic artery in the hilum can include up to seven
branches at various division levels and in various anatomic arrangements; they are the superior terminal artery, the inferior terminal
artery, the medial terminal artery, the superior polar artery, the inferior polar artery, the left gastroepiploic artery, and the short gastric
arteries. Veins usually lie behind arteries except at the ultimate division level, where they may be anterior or posterior. According to
Lipshutz, 72% of spleens have three terminal branches (superior polar, superior and inferior terminal) and 28% have two, the other
remaining branches being collaterals. When the superior terminal is excessively large, the inferior terminal is rudimentary, and more
blood supply often comes from the left gastroepiploic and polar vessels. Up to six short gastric arteries may arise from the fundus of the
stomach, but usually only those (1-3) opening into the superior polar artery of the spleen need to be ligated during laparoscopic
splenectomy.15,16 (“The anatomical basis for laparoscopic splenectomy”—Reprinted from: Can J Surg 36:484-488, 1993, by permission
of the publisher. © 1993 Canadian Medical Association.)

sections (Fig 1); the bundled type present in the remain- Scoson-Javoschewitsch found the tail of the pancreas to
ing 30% of specimens (Fig 2).1 be in direct contact with the spleen in 30% of cadavers.
Before it divides, the splenic trunk usually gives off a Baronfsky confirmed this finding and added that the dis-
few slender branches to the tail of the pancreas. The most tance was less than 1 cm in 73% of their patients.5,6
important, called the pancreatica magna, is familiar to The surgeon should appreciate the infinite variability
vascular radiologists. It is an important landmark in se- of the anatomy because of differences in the characteris-
lective angiography of the splenic artery. Severe pancre- tics of the blood supply, the presence of notches or a
atitis has been reported following its occlusion during smooth spleen surface and the relationship of the splenic
embolization procedures or while attempting to ligate the hilum to the tail of the pancreas. On seeing the spleen and
splenic artery in the lesser sac.2 The number of arteries its hilum, the surgeon can usually predict its type of
entering the spleen is not determined by its size, but the vascularization (Fig 3). A notched spleen with a wide
presence of notches and tubercles usually correlates well hilum will have a more complicated type of blood supply.
with a greater number of entering arteries. Henschen drew attention to the fact that a lobulated and
What is important to know is that despite the fact that no unevenly contoured spleen has a more complicated dis-
two spleens have the same anatomy, most specimens have tributed type of anatomy and more vessels as opposed to
two or three terminal branches entering the hilum (superior a spleen that has a more even inner surface.7
polar, superior, and inferior terminal). Two-colored corro- Early observation of the percentage of the hilar surface
sion casting and anatomic dissection have defined splenic penetrated by blood vessels is the best clue to determine the
lobes and segments that correspond to the entering terminal type of blood supply. If splenic branches enter the hilum
arteries, confirming the terminal nature of splenic blood over 25% to 33% of the medial surface of the spleen, a
supply. Relative avascular planes are identified between magistral or bundled pattern of blood supply exists. If many
lobes and segments. When one considers the superior pole branches enter over 75% of the medial surface of the spleen,
fed by the short gastric vessels and the inferior pole by the a distributed pattern is present. Understanding the ligament
gastroepiploic branches, there can be anywhere from three infrastructure of the spleen is another prerequisite to safe
to five splenic lobes for most patients. The simple fact is that laparoscopic splenectomy (Fig 4).1
the surgical unit of the spleen is based on surgically accessi- The preoperative determination of spleen size by ultra-
ble vessels at the hilum.3,4 sound or computed tomography (CT) also helps to plan
Laparoscopic Splenectomy 45

4 Suspensory ligaments of the spleen. Duplications of the peritoneum form the many suspensory ligaments of the spleen. On the
medial side, posteriorly, the lienorenal ligament contains that tail of the pancreas and the splenic vessels. Anteriorly, the gastro-
splenic ligament contains the short gastric and the gastroepiploic arteries. The remaining ligaments are usually avascular except in
patients with portal hypertension or myeloid metaplasia. The longest is the phrenocolic ligament, which courses laterally from the
diaphragm to the splenic flexure of the colon; its top end is called the phrenosplenic ligament. The attachment of the lower pole on
the internal side is called the splenocolic ligament. Between the phrenocolic and the splenocolic ligaments, a horizontal shelf of
areolar tissue is formed on which rests the inferior pole of the spleen. It is often modeled into a sac that opens cranially called the
sustentaculum lienis, acting as a brassiere to the lower pole of the spleen.15 (“The anatomical basis for laparoscopic splenectomy”—
Reprinted from: Can J Surg 36:484-488, 1993, by permission of the publisher. © 1993 Canadian Medical Association.)

the operation. An ultrasound or CT examination is ob- The surgeon will then have to decide whether clips or
tained to assess spleen size (maximum pole length), mea- linear staplers are appropriate for vascular control.
sured as the joining line between the two organ poles and
divided into three categories: (a) normal spleen (⬍11 cm OPERATIVE TECHNIQUE
long), (b) moderate splenomegaly (11-20 cm), and (c)
severe or massive splenomegaly (⬎20 cm).8 Because Placing Ports
spleens greater than 30 cm long present special technical Laparoscopic splenectomy can be performed through ei-
problems currently testing the limits of laparoscopic sur- ther a lateral or an anterior approach. By far, the lateral
gery, we have used a fourth category called mega-spleens. approach is preferred because it makes the operation
In practical terms, surgery on a spleen with a distrib- much simpler (Table 2). However, no matter what ap-
uted type of blood supply will usually mean dissection of proach is used, the first trocar is always inserted through
more blood vessels that are, however, spread over a wider an open technique.
area of the splenic hilum. Operation on a spleen with a If an anterior approach is used, the patient is placed in
bundled-type blood supply will usually mean fewer ves- a modified lithotomy position to allow the surgeon to
sels; the hilum will be more compact and narrow, making operate between the legs and the assistants to be on each
dissection and separation of the vessels more difficult. side (Fig 5).
 Table 2. Advantages of the Lateral Approach to Laparoscopic Splenectomy
1. Allows dissection of the splenic vessels in the relatively avascular areolar tissue of the retroperitoneum
2. Almost eliminates inadvertent trauma from instruments usually held by assistants to lift the lower pole of the spleen. Little force is necessary to
retract the spleen. Gravity is almost all that is required as the spleen naturally will fall toward the left lobe of the liver and out of the way
3. Easy access to the phrenocolic ligament allowing early dissection, leaving a generous portion of the splenic side that can be grasped easily to
manipulate the spleen
4. Greater ability to separate the gastrosplenic and lienorenal ligaments to identify the anatomic structures they contain
5. Easier identification of the tail of the pancreas, especially in its superior and posterior aspect
6. More room in this position to insert the spleen in a plastic bag before extraction
7. If blood loss occurs, it will tend to flow away from the hilum and not obscure dissection. In the anterior approach, blood will pool in the hilum

5 Port placement anterior approach. Position of the operating team and the trocars: (S) surgeon, (A) assistant, (1) 5-mm trocar, (2)
12-mm trocar, (3) 10 or 12 mm trocar. For the anterior approach, a 12-mm trocar is introduced through an umbilical incision using an
open approach under direct vision. A 10-mm laparoscope (0-degree or 30-degree) is connected to a video system and three or four 5 and
12-mm trocars are placed in a half-circle away from the left upper quadrant. Placement of trocars is essentially dictated by body habitus
and the size of the spleen. Careful selection of all trocar sites is made to optimize work angles. As needed, the 12-mm ports are used to
allow introduction of clip appliers, staplers, or the laparoscope from a variety of angles. The anterior approach is probably better suited to
a situation where concomitant surgery is needed, such as cholecystectomy. Moreover, dealing with a very large spleen is probably safer
with an anterior approach and HALS techniques or possibly prior splenic artery embolization.
Laparoscopic Splenectomy 47

6 Port placement lateral approach. Three 12-mm trocars are used anteriorly along the left costal margin. The fourth (5-mm or
12-mm) trocar is placed posterior to the iliac crest. The patient is put on a beanbag in the right lateral decubitus position. The
operating table is flexed and the bolster is raised to increase the distance between the lower rib and the iliac crest. Usually four
12-mm trocars are used around the costal margin to allow maximum flexibility for the interchange of cameral, clip applier, linear
stapler, and other instruments. Three trocars are located anteriorly along the rib margin, and one is located in the left flank. Enough
distance between trocars is required to preserve good working angles and easy triangulation. There is some advantage in slightly
tilting the patient backward, as to do so allows more freedom to move the instruments placed along the left costal margin, especially
for lifting movements, when the instrument handles can come too close to the operating table. For the same reason, it is
advantageous to place the anterior or abdominal side of the patient closer to the edge of the operating table. Using some reverse
Trendelenburg positioning also allows the spleen to move away from the diaphragm. Usually the fourth posterior trocar cannot be
inserted until the splenic flexure of the colon or sometimes the left kidney is mobilized. With experience, the number of 12 mm
trocars can be reduced and replaced with 5 mm trocars to gain a cosmetic advantage.
48 Poulin et al

7 Port placement needlescopic tech-

nique. For maximal cosmetic advan-
tage, needlescopic techniques can be
used where the 12-mm trocar is placed
in the umbilicus (the escape hatch) and
two or three 3-mm trocars are used sub-
costally. The vertical umbilical incision
and the three 3-mm port sites leave vir-
tually no visible scars. This requires the
sequential use of a 10 mm and a 3 mm
laparoscope (double set up). Because
the smallest clip applier is a 5-mm in-
strument, a 5 mm trocar can also be
placed posteriorly in the flank for more
flexibility if safety is a concern. A 5-mm
flank incision is not as apparent.
Whether it is justifiable to pursue push-
ing the limits of minimally invasive sur-
gery to this level for mostly cosmetic
reasons remains debatable.

The lateral approach to laparoscopic splenectomy was 9). Only when the anatomy is well displayed will the
first described for laparoscopic adrenalectomy and has surgeon be able to determine which operative strategy
become the approach of choice for most patients (Table 2; will simplify the procedure and lead to the shortest oper-
Figs 6 and 7).9 ative time. At this point, it is important to emphasize the
need for precise and delicate surgical technique to avoid
any capsular breach during dissection or extraction. This
Looking for Accessory Splenic Tissue
can lead to splenosis and recurrent disease, especially in
When splenectomy is undertaken for hematological dis- immune purpura.11
orders, it is important for the surgeon to identify and
remove accessory splenic tissue to avoid disease recur-
Reviewing the Options
rence. This is particularly important in immune throm-
bocytopenic purpura (ITP), which constitutes the most Once the anatomy has been defined by opening the lesser
frequent indication of elective splenectomy in most clin- sac, a number of options become apparent. The surgeon
ical reports. Whether a lateral or anterior approach is can approach dissection of the blood supply from the
used for laparoscopic splenectomy, identification and ex- front or the back of the spleen. Occasionally it is easier to
cision of accessory splenic tissue should be performed at alternate from front to back. Depending on the number of
the beginning of the procedure when little dissection vessels entering the splenic hilum, how easy they are to
or blood staining has obscured the operative field dissect apart and for cost considerations, clips or a linear
(Fig 8).10-12 stapler will be used for vessel control. The surgeon should
also assess how easy it is to create a window above the tail
of the pancreas. When this is possible, a simple bundled
Opening the Splenic “Tent”
blood supply can be entirely divided with a single appli-
With so much possible variation, it is important at the cation of the linear stapler with a vascular cartridge. Short
start of the operation to be able to display the anatomy so gastric vessels can be clipped, stapled or controlled with
as to adapt operative strategy to each patient. This is done an ultrasonic dissector. There are new and promising
by the demonstration of the splenic “tent.” In essence, tissue welding devices that have enabled control of all
this is the surgeon’s consistent entrance into the lesser splenic vessels in certain conditions without the use of
sac, enabling easy separation of the gastrosplenic and the clips or staples. This has the potential to simplify the
lienorenal ligaments and their anatomical structures (Fig operation even more (Figs 10 and 11).
Laparoscopic Splenectomy 49

8 Accessory spleens. Sites where accessory

spleens are found in order of importance.
(From Curtis GH, Movitz D: Ann Surg 123:
276-298, 1946, with permission.) A number of
studies have determined the most likely and
unlikely locations for accessory spleens. The
majority of accessory spleens (87%) are located
within a short distance of the splenic hilum:
hilar region (54%), pedicle (25%), tail of the
pancreas (6%), splenocolic ligament (2%). The
surgeon should look for and remove accessory
spleens at the beginning of the operation be-
cause it is more easily done when the field has
not been fully dissected and stained with
blood.10

Extracting the Specimen are used to hold the two rigid edges of the bag and effect
After achieving control of the blood supply, the spleen is partial closure. One should note that it is difficult to insert
inserted in a plastic bag, and this is often simplified by the spleen into the plastic bag before unfolding and open-
preserving the upper portion of the phrenocolic ligament ing the bag completely. Bagging the resected spleen re-
during its initial dissection. After final transection of the quires patience and imagination and at first can be a
phrenocolic ligament and lysis of diaphragmatic adhe- frustrating experience (Fig 12). The 10-mm jaw forceps
sions when they are present, extraction is performed holding the edges of the lower end of the bag inside the
through one of the anterior ports. Extraction through the abdomen is pushed through one of the mid anterior trocar
posterior port is made more difficult by the thickness of sites, and the tip of the bag is grasped and brought out of
the muscle mass at this level and will usually require the wound. Gentle traction on the bag from the outside
opening the incision and fulgurating more muscle than is brings the spleen close to the peritoneal surface of the
necessary. extracting incision. It is important during this maneuver
For specimen bagging purposes, a medium or large, to pull out only the ridged edges of the plastic bag while
heavy-duty plastic home freezer bag that has been steril- keeping a finger inside; otherwise it is easy for the spleen
ized is folded and introduced into the abdominal cavity to flip out of the bag, and the maneuver has to be repeated
through one of the 12-mm trocars. The bag is unfolded again. The use of sterilized home freezer bags is the most
and the spleen slipped inside to avoid splenosis from the cost-effective means of bagging and extracting the spleen.
manipulations necessary for extraction. Grasping forceps The thick freezer bags should not be confused with other
50 Poulin et al

9 Opening the splenic “tent.” Separation of the gastrosplenic and lienorenal ligaments demonstrates all of the anatomic elements
as seen in the lateral approach after incision of the ligaments attached to the lower pole of the spleen. The splenic flexure is
mobilized by incising its peritoneal attachments. How much mobilization of the splenic flexure is required is patient dependent. The
lower part of the phrenocolic, the sustentaculum lienis, and the splenocolic ligament are incised at the lower pole of the spleen along
with the left portion of the gastrocolic ligament. The branches of the left gastroepiploic artery encountered during this dissection
around the lower pole of the spleen are taken with cautery or clips, depending on their size. This portion of the operation can be
tedious as there can be up to five branches of the gastroepiploic artery of various sizes going to the lower pole of the spleen. This will
open the lesser sac. It will allow access to the gastrosplenic ligament, which can be readily separated from the lienorenal ligament
in this position. Incising the splenocolic ligament, the sustentaculum lienis, and the lateral portion of the gastrocolic ligament is the
most productive move of this approach. Gentle upward retraction of the lower pole of the spleen then creates a “tent-like” structure
with the gastrosplenic ligament making up the left and the lienorenal ligament the right panels of the tent. The stomach makes up
the “floor” of the tent. All the pertinent splenic anatomy is then readily seen in one exposure. Surgeons performing laparoscopic
splenectomy through the lateral approach should always try to reproduce this maneuver to separate the gastrosplenic from the
lienorenal ligament and clearly demonstrate all the noteworthy anatomic structures. The vessels contained in each ligament and the
tail of the pancreas are easily identified and dissected. The avascular portion of the gastrosplenic ligament is then incised sufficiently
to allow exposure of the hilar structures in the lienorenal ligament; this is done with gentle elevation of the lower pole. One should
note that with the patient in the lateral position, the spleen almost retracts itself as it naturally falls toward the left lobe of the liver.
The role of the assistant retracting the spleen is, therefore, much less critical in this approach. At this point, the surgeon can usually
assess the geography of the hilum and have an idea of the degree of difficulty of the operation. Then if a fourth trocar is required,
it is placed posteriorly under direct vision, taking care to avoid the left kidney. Care must also be taken in the choice of placement
for the trocars situated immediately anterior and posterior to the iliac crest. The iliac crest can impede movements to mobilize
structures upward if the trocars are placed over it rather than in front and behind it.
Laparoscopic Splenectomy 51

10 Approaching the hilum from the front. Peeking in the splenic tent in front of the splenic hilum allows the surgeon to survey
for a number of technical options. First, a tortuous main splenic artery may be observed above the tail of the pancreas and distal to
the pancreatic magna artery. It can be clipped early and control most of the arterial splenic supply, except for the collateral vessels
(short gastric vessels and branches of the gastroepiploic artery to the lower pole). Second, the short gastric vessels may be found to
be easily accessible and taken early, thus exposing the superior pole. Third, the branching pattern at the hilum (two, three, or more
branches) can be assessed. For example, a bundled blood supply with two main branches can allow safe creation of a window above
the tail of the pancreas allowing stapling of the entire arterial and venous blood supply with a single stapler application.

plastic bags that are thinner and too prone to tearing though a number of variations exist, the hand port
during fragmentation and other manipulations, making consists of a sealed cuff that enables insertion and
them improper for extraction purposes. Commercially withdrawal of a hand in the abdomen without loss of
available retrieval bags are easier to use but are far more pneumoperitoneum during the operation, thus recov-
expensive and limited to smaller spleens. ering the tactile sensation lost in conventional laparo-
A biopsy of a size suitable for pathological identifica- scopic surgery. A number of models exist and use ei-
tion is obtained by incising the splenic tip. Subsequently, ther an inflatable sleeve clipped to an O-ring, a spiral
the spleen is fragmented with finger fracture and the re- inflatable valve, or a flap valve to maintain pneumo-
sulting blood is suctioned. The remaining stromal tissue peritoneum.
of the spleen is then extracted through the small incision, In the case of laparoscopic splenectomy, there is debate
hemostasis again verified, and all trocars removed. Trocar as to where the incision is best placed, depending on
sites are closed with resorbable sutures and paper strips. whether the surgeon is left or right handed. It has been
No drains are used. described in the upper midline, the right upper quadrant,
the left iliac fossa, and for a very large spleen, in a Pfan-
Hand-Assisted Laparoscopic Splenectomy nenstiel position. Most surgeons agree that the nondomi-
Hand-assisted laparoscopic surgery (HALS) refers to nant hand should be used in the device. There are obvious
laparoscopic procedures performed with the aid of a advantages and drawbacks to this technique. The most
plastic device inserted in a 7.5 to 10 cm wound. Al- apparent disadvantage is the cosmetic cost of a longer
52 Poulin et al

11 Approaching the hilum from the back. To approach the hilum from the back, the phrenocolic ligament is first incised toward
the diaphragm. A 2-cm wide portion of the ligament is left attached to the spleen, making a long structure from which the spleen
can be manipulated with graspers. With the camera in the lower or posterior trocar site, the tail of the pancreas is then dissected
from the structures of the hilum in the areolar avascular tissue of the retroperitoneum. It is important to locate the tail of the
pancreas and dissect it away from its position close to the splenic hilum to avoid injury during control of the vessels. If a distributed
type of anatomy is present with its wide hilum, the splenic branches will necessitate dissection and clipping. The bundled type lends
itself more to a single use of the linear stapler as long as the tail of the pancreas is identified and dissected away when required. When
this is possible, a window is created above the hilar pedicle in the lienorenal ligament so that all structures can be included within
the markings of the linear stapler under direct vision. The viewing angles provided by moving the camera into the various trocars
make this maneuver much easier in the lateral position than in the anterior approach. The dissection is continued with individual
dissection and clipping of short gastric vessels. Occasionally, these vessels can also be taken en masse with the linear stapler. Sutures
are rarely necessary during laparoscopic splenectomy and have been used only occasionally to control a short gastric vessel too short
to be clipped safely. This portion of the operation is performed while the spleen hangs by the upper portion of the phrenocolic
ligament. The experienced surgeon also learns to move the spleen back and forth so that it can be observed both from an anterior
and posterior perspective. The surgeon will then decide whether vessels are more easily approached from the back or the front for
dissection and ligation.

abdominal incision, except in the Pfannenstiel position. Although the final role of HALS splenectomy is still
Moreover, this technique would seem to defeat the goal of being defined, it will probably find a place in laparoscopic
developing surgical techniques that decrease surgical splenectomy for large spleens with the threshold yet to be
trauma even further. However, comparative studies of determined. It will also probably be helpful to surgeons
laparoscopic splenectomy for large spleens (⬎700 g) performing laparoscopic splenectomy during their learn-
seem to indicate outcomes similar to conventional lapa- ing curve. It has also curtailed the role of preoperative
roscopic techniques. splenic embolization for most very large spleens.2,13
Laparoscopic Splenectomy 53

12 Securing and extracting the spleen. Spleens removed through the anterior or lateral approach are extracted after finger
fragmentation in a plastic bag from the umbilical or subcostal trocar site. It is rarely necessary to enlarge this incision to more than
2 or 3 cm. A small subcostal incision has been used as the extraction site during laparoscopic splenectomy through the anterior
approach to deal better with diaphragmatic adhesions. When the lateral approach is used, extraction is more easily performed
through one of the ports situated anteriorly. This extraction site also requires little or no enlargement. On occasion, for a spleen
longer than 20 cm, a 7.5 to 10 cm Pfannenstiel incision is used, and the forearm is introduced into the abdomen to deliver the spleen
in the pelvis for extraction in large fragments under direct vision. The surgeon can also use this incision to hand-review the hilum
videoscopically to ensure that all vascular structures have been properly identified and controlled. The abdomen is copiously
irrigated before closure. Special mention should be made of laparoscopic splenectomy for malignant disease. In cases where
lymphoma or Hodgkin’s disease is suspected, preoperative splenic artery embolization or finger fragmentation in a plastic bag is not
used for fear of making the histological diagnosis difficult to obtain. Extraction of intact spleens through a small left subcostal or
median incision has also been described when it is required to preserve tissue architecture. The various techniques of fragmentation
and extraction of splenic tissue during laparoscopic splenectomy should be discussed and agreed on with the pathologist to ensure
that proper pathological diagnoses are not compromised by necrotic tissue in the case of preoperative splenic artery embolization
or altered tissue architecture through finger fragmentation, especially if the diagnosis of malignancy is suspected but not proven.
The choice of the appropriate extraction technique is, therefore, largely dependent on the type of splenic pathology and the size of
the spleen.

POSTOPERATIVE CARE AND SURGICAL Postoperative pain medication is individualized with a

COMPLICATIONS view of ensuring complete patient comfort. Meperidine
(demerol) injections can be used during the first night,
Postoperative Care followed by an oral acetaminophen/codeine preparation
The postoperative care of a laparoscopic splenectomy pa- or acetaminophen alone. Alternatively, when the patient
tient is usually straightforward. The nasogastric tube is has no history of ulcer or dyspepsia, a 100-mg supposi-
either removed in the recovery room after making sure tory of indomethacin is inserted before induction of an-
that the stomach has been emptied or the next morning, esthesia and every 12 hours for three to five doses. Long-
depending on the duration and the difficulty of the pro- acting oral anti-inflammatory medication can also be used
cedure. The urinary catheter is usually removed before instead of indomethacin suppositories when oral intake
the patient is discharged from the recovery room. Clear has been established. Then, depending on the intensity of
fluids are permitted the next day, and when this is well postoperative pain, a few meperidine injections are used
tolerated, the patient is allowed to move to a diet of their for the first 12 to 24 hours, followed by oral acetamino-
choice. phen; this combination has produced the best results.
54 Poulin et al

Because of side effects of nausea, vomiting, abdominal vention of complications. All instruments, including
fullness, and constipation, codeine is avoided if possible. those handled by assistants, should be moved only under
When indomethacin is used, prophylactic doses of sub- direct vision. Retraction of the liver and stomach and
cutaneous heparin are avoided, especially when platelet elevation of the spleen require constant concentration to
count is low or a platelet function abnormality is present. avoid lacerations with subsequent hemorrhage or perfo-
Oral steroids are started on the first postoperative day ration, especially when using the anterior approach.
after an overlap intravenous injection if steroid coverage There should be no iatrogenic trauma to the spleen dur-
is required. Thereafter, steroids are gradually decreased. ing the procedure to eliminate the possibility of splenosis
Patients are allowed to shower on the day following sple- later on. For the same reason, if splenic trauma occurs
nectomy as long as they dry the paper strips covering the intraoperatively or intra-abdominal fragmentation is re-
trocar sites. They are advised to keep the paper strips quired for extraction of a large spleen, copious irrigation
covering trocar incisions for 7 to 10 days. No limitation should be used before closure.
on physical activity is imposed, and the patient is allowed
to tailor his activities to his degree of asthenia or discom- REFERENCES
fort, except for cases of laparoscopic partial splenectomy 1. Michels NA: The variational anatomy of the spleen and splenic
where empirically patients are asked to refrain from stren- artery. Am J Anat 70:21-72, 1942
2. Poulin EC, Mamazza J, Schlachta CM: Splenic artery embolization
uous activity for 1 month.
before laparoscopic splenectomy. An update. Surg Endosc 12:870-
875, 1998
Surgical Complications 3. Liu DL, Xia S, Xu W, et al: Anatomy of vasculature of 850 spleen
specimens and its application in partial splenectomy. Surgery 119:
The complications of splenectomy include intraoperative 27-33, 1996
and postoperative hemorrhage, left lower lobe atelectasis 4. Seshadri PA, Poulin EC, Mamazza J, et al: Technique for laparo-
and pneumonia, left pleural effusion, subphrenic collec- scopic partial splenectomy. Surg Laparosc Endosc 10:106-109,
2000
tion, iatrogenic pancreatic, gastric and colonic injury, and
5. Baronofsky ID, Walton W, Noble JF: Occult injury to the pancreas
venous thrombosis. following splenectomy. Surgery 29:8523-856, 1951
Success with laparoscopic splenectomy depends 6. Ssoson-Jaroschewitsch A: Zur chirurgischen anatomie des milzhi-
largely on proper preparation and avoiding complications lus. Zeitsch f. d. ges. Anat I Abt 84:218-224, 1937
and technical misadventures. Recognition of anatomic 7. Henschen C: Die chirurgische anatomoie der milzgefiisse.
elements and their arrangement is paramount. Vascular Schweiz Med Wochensch 58:164-170, 1928
8. Goerg C, Schwerk WB, Goerg K, et al: Sonographic patterns of the
structures should be cleanly isolated and dissected from affected spleen in malignant lymphoma. J Clin Ultrasound 18:
surrounding fat. Most can then be controlled safely and 569-574, 1990
cost-effectively with two clips placed proximally and dis- 9. Gagner M, Lacroix A, Bolte E, et al: Laparoscopic adrenalectomy:
tally. Staplers should be used with care and should not be The importance of a flank approach in the lateral decubitus posi-
applied blindly. The stapler tip should be clearly seen to tion. Surg Endosc 8:135-138, 1994
10. Curtis GH, Movitz D: The surgical significance of accessory
be free of tissues before it is closed; otherwise, significant
spleens. Ann Surg 123:276-298, 1946
hemorrhage from a partial section of a major splenic 11. Gigot JF, Jamar F, Ferrant A, et al: Inadequate detection of acces-
branch might occur after release of the instrument. Blind sory spleens and splenosis with laparoscopic splenectomy. A
application of the stapler may also result in damage to the shortcoming of the laparoscopic approach in hematologic dis-
tail of the pancreas, often lying close to the inner surface eases. Surg Endosc 12:101-106, 1998
of the spleen, especially in the anterior approach. 12. Merlier O, Ribet M, Mensier E, et al: Role of accessory spleen in
recurrent hematologic diseases. Chirurgie 118:229-235, 1992
Improper use of cautery can cause iatrogenic injury to 13. Targarona EM, Balague C, Cerdan G, et al: Hand-assisted laparo-
the stomach, colon, and pancreas. Structures close to the scopic splenectomy (HALS) in cases of splenomegaly: A compar-
lower pole in the gastrocolic ligament can be approached ison analysis with conventional laparoscopic splenectomy. Surg
aggressively with cautery, but blind fulguration of fat in Endosc 16:426-430, 2002
the hilum can result in serious bleeding. The instrument 14. Testut L: Traité d’anatomie humaine 7 ed. Paris, Librairie Octave
Doin, 1923, pp 942-960
should be activated only in proximity to the target organ
15. Poulin EC, Thibault C: The anatomical basis for laparoscopic
to avoid arcing and spot necrosis, which may result in splenectomy. Can J Surg 36:485-488, 1993
delayed perforation and sepsis. 16. Lipshutz B: A composite study of the coeliac axis artery. Ann Surg
The role of the assistants is also important in the pre- 65:159-163, 1917
Pancreatic Pseudocyst Drainage
Gordie K. Kaban, Richard A. Perugini, Donald R. Czerniach, and
Demetrius E.M. Litwin

he management of pancreatic pseudocysts is a chal- often associated with persistent ductal abnormalities and
T lenging clinical problem that has become multi-dis-
ciplinary, often involving the collaboration of surgeons,
are less likely to resolve spontaneously.9

gastroenterologists, and interventional radiologists. Un- PSEUDOCYST VERSUS NEOPLASM

fortunately, questions such as the timing and mode of The distinction between true cyst and pseudocyst is im-
intervention have yet to be definitively answered in clin- perative especially if nonoperative treatment is planned.
ical trials. What is clear is that the burgeoning field of Pseudocysts constitute the majority of cystic lesions re-
minimally invasive surgery and interventional endoscopy lated to the pancreas. Nevertheless, approximately 10% of
has provided a number of alternatives to open surgical cystic structures are neoplastic in origin, supporting cyst
treatment. The lingering questions regarding optimal wall biopsy before surgical drainage at laparotomy or
management and the growing number of therapeutic op- laparoscopy.3 For this reason, asymptomatic, incidental
tions are promising to make this an exciting, if not con- pancreatic cysts, especially in the elderly, should not be
troversial period in the evolution of pseudocyst therapy. dismissed as pseudocysts.4 This is a classic pitfall in the
management of cystic lesions of the pancreas.
DEFINITION Pseudocysts can occur with a wide frequency ranging
A pseudocyst by definition is a well localized, pancreatic from less than 2% to 70% following an acute episode of
fluid filled cyst, lined by a nonepithelialized surface.1 pancreatitis, and occur most frequently following alco-
They are commonly found in a retro-gastric location holic pancreatitis.6 The prevalence of pseudocysts has
within the lesser sac or in relation to the body or tail of the changed as definitions and imaging techniques have been
pancreas (Fig 1). Unusual locations, such as the groin2 refined. The commonly identified fluid collections seen
and mediastinum have been reported, suggesting that any by computed tomography (CT) following an episode of
space communicating with the retroperitoneum or peri- acute pancreatitis should not be mistaken for the less
toneal cavity is subject to pseudocyst formation following frequent, mature-walled pseudocyst.
pancreatic injury.
NATURAL HISTORY
PATHOPHYSIOLOGY Our understanding of the natural history of pseudocysts
has been critically important in the development of man-
The current understanding of pseudocyst formation is
agement strategies but remains a controversial topic.
based on the theory of an initial pancreatic insult, such as
Early surgical dogma mandated that pseudocysts greater
trauma or acute pancreatitis, which results in pancreatic
than 6 cm in diameter or existing for greater than 6 weeks
ductal disruption.1 The surrounding adipose tissue and
from the initial pancreatic insult undergo operative drain-
viscera undergo an inflammatory reaction in response to
age.5 This was based on the perception that the risk of
the liberated and activated pancreatic exocrine secre-
complications from pseudocysts during expectant man-
tions. The resulting fibrous peel “walls off” the pancreatic
agement outweighed the surgical risks of drainage for
secretions, creating a nonepithelialized cyst. In contrast,
cysts meeting these criteria. As experience grew, it be-
pseudocysts arising in the setting of chronic pancreatitis
came clear that neither the size, nor the age of the pseudo-
have a different pathophysiology. These pseudocysts are
cyst could be used as an absolute criterion for interven-
tion.7,8 Although pseudocyst complications remain a
From the Department of Surgery, University of Massachusetts Medical School, concern with observation alone, spontaneous resolution
Worcester, MA. of asymptomatic pseudocysts has been shown to occur in
Dr. G.K. Kaban receives funding from United States Surgical Corporation. nearly 60% of patients managed nonoperatively.
Address reprint requests to Demetrius E.M. Litwin, MD, Minimally Invasive
Surgery Service, Department of Surgery, University of Massachusetts Medical
School, Worcester, MA 01655. INDICATIONS FOR INTERVENTION
© 2004 Elsevier Inc. All rights reserved.
1524-153X/04/0601-0008$30.00/0 Most commonly, immature fluid collections are identified
doi:10.1053/j.optechgensurg.2004.01.008 early in the course of acute pancreatitis and are followed

Operative Techniques in General Surgery, Vol 6, No 1 (March), 2004: pp 55-62 55

56 Kaban et al

1 Computerized tomographic scan of a large, thick walled pancreatic pseudocyst within the lesser sac.

serially by CT for resolution. If a pseudocyst develops in THERAPEUTIC MODALITIES

the course of observation and fails to resolve spontane-
ously, there are several indications for intervention. In There are four approaches to pseudocyst drainage once
general, the pseudocyst that is symptomatic, is enlarging the need is recognized: open surgical, percutaneous, en-
by serial radiologic examination, or is found to be infected doscopic, and laparoscopic.
mandates drainage.6 Should the suspicion of infection
arise, the cyst should be aspirated and infection con- Open Surgical Drainage
firmed by Gram stain and culture. Infected cysts identi- Open surgical drainage by way of cyst-gastrostomy, -jeju-
fied following a well documented episode of pancreatitis nostomy, or -duodenostomy, for a lack of alternatives,
that do not appear to contain appreciable amounts of was the mainstay of treatment for many years. It remains
debris should then undergo CT guided catheter drain- a definitive treatment option, but has been usurped by
age.10 less invasive modalities. Open surgical drainage remains
The more common reason for intervention is the symp- the procedure of choice for the pseudocyst that is suspi-
tomatic pseudocyst. Complaints include persistent ab- cious for neoplasm, the infected complex pseudocyst, and
dominal pain following an episode of pancreatitis, ab- for failures or recurrences following other nonsurgical
dominal fullness, nausea, and weight loss. Mechanisms interventions.
for the evolution of symptoms are quite variable, often
relating to the location of the pseudocyst. Less common
presentations include jaundice from obstruction of the Percutaneous Drainage
biliary tree, obstruction of the gastrointestinal tract, rup- Percutaneous drainage of pancreatic pseudocysts is pres-
ture of the cyst into the peritoneum, or hemorrhage into ently indicated for the infected pseudocyst. Simple needle
the cyst cavity. Cyst size cannot be used as a sole criterion aspiration of pseudocysts is accompanied by a high recur-
for drainage, however, larger cysts tend to be symptom- rence rate.11 Drainage through an indwelling catheter can
atic and are therefore more likely to require intervention.7 be remarkably successful but is fraught with potentially
Although there is little supporting data, several authori- long periods of drainage12,13 and the risk of pancreatic
ties have recommended intervention for any pseudocyst fistula, which may ultimately require surgical interven-
found to be increasing in size on serial radiologic evalua- tion. In a review of published reports of percutaneous
tion.6,7 approaches with continuous catheter drainage, recur-
Pancreatic Pseudocyst Drainage 57
rence ranged from 0% to 22%, with failure of drainage The laparoscopic approach, in contrast to other tech-
approaching 33% in some studies.11 niques, also allows a confident biopsy of the pseudocyst
wall. Although less investigated than other minimally in-
Endoscopic Drainage vasive techniques, the advantages of laparoscopy still
hold promise for further application.
There are two basic endoscopic approaches to the drain-
age of pseudocysts: trans-mural and trans-papillary.
Trans-mural drainage involves the placement of one or TECHNIQUE OF LAPAROSCOPIC
more large bore stents through the gastric or duodenal PSEUDOCYST-GASTROSTOMY
wall into the cyst. This has been performed with and
without endoscopic ultrasound (US) assistance. In one of Our procedure of choice for draining pancreatic pseudocysts
the largest series of trans-mural drainage (34 patients), is pseudocyst-gastrostomy. Laparoscopic management of
Beckingham and coworkers were able to demonstrate a pancreatic pseudocysts typically involves the following
71% success rate with a 7% recurrence rate.14 Similar steps:
results have been found in more recent publications.15 1. Localization of the pseudocyst
Limitations of this procedure include thick-walled cysts 2. Anterior wall gastrotomy
(⬎1 cm) and those not in close proximity to the duode- 3. Biopsy of the pseudocyst wall to rule out a cystic
num or stomach. Complications such as bleeding, infec- pancreatic neoplasm
tion of the pseudocyst, and perforation have occurred, 4. Creation of an anastomosis between pseudocyst and
although no associated mortality has been reported.14 gastrointestinal tract of sufficient length to allow for
Trans-papillary drainage is used primarily for pseudo- drainage (ie, approximately 60 mm)
cysts that communicate with the pancreatic ductal sys- 5. Verification of hemostasis
tem. This technique allows drainage of the collection di- 6. Gastrotomy closure
rectly into the ductal system, can address an obstruction Following the establishment of pneumoperitoneum
of the pancreatic duct, and avoids some of the complica- and confirmation of safe entry into the peritoneal cavity,
tions of trans-mural drainage. we proceed with a three-trocar technique. Additional tro-
The only caveat to endoscopic therapy is the inability to cars can be liberally added as necessary. We place one 5 to
perform adequate debridement and cyst wall biopsy. If 12 mm trocar in the left upper quadrant subcostally, and
there is any concern that a cystic neoplasm is present, one 5 mm trocar in the left upper quadrant just above the
surgical therapy in the form of laparoscopy or open ex- level of the umbilicus. The surgeon is located to the pa-
ploration should be performed. tient’s left side. The camera operator is located to the
patient’s right side.
Laparoscopic Drainage The operation proceeds by incising the anterior wall of
There are many reports of laparoscopic management of the stomach with an ultrasonic dissector to create a large
pancreatic pseudocysts. Unfortunately, the majority of access gastrotomy. Next, the surgeon must determine the
these involve very few cases. While case reports under- precise area where the pseudocyst abuts the posterior wall
score the feasibility of the laparoscopic approach, they do of the stomach. This can usually be accomplished by
not allow for determination of the success rate or the visual inspection and palpation. If there is any question as
potential recurrence rate. Parks and Henniford reported to the location of the pseudocyst, ultrasound can be uti-
one of the largest series, utilizing a variety of ap- lized to identify the lesion.
proaches.16 Twenty-nine cases were attempted by several An alternative technique for performing a pseudocyst
techniques, including lesser sac cyst-gastrostomy,9 mini- gastrostomy involves entering the lesser sac via the gas-
laparoscopic cystgastrostomy,5 transperitoneal intragas- trocolic ligament. Additional trocars including one in the
tric cystgastrostomy,11 Roux en Y cyst jejunostomy,3 and right upper quadrant may be required. Once the lesser sac
external drainage.1 The procedure was completed in 28 of is entered and the gastrocolic ligament is opened widely,
29 cases; in one case it was aborted because of gastric the stomach is retracted cephalad and the pseudocyst is
varices. Unfortunately no long-term follow-up was avail- identified using the above-mentioned techniques of aspi-
able. In other case reports of successful laparoscopic man- ration with a needle or intra operative ultrasound. An
agement of pancreatic pseudocysts, patients remain ultrasonic dissector is used to create an access gastrotomy
asymptomatic with follow-up ranging from 2 to 12 and pseudocystotomy. A side-to-side pseudocyst-gastro-
months.17-21 The strength of the laparoscopic approach is stomy can be performed with an endoscopic 2.5 mm lin-
the versatility in both the technique of drainage, as well as ear stapler. The access pseudocyst-gastrotomy must then
the potential to drain pseudocysts at various locations. be closed with suture.
58 Kaban et al

2 The first step in the laparoscopic management of pancre-

atic pseudocysts is obtaining access to the peritoneal cavity and
establishing pneumoperitoneum. We prefer to accomplish this
using an open cut-down technique to place a blunt Hasson
trocar at the umbilicus under direct vision. In patients who
have undergone prior abdominal procedures and in whom we
suspect dense adhesions in the midline, we use a blind Veress
needle technique in the left upper quadrant to establish pneu-
moperitoneum. We then place a 5 mm trocar followed by a 5
mm 30° laparoscope in either of these locations. We have found
this to be a safe way to access the abdominal cavity in patients
with significant midline adhesions.

3 Following anterior wall

gastrotomy, the pseudocyst is
aspirated to further confirm its
location. The surgeon may use
either a spinal needle or a
Veress needle percutaneously
passed through the posterior
wall of the stomach.
Pancreatic Pseudocyst Drainage 59

4 Once the location of

pseudocyst adherence is
determined, an ultrasonic
dissector or cautery is used
to develop a communica-
tion between the posterior
gastric wall and the pseudo-
cyst. A suction irrigation
apparatus must be readily
available to avoid wide
spillage of the pseudocyst
contents and contamina-
tion of the peritoneal cav-
ity. It is critical at this point
to send a biopsy from the
pseudocyst wall to rule out
the presence of epithelial
cells. If these are present,
the diagnosis is a cystic
neoplasm of the pancreas
and a pancreatic resection
is indicated.

5 The pseudocyst-gastrostomy is elongated. This can be accomplished with the use of a 60 mm endoscopic linear stapling device
with 2.5 mm staples. For thicker walled pseudocysts 3.5 mm or larger staples must be used. The anastomosis must be closely
examined for hemostasis. If any hemorrhage occurs, it should be controlled with interrupted figure of eight sutures. The surgeon
must be prepared to complete the whole anastomosis by intracorporeal suturing if the psuedocyst is not suitable for stapling.
Alternatively, the pseudocyst-gastrostomy may be created using an ultrasonic dissector, followed by marsupialization of the margin
with a running nonabsorbable suture.
60 Kaban et al

6 Once hemostasis is verified,

the anterior wall of the stomach is
closed. This can be accomplished
with an endoscopic linear sta-
pling device or continuous run-
ning suture, depending on sur-
geon preference.

TECHNIQUE OF LAPAROSCOPIC PSEUDOCYST-JEJUNOSTOMY

7 Roux-en-Y pseudocyst-jejunostomy is a technique that is useful for pseudocysts that are not intimately adherent to the
posterior wall of the stomach. Port positioning in part will be determined by the position of the pseudocyst. Port positioning can be
liberal, but likely can be accomplished using a 5 to 12 mm right upper quadrant epigastric trocar, a 5 to 12 mm left upper quadrant
subcostal trocar, a 5 mm left upper quadrant trocar just above the level of the umbilicus, and an umbilical camera port. The creation
of a Roux limb of jejunum proceeds by using upward retraction on the transverse colon to identify the ligament of Treitz. This also
exposes the pseudocyst through the transverse mesocolon. The jejunum is then followed downstream to a point that will reach the
pseudocyst without undue tension. The small bowel is transected at this point with an endoscopic 2.5 mm linear stapler. One
additional firing of an endoscopic 2.5 mm linear stapler is used to transect the mesentery of this segment of jejunum perpendicular
to the long axis of the intestine to gain added mobility.
Pancreatic Pseudocyst Drainage 61

8 After mesenteric diver-

sion, the distal segment is fol-
lowed downstream at least 40
cm, at which point a side-to-
side jejunojejunostomy is
performed using an endo-
scopic 2.5 mm linear stapler.

9 The Roux limb of jeju-

num that has been fashioned is
delivered into the upper abdo-
men. An ultrasonic dissector is
used to create a pseudocysto-
tomy through the transverse
mesocolon and a jejunotomy.
An endoscopic 2.5 mm linear
stapler is then used to create a
side-to-side pseudocyst-jeju-
nostomy. The access pseudo-
cystotomy-jejunotomy is then
closed using running or inter-
rupted suture.
62 Kaban et al

CONCLUSION 8. Vitas GJ, Sarr MG: Selected management of pancreatic pseudo-

cysts: Operative versus expectant management. Surgery 111:123-
The spectrum of minimally invasive techniques that have 130, 1992
developed over the last 20 years has gradually improved 9. Warshaw AL, Rattner DW: Timing of surgical drainage for pan-
creatic pseudocyst. Clinical and chemical criteria. Ann Surg 202:
but also complicated the management of pancreatic
720-724, 1985
pseudocysts. It remains to be seen which technique, if 10. Adams DB, Harvey TS, Anderson MC: Percutaneous catheter
any, will surface as definitive therapy. The complex vari- drainage of infected pancreatic and peripancreatic fluid collec-
ability of pseudocysts in terms of location, maturity, set- tions. Arch Surg 125:1554-1557, 1990
ting, and pancreatic ductal anatomy, will most likely per- 11. Gumaste VV, Pitchumoni CS: Pancreatic pseudocyst. Gastroen-
petuate many of the current modalities for certain subsets terologist 4:33-43, 1996
12. Heider R, Meyer AA, Galanko JA, et al: Percutaneous drainage of
of patients. This is certainly true for laparoscopic inter-
pancreatic pseudocysts is associated with a higher failure rate than
vention, which as a minimally invasive technique is still surgical treatment in unselected patients. Ann Surg 229:781-791,
maturing but has the versatility to remain an important 1999
part of the evolving treatment algorithm for pancreatic 13. VanSonnenberg E, Wittich GR, Casola G, et al: Percutaneous
pseudocysts. drainage of infected and non-infected pancreatic pseudocysts: Ex-
perience in 101 cases. Radiology 170:757-761, 1989
REFERENCES 14. Beckingham IJ, Krige EJ, Bornman PC, et al: Long term outcome of
1. Bradley EL: A clinically based classification system for acute pan- endoscopic drainage of pancreatic pseudocysts. Am J Gastroen-
creatitis. Arch Surg 128:586-590, 1993 terol 94:71-74, 1999
2. Salvo AF, Nematolahi H: Distant dissection of a pancreatic 15. Vitale GC, Lawhon JC, Larson GM, et al: Endoscopic drainage of
pseudocyst into the right groin. Am J Surg 126:430-432, 1973 pancreatic pseudocyst. Surgery 126:616-621, 1999
3. Yeo LJ, Sarr MG: Cystic and pseudocystic diseases of the pancreas. 16. Park AE, Henniford BT: Therapeutic laparoscopy of the pancreas.
Curr Probl Surg 31:167-243, 1994 Ann Surg 236:149-158, 2002
4. Castillo CF, Targarona J, Thayer SP, et al: Incidental pancreatic 17. Fowler DL, White SA: Laparoscopic cystogastrostomy. Surg En-
cysts: Clinicopathologic characteristics and comparison with dosc 9:626, 1995
symptomatic patients. Arch Surg 138:427-434, 2003 18. Gagner M: Laparoscopic transgastric cystgastrostomy for pancre-
5. Bradley EL, Clements JL, Gonzalez AC: The natural history of atic pseudocyst. Surg Endosc 8:239, 1994
pancreatic pseudocysts: A unified concept of management. Am J 19. Ibrahim IM: Laparoscopic cyst-gastrostomy. Surg Endosc 8:975,
Surg 137:135-141, 1979 1994
6. Pitchumoni SC, Agarwal N: Pancreatic pseudocysts: When and 20. Morino M, Garrone C, Locatelli L, et al: Laparoscopic manage-
how should drainage be performed. Gastro Clin North Am 28: ment of benign pancreatic cystic lesions. Surg Endosc 9:625,
615-635, 1999 1995
7. Yeo CJ, Bastides JA, Lynch-Nyhan A, et al: The natural history of 21. Mouiel J, Crave F: Pancreatic cyst treated by laparoscopic cysto-
pancreatic pseudocysts documented by computed tomography. jejunal anastomosis on a Roux-en-Y loop. Surg Endosc 9:625,
Surg Gynecol Obstet 170:411-417, 1990 1995
Laparoscopic Distal Pancreatectomy
Steven M. Strasberg, MD

aparoscopic distal pancreatectomy is an uncommonly pling. Our preference is to transect the gland using a
L performed “innovative” procedure with about 50
cases reported in the literature to the end of 2002. The
bipolar cautery device and then suture both the duct and
the gland. It has been shown in open distal pancreatec-
largest case series is nine patients. The most common tomy that suture of the duct is associated with a lowered
indications for the procedure have been insulinoma, postoperative fistula rate. With any method, postopera-
chronic pancreatitis, and cysts of the pancreas. A few tive fistula and fluid collections have been a problem. The
procedures have been performed for adenocarcinoma and benefits of the procedure are those normally associated
nonfunctioning islet cell tumors. The usual reason for with laparoscopic procedures: less pain, shorter hospital-
choosing resection over enucleation for islet cell tumors ization, and earlier return to work. The conversion rate
has been proximity to the pancreatic duct. has been about 15%, usually because of poor visibility or
As would be expected with an operation in its infancy, hemorrhage.
a dominant technique has not yet emerged. Three ap-
Patients being considered for this procedure should be
proaches have been described including distal pancreatec-
made aware of the innovative nature of the method, in-
tomy with splenectomy, distal pancreatectomy with pres-
cluding the fact that only a relatively small number of the
ervation of spleen and splenic vessels, and distal pancre-
procedures have been performed and that the procedure
atectomy with preservation of spleen but resection of
retropancreatic splenic vessels. In the latter case, the is in a stage of evolution. It is the author’s opinion that the
spleen is dependent on blood supply from the short gas- procedure should not be used for solid malignancies of
tric vessels. Likewise, there is no standard method for the the pancreas at the present time. Benign tumors and cysts
management of the pancreatic stump. In most, occlusion and focal pancreatitis seem to be the best indications
and transection has been accomplished using a stapler, currently.
but often the shape of the pancreas is unsuitable for sta- The procedure described below is of the spleen-spar-
ing, splenic vessel-sparing type. The patient is positioned
on a bean bag, with the legs on spreader bars and with the
From the Department of Surgery and Institute for Minimally Invasive Surgery, left side rolled up about 20°. The camera is positioned at
Washington University in St. Louis, St. Louis, MO.
Address reprint requests to Steven M. Strasberg, MD, Department of Surgery,
the umbilicus, and four additional ports are inserted in an
Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, arc about 15 cm from the midpoint of the body of the
MO 63110. pancreas. One of these is used to retract the stomach and
© 2004 Elsevier Inc. All rights reserved.
1524-153X/04/0601-0009$30.00/0
liver, two by the operator who stands between the legs
doi:10.1053/j.optechgensurg.2004.01.005 and one by the assistant.

Operative Techniques in General Surgery, Vol 6, No 1 (March), 2004: pp 63-67 63

64 Steven M. Strasberg

OPERATIVE TECHNIQUE

1 The greater omentum is opened

just below the gastroepiploic arcade.
This dissection should be carried
over to the short gastric vessels on
the left and to the pylorus on the
right. There are usually filmy con-
genital adhesions between the pan-
creas and the stomach that require
division. The entire anterior surface
of the body of the pancreas should
be made visible. For lesions in the
neck it is desirable to divide the right
gastroepiploic vessels (not shown).

2 The anterior surface of the

pancreas is displayed. The initial
mobilization of the distal pancreas
is commenced by division of the
peritoneum at the inferior border
of the pancreas. This is usually a
filmy avascular plane although oc-
casionally small arteries and veins
that run up into the mesocolon are
present. The division of perito-
neum should be extended left-
wards from the neck of the pan-
creas to the pancreatic trail.
Laparoscopic Distal Pancreatectomy 65

3 Once the dissection on the in-

ferior border has been carried over
to the left, the pancreas is rolled up
exposing the posterior surface.
Whenever possible, the dissection
occurs on the underside and infe-
rior border of the pancreas. Such
dissection is carried over as far as
the tail of the pancreas. The tail of
the pancreas is mobilized by divid-
ing the tissues between it and left
part of the transverse colon and the
splenic flexure.

4 The posterior wall of the splenic

vein is exposed. A layer of retroper-
itoneal fascia covers the splenic vein
posteriorly. This is incised longitu-
dinally and the wall of the vein is
exposed. Small tributaries of the
splenic vein coming from the back of
the pancreas are divided between
clips or with a bipolar cautery de-
vice.
66 Steven M. Strasberg

5 Attention is then turned to the

superior border of the pancreas. A
tape is placed around the splenic ar-
tery to obtain vascular control. The
peritoneum is opened at the supe-
rior border of the gland exposing the
splenic artery and its branches.

6 As a result of the preceding

steps, the superior and inferior bor-
der and the underside of the distal
pancreas have been freed. The body
of the pancreas is elevated off the
splenic vein and artery beginning
at the tail, taking remaining
branches of these structures as they
pass into the pancreas. This pro-
cess is continued until the body of
the pancreas is freed for at least 1
cm to the right of the most right-
ward edge of the lesion. Two stay
sutures are placed in the neck of
the pancreas and the pancreas is
prepared for division along the
body of the pancreas proximal to
the lesion.
Laparoscopic Distal Pancreatectomy 67

7 (A) After division of the pan-

creas, with a bipolar cautery device,
the pancreatic duct is visualized and
oversewn with a single nonabsorb-
able fine suture. (B) The pancreatic
stump is then oversewn with a run-
ning suture.