Initial experience of single-incision plus one port total laparoscopic pancreaticoduodenectomy

From November 2021 to March 2022, 57 cases of LPD were performed by a single surgical team in the Department of Pancreatic Surgery, West China Hospital, Sichuan University. Data were prospectively recorded in the database. Among these patients, 10 accepted SILPD + 1 (SILPD + 1 group), and 47 accepted CLPD (CLPD group). The inclusion criteria of SILPD + 1 and CLPD were almost the same, except that we tended to choose lower body mass index (BMI) and younger patients for SILPD + 1 just as SILPD [7]. The final decision on the surgical approach (SILPD + 1 or CLPD) was made by the surgeon and patient. We decided to perform only OPD for patients with suspected artery involvement (4 patients) or those who rejected to accept laparoscopic surgery (2 patients). For the remaining patients, we adopted the policy of attempting laparoscopic surgery, and 10 patients were actively converted to laparotomy by the surgeon in the exploration phase. Thus, these 16 patients were excluded from this study. Data in terms of demographic characteristics (surgical approach, age, sex, BMI, American Society of Anesthesiology (ASA) score, hemoglobin, total bilirubin, tumor size, pathological diagnosis, pancreatic duct diameter, and gland texture), intraoperative variables (venous resection, estimated blood loss, and transfusion) and postoperative variables (postoperative hospital stay, visual analog scale (VAS), exhaust time, time of drainage tube remove, and complications) were collected. Follow-up data were collected one month after the surgery. Informed consent was obtained from all patients, and the study was approved by the Ethics Committee of Sichuan University (approval number 2021(1040)).

All patients underwent enhanced computed tomography preoperatively to confirm the diagnosis and evaluate the extent of the tumor. Other routine examinations were performed, such as blood tests, electrocardiograms, and chest X-rays. Percutaneous transhepatic choledochus drainage was selectively performed for patients with severe jaundice to facilitate biliary drainage preoperatively. A nasogastric tube (NGT) was used during surgery and removed 1–2 days after surgery, and oral intake was advanced as tolerated [10]. Serum and drainage amylases were routinely assessed on postoperative days (PODs) 1, 3, 5, and 7. Computed thoracic and abdominal cavities tomography was performed on POD 4 or 5. The abdominal drainage was removed for patients with drainage amylase lower than 3000 U/L when computed tomography demonstrated no abnormal findings. Patients were discharged when oral intake and moderate activity were tolerated without any abnormal postoperative complications or laboratory findings [7].

Under general anesthesia, the patient was placed in the supine position with legs apart. A 10 mm trocar was placed for the telescope. For the CLPD group, five trocars (three 12 mm trocars, a 10 mm trocar, and a 5 mm trocar) were placed in a “V”-shape (Fig. 1a). For the SILPD + 1 group, a 4 cm incision was made in the umbilical midline. Three trocars (a 12 mm, a 10 mm, and a 5 mm trocar) were inserted through the glove fingers. Then, a homemade multichannel device comprising a soft-tissue retractor with a surgical glove was inserted. An additional 12 mm trocar was placed slightly lateral to the left midclavicular line at the level of 1 cm below the costal edge (Fig. 1b). For the CLPD group, the CO₂ pneumoperitoneum was established at 12–13 mmHg. For the SILPD + 1 group, the CO₂ pneumoperitoneum was established at 8–10 mmHg. The surgical technique has been described previously [11, 12]. In a typical procedure, the gastrocolic ligament was opened after exploration, and the hepatic flexure of the colon was fully taken down. Next, an extended Kocher maneuver was performed. Then, the duodenum, gastroduodenal artery, common hepatic duct, pancreatic neck proximal jejunum, and uncinate process of the pancreas were dissected (Fig. 2). Finally, pancreatojejunostomy was performed in Bing’s duct-to-mucosa manner [12] which has been described previously. A hepaticojejunostomy was created as an end-to-side anastomosis. We used extracorporeal gastrojejunostomy for SILPD + 1 and intracorporeal gastrojejunostomy for CLPD. For the CLPD group, the specimen was removed via an enlarged trocar site, and the abdominal cavity was drained through other trocar sites (Fig. 1c). For the SILPD + 1 group, the specimen was removed via the incision, and the abdominal cavity was drained through the trocar site (Fig. 1d).

This study used the International Study Group of Pancreatic Surgery’s definitions of pancreatic fistula and post pancreatectomy hemorrhage (PPH) [13, 14]. Follow-up data included the cosmetic score which was defined by Dunker [15]. Mortality was defined as death that occurred within 90 days of surgery. The length of postoperative hospital stay was calculated from the day of surgery up to, and including, the day of discharge. Postoperative complications were defined according to the Clavien – Dindo classification of surgical complications [16].