Pancreatic duplication associated with a gastric duplication cyst: laparoscopic approach

In this video, a laparoscopic distal pancreatectomy with a splenectomy is demonstrated. The colon is mobilized from the omentum and the splenic flexure is lowered completely. The dissection is completed towards the right side in order to access the pancreatic isthmus. The dissection is initiated at the level of the inferior pancreatic port in order to identify the mesentericoportal axis. The retropancreatic dissection is performed. The splenic vein and the splenic artery are dissected and taped. A tape is placed around the pancreas in order to facilitate the dissection thanks to the traction exerted. The pancreas is divided by means of a stapler, tan cartridge. The splenic vessels were divided through Hem-o-lok™ Polymer Locking Ligation Systems. The dissection is performed from the right to the left side of the retropancreatic region. The greater omentum is dissected in close contact with the greater curvature of the stomach. The short gastric vessels are progressively divided. The division of the posterior mesogastrium allows to completely free the specimen, which is then placed in a bag. The specimen is removed through a suprapubic Pfannenstiel’s incision.

Insulinoma is the most common pancreatic endocrine neoplasm. Treatment is by excision. In the pre-laparoscopic era, the enucleation was performed by laparotomy, but surgeons have shown that it can be performed laparoscopically. Preoperative localization is important in planning port placement and in guiding laparoscopic ultrasonography if necessary.
When enucleation is performed, the pancreatectomy provides no oncologic advantage.

The majority of insulinomas are benign, solitary, and are located within the pancreatic parenchyma. Because of the characteristic clinical presentation of hypoglycemia, they are usually diagnosed when they are still small (

This video shows the case of a 48-year-old male patient with a history of epigastric pain for 20 days, with the presence of nausea and vomiting but no self-reported fever. The patient was presented at the ER for examination. Computerized tomography (CT) scanning revealed a very rare case of pancreatic duplication associated with a gastric duplication cyst. He was referred to our service and then treated by laparoscopic route with partial gastrectomy and pancreatic resection (pancreas horn). On the 2nd postoperative day, the patient was discharged and allowed for free oral feeding. This is the second study in the literature reporting a case of laparoscopic resection of a gastric duplication cyst together with pancreatic resection. Of note, this is the first study in which the accessory pancreas communicates with the pancreatic head.

Insulinoma is the most common functional neuroendocrine tumor of the pancreas. Most insulinomas are benign and solitary. Surgical resection is preferred for insulinomas and cure is achieved in more than 90% of the patients. Successful surgery requires accurate localization based on contrast enhanced CT-scan, PET-scan, and intraoperative ultrasound. This video shows a laparoscopic left pancreatectomy in a young patient presenting with typical symptoms evocative of Whipple's triad. Preoperative imaging studies identified two pancreatic tumors. Laparoscopic exploration and ultrasound identified four distinct tumors, all of them expressing somatostatin and insulin. This clinical case highlights the necessity and value of ultrasound exploration during surgery for neuroendocrine tumors.

We report the case of a 55-year-old woman with a hypervascularized lesion at the posterior aspect of the pancreatic tail, which is evocative of an endocrine tumor of the pancreas. We decided to perform a laparoscopic enucleation of this tumor using a posterior approach. The patient is positioned in a right lateral decubitus. The intervention begins with the opening of the posterior mesogastrium, which allows to tilt the entire splenopancreatic block to the right. The tumor located on the posterior aspect clearly appears. An enucleation of the tumor is then performed using the monopolar cautery hook. In order to facilitate the lesion's exposure, a traction suture will be placed. This helps to expose the tumor. The inferior border of the tumor is freed from the splenic vein and the monopolar hook allows to perform a step-by-step enucleation. An intrapancreatic freeing of the lesion's deep plane is achieved using the Sonicision™ device. The tumor is placed into a bag and extracted through a port. The extemporaneous exam confirms the diagnosis of an endocrine tumor. Hemostasis is controlled. The splenopancreatic block is put back in its original anatomical position. There is no pancreatic fistula. The patient is discharged on postoperative day 5. The final diagnosis confirms a G1 endocrine tumor.

Benign inflammatory lesions, cystic neoplasms, and neuro-endocrine tumours in the body and tail of the pancreas are considered good indications for laparoscopic distal pancreatectomy and/or en-bloc pancreatosplenectomy. Laparoscopic resection of malignant neoplasms has raised concern about the radicality of resection and oncological outcomes.
This video demonstrates the technique of laparoscopic radical antegrade pancreatosplenectomy (lap-RAP), which achieves a radical resection with clear circumferential margins. The resection proceeds from right to left to include a coeliac lymphadenectomy, early division of the splenic artery, splenic vein and neck of pancreas, and medial to lateral mobilization of the pancreas posterior to Gerota's fascia to ensure an adequate posterior oncological clearance.
Lap-RAP extends the benefits of laparoscopic pancreatectomy to include malignant lesions in the body and tail of the pancreas.
This video is recommended for experienced laparoscopic surgeons.

The indication for robotic surgery in pancreatic disease has been controversial. In this key lecture, Dr. Giulianotti explains the advantages and possible benefits of the robotic approach.

In this authoritative lecture, Dr. Horacio J Asbun outlines basic principles and technical recommendations for laparoscopic pancreatectomy.