Pancreatic duplication associated with a gastric duplication cyst: laparoscopic approach

We report the case of a robot-assisted pancreaticoduodenectomy for vaterian ampulloma. The patient is positioned in the French position with the assistant between the legs and the robot at the head. Five trocars are used: the camera is introduced through the umbilical trocar. The operation begins with the exploration of the peritoneum and of the liver. The gastric antrum is divided. Each structure of the hepatic pedicle is skeletonized. The superior border of the pancreas is dissected, hence allowing to approach the mesentericoportal axis.
The surgeon proceeds to the inferior border of the pancreas in order to find the mesentericoportal axis and to achieve a retropancreatic passage, which is where the pancreas will be divided. The pancreas is divided using the Sonicision™ cordless ultrasonic dissection device. The first jejunal loop is divided with a stapler. The specimen is totally mobilized ‘en bloc’, and freed from the portal vascular axis with a dissection of the right border of the coeliac trunk. At the end of the dissection, the different arterial and venous structures are skeletonized with a lymph node resection. The reconstruction is performed with a pancreaticogastrostomy, hepaticojejunostomy, and gastrojejunostomy.

In this authoritative lecture, Dr. Asbun briefly describes the main principles related to the management of laparoscopic HPB surgery complications. He highlights the main resources, which can be assessed by the surgeon in order to overcome vascular complications. He outlines key steps to control bleeding and provides technical recommendations to repair vessels and to control bleeding with examples of different cases.

We report the case of a 43-year-old male patient who was diagnosed with insulinoma and had a robotic enucleation of an isthmic pancreatic tumor in November 2012. However, the patient presents with clinical recurrences of hypoglycemia 18 months later. Re-evaluation studies demonstrated a local recurrence. A laparoscopic central pancreatectomy was indicated. The procedure started with the opening of the lesser sac. The splenic vessels were dissected and controlled. A retropancreatic passage along the venous mesenterico-portal axis was performed. Ultrasonography was carried out to assess the pancreatic recurrence area. The pancreas isthmus was transected. A pancreaticogastric anastomosis was performed at the posterior aspect of the stomach. The resected specimen confirms the recurrence of an insulinoma, which has been entirely removed.

This is the case of a robotic pancreaticoduodenectomy for an intraductal papillary mucinous neoplasm (IPMN) performed in a 50-year-old patient discovered on pancreatic MRI after three episodes of acute pancreatitis.

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 (

In this lecture, indications of laparoscopic pancreatic surgery are discussed. Following enthusiasm for the procedure at first, the Whipple operation now seems to be abandoned, while treatment of pancreatic islet cell tumors, pseudocystic and distal lesions are feasible and give good results.

Distal pancreatectomy is the standard curative treatment for symptomatic benign, premalignant, and malignant disease of the pancreatic body and tail. Nowadays, more than 80% of distal pancreatectomies are performed laparoscopically. The basic advantages of this approach over the open approach are the following: reduced blood loss, fewer complications, and shorter hospital stay. Pancreatic neoplasms, chronic pancreatitis, and pancreatic cysts are the main indications for laparoscopic distal pancreatectomy. Distal pancreatosplenectomy and spleen-preserving pancreatectomy are contraindicated in metastatic diseases, peritoneal carcinosis, vascular invasion, and pancreatitis involving the entire pancreas. Spleen-preserving distal pancreatectomy should be attempted in case of benign disease. Spleen preservation should preferably be achieved by preserving the splenic vessels (Kimura technique), but also by resecting the splenic vessels and maintaining vascularity through the short gastric vessels and the left gastroepiploic artery (Warshaw’s technique).

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.