Safety and feasibility of laparoscopic pancreatoduodenectomy

Laparoscopic pancreaticoduodenectomy (LPD) has been safely performed by experts with favorable surgical outcomes. However, the feasibility of LPD remains controversial. LPD is generally considered a challenging operation that requires advanced laparoscopic techniques. In particular, pancreatic reconstruction can be safely performed by only laparoscopic experts. Thus, guidelines created by LPD experts are valuable in indicating the future direction of LPD. Qin et al. developed practical guidelines regarding the safety and feasibility of LPD with 28 international experts from eight countries (1). To create these guidelines, the first summit on minimally invasive pancreatico-biliary surgery was held in Wuhan, China, to promote the development of LPD. Based on a systematic literature review and expert opinions, 16 statements were created by the experts. These statements provide useful guidelines not only for surgical trainees who will attempt LPD but also for specialized surgeons. This expert consensus will contribute to the safe implementation of LPDs in the future.

Recently, the development of robotic technology has been remarkable, and many studies have shown that robotic surgery provides better surgical results than laparoscopic surgery in minimally invasive pancreaticoduodenectomy (MIPD) (2,3). Therefore, many surgeons may believe that MIPD should be performed with robotic surgery. Here, the significance of conducting this project is that it focuses on surgeons who need laparoscopic surgery to perform MIPD due to the high cost of robotic surgery. Experts have performed LPD with feasible surgical outcome compared with open surgery, and have provided beneficial information.

In this consensus meeting, statements regarding the safety and feasibility of LPD were summarized based on the surgical results reported by LPD experts. First, they stated that complication rates including postoperative pancreatic fistula (POPF) in patients who underwent LPD was equivalent to open pancreaticoduodenectomy (OPD), and LPD had benefits such as reduced blood loss and surgical site infection rate and shortened hospital stay. In addition, as another advantage of LPD, they described that patients who undergo LPD experience improved quality of life in the first 6 months after surgery. They also described oncological factors, stating that the number of harvested lymph nodes and positive resection margins were comparable between LPD and OPD; further, recurrence-free and overall survival after LPD were equal to that after OPD. Thus, their statements showed that LPD performed by experts had several advantages over OPD. However, as these experts mentioned, sufficient training is required due to its difficulty. Recently, some studies have reported that LPD has higher conversion and complication rates than robotic pancreaticoduodenectomy (RPD), and longer learning curve has been reported to be required in LPD compared with RPD (4,5). Therefore, an expert statement on the process of becoming an LPD expert is very important.

Ensuring safety is extremely important until LPD trainees obtain sufficient surgical skills. Thus, the experts have summarized several statements regarding operator criteria for the implementation of LPD. Regarding the LPD learning curve, their statements have described that surgeons needed 30–50 case experiences to obtain technical competence in LPD. They suggested that the surgeon attempting to introduce LPD requires both advanced laparoscopic skills and >50 cases of open OPD experience. They also mentioned appropriate center criteria for LPD and recommend that LPD should be performed in a pancreatic center with at least 25 cases of OPD per year. Pancreaticoduodenectomy has a higher rate of serious complications than other gastrointestinal surgery, and recovery after complications is very important. It has been reported that OPD mortality in low-volume centers was significantly high compared to OPD mortality in high-volume centers, and strict center criteria are very important for safe LPD (6). They also propose that LPD should be performed only by surgeons who received training in high-volume pancreatic centers, and encourage surgeons to pursue training.

Needless to say, establishing surgical training program is important to stabilize surgical outcome of LPD. In the statements, they have reported the usefulness of various training methods including video training, box trainers, virtual reality simulators, and proctored practice on porcine model. They described that LPD training programs should be established at large-volume pancreatic centers with a protocol in place to certify appropriately trained surgeons. In Europe, LPD training programs; the Longitudinal Assessment and Realization of Laparoscopic Pancreatic Surgery (LAELAPS-2) was established by LPD experts, and they conducted randomized trials of OPD and LPD performed by surgical trainees who received this training program (7). However, this clinical trial was suspended because of the high mortality of LPD. Members of this consensus meeting were involved in the development of this training program, and we hope that they will establish novel training program to provide safe introduction of LPD in the future. In addition, the statement regarding the surgical team is noteworthy. Although there is no paper report regarding the composition of the surgical team in LPD, it seems to be important that the operating surgeon, assistant surgeon, anesthesiologist, and nursing team for LPD should be fixed for safe LPD as an expert opinion.

This consensus meeting showed that LPD performed by experts were safe and feasible, but required adequate training and strict operator/center criteria. Most surgeons now consider RPD as the mainstream of MIPD, therefore, their statement is meaningful in re-considering the role of LPD.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Hepatobiliary Surgery and Nutrition. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-21-533/coif). The authors have no conflicts of interest to declare.

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References

1. Qin R, Kendrick ML, Wolfgang CL, et al. International expert consensus on laparoscopic pancreaticoduodenectomy. Hepatobiliary Surg Nutr 2020;9:464-83. [Crossref] [PubMed]
2. Kamarajah SK, Bundred J, Marc OS, et al. Robotic versus conventional laparoscopic pancreaticoduodenectomy a systematic review and meta-analysis. Eur J Surg Oncol 2020;46:6-14. [Crossref] [PubMed]
3. Lof S, Vissers FL, Klompmaker S, et al. Risk of conversion to open surgery during robotic and laparoscopic pancreatoduodenectomy and effect on outcomes: international propensity score-matched comparison study. Br J Surg 2021;108:80-7. [Crossref] [PubMed]
4. Ricci C, Casadei R, Taffurelli G, et al. Minimally Invasive Pancreaticoduodenectomy: What is the Best "Choice"? A Systematic Review and Network Meta-analysis of Non-randomized Comparative Studies. World J Surg 2018;42:788-805. [Crossref] [PubMed]
5. Chan KS, Wang ZK, Syn N, et al. Learning curve of laparoscopic and robotic pancreas resections: a systematic review. Surgery 2021;170:194-206. [Crossref] [PubMed]
6. Kimura W, Miyata H, Gotoh M, et al. A pancreaticoduodenectomy risk model derived from 8575 cases from a national single-race population (Japanese) using a web-based data entry system: the 30-day and in-hospital mortality rates for pancreaticoduodenectomy. Ann Surg 2014;259:773-80. [Crossref] [PubMed]
7. de Rooij T, van Hilst J, Topal B, et al. Outcomes of a Multicenter Training Program in Laparoscopic Pancreatoduodenectomy (LAELAPS-2). Ann Surg 2019;269:344-50. [Crossref] [PubMed]