浅野 之夫

In the field of gastroenterological surgery, laparoscopic surgery has advanced remarkably, and now accounts for most gastrointestinal operations. This paper outlines the current status of and future perspectives on robot-assisted laparoscopic pancreatectomy. A review of the literature and authors' experience was undertaken. The da Vinci Surgical System is a robot for assisting laparoscopy and is safer than conventional endoscopes, thanks to the 3-dimensional hi-vision images it yields, high articular function with the ability to perform 7 types of gripping, scaling function enabling 2:1, 3:1, and 5:1 adjustment of surgeon hand motion and forceps motions, a filtering function removing shaking of the surgeon's hand, and visual magnification. By virtue of these functions, this system is expected to be particularly useful for patients requiring delicate operative manipulation. Issues of importance remaining in robot-assisted laparoscopic pancreatectomy include its time of operation, which is longer than that of open surgery, and the extra time needed for application of the da Vinci compared with ordinary laparoscopic surgery. These issues may be resolved through accumulation of experience and modifications of the procedure. Robot-assisted laparoscopic pancreatectomy appears likely to become a standard procedure in the near future.

To apply duodenum-preserving pancreatic head resection (DPPHR) as radical procedure for benign or low-grade malignant tumors, it needs the reconciliation of complete pancreatic head resection and preservation of the bile duct and peripancreatic vessels. Several modifications have been introduced and applied to remove these lesions, however, the techniques have not been made clear in the management of the peripancreatic vessels and the bile duct. The long-term outcomes of the DPPHR have been reported as extremely rare in comparison with pylorus preserving pancreatoduodenectomy (PPPD) in these pancreatic head tumors. The angiograms by multi-detector row CT (MD-CT) can be reconstructed more physiologically than selective angiography. The anterior arcade is predominant in 43% of 64 patients. Therefore, we modified the DPPHR to include a complete resection of the pancreatic head and the preservation of both anterior and posterior arterial arcades. The bile duct is covered by the pancreatic parenchyma in various ways. The techniques of the preservation of the bile duct are also introduced. We performed 21 DPPHRs and 19 PPPDs in the patients with benign or low-grade malignant pancreatic head tumor. There was no significant difference in operative factors. The postoperative death was one patient in PPPD, but none in DPPHR. The postoperative complications of PPPD were more often than that of DPPHR. There is no postoperative recurrence in DPPHR in the follow-up period from 2 to 216 months. Both exocrine and endocrine function and the long-term results following DPPHR were superior to those following PPPD. The DPPHR should be favored over the PPPD in benign or low-grade malignant tumors of the head of the pancreas if there is no compromise with oncologic radicality.

Introduction Single-incision laparoscopic surgery (SILS) offers the potential advantages of reduced postoperative pain and a lower incidence of port-site complications. Moreover, careful attention to closure can reduce the scarring after surgery. Consequently, this method is a promising technique for reducing postoperative pain, decreasing complications, and improving cosmesis. We have performed cholecystectomy in eight patients by SILS. The umbilicus was the point of entry to the abdomen in all patients. Methods Between May 2009 and October 2009, 31 patients underwent cholecystectomy at our hospital. The umbilicus was the point of entry to the abdomen in all patients. Three SILSs were performed using a new SILS port, and five SILSs were performed by the conventional method in which three ports are inserted into the umbilicus; the remaining ten patients underwent multiple-incision laparoscopic cholecystectomy (standard cholecystectomy). The results for the patients who underwent standard cholecystectomy, conventional SILS, and SILS using the new port were compared using the Mann-Whitney U test. The data are expressed as mean +/- standard deviation. Result Of the eight cholecystectomies carried out, three were performed by SILS using the new port. No complications or mortalities were associated with this technique. The mean operating times for conventional SILS, SILS with the new port, and standard cholecystectomy were 154 +/- 57, 120 +/- 11, and 100 +/- 51 min, respectively; these inter-group differences are not significant. The blood loss in conventional SILS, SILS with the new port, and standard cholecystectomy was 9 +/- 16, 1, and 6.1 +/- 11 g, respectively; these inter-group differences are not significant. All umbilical incisions were concealed within the umbilicus. Conclusion Cholecystectomy performed using SILS with the new port is a safe and feasible approach with reasonable operation times.

During a pancreatoduodenectomy (PD) it is important that the anatomy of the arcade of blood vessels in the head of the pancreas is fully understood before the surgery in order to reduce intraoperative bleeding. In most of the patients our group has treated, the inferior pancreaticoduodenal artery (IPDA), one of the efferent arteries of the head of the pancreas, has formed a short common trunk with the first jejunal artery (FJA). Thus, by first locating the origin of the FJA, it was easier to locate the IPDA. There are two ways to locate the IPDA: (1) by measuring the distance between the origin of the superior mesenteric artery (SMA) and that of the FJA; (2) by measuring the distance between the origin of the middle colic artery (MCA) and that of the FJA. Here, we report our measurements of both distances using three-dimensional (3D) models of arteries constructed with multidetector-row computed tomography (MD-CT) images and discuss which is the better measurement to determine the location of the IPDA during PD. A total of 140 patients underwent 64-MD-CT imaging to acquire early and late arterial phase scans. The distance between the origin of the SMA and that of the FJA and the distance between the origin of the MCA and that of the FJA origin were measured. In patients whose IPDA formed either a common trunk with the FJA or arose directly from the SMA, the IPDA or the common truck was located in parallel with the SMA at a very short distance of approximately 18 mm from the MCA origin towards the center. The distance between the SMA origin and the IPDA was significantly longer (approximately 36 mm). Therefore, locating the MCA origin during PD helped determine the location of the IPDA. However, in patients whose anterior inferior pancreaticoduodenal artery (AIPDA) and posterior inferior pancreaticoduodenal artery (PIPDA) arose separately, the distance between the AIPDA origin and the MCA origin was approximately 18 mm, the distance between the AIPDA origin and the PIPDA origin was approximately 19 mm, and the distance between the PIPDA origin and the SMA origin was 19 mm. Thus, locating the SMA helped determine the location of the IPDA during PD in these patients. Based on our findings that the distance between the IPDA origin and the MCA origin was short, we have shown that it is effective to locate the MCA origin in order to determine the location of the IPDA.

The current literature contains little information about laparoscopic surgery for pancreatic disease. We performed spleen-preserving distal pancreatectomy on 7 cases during the period from 2005 to 2008 at our university hospital, including 2 laparoscopic operations. Case 2: A 54-year-old woman was found to have a hypoechoic 4x4 cm lesion in the tail of the pancreas, adjacent to and impinging on the spleen. On careful assessment we suspected a mucoid cystic tumor (MCT), and performed a laparoscopic spleen-preserving distal pancreatectomy. Blood loss was 380 g, and operating time was 310min. Case 1: A 27-year-old woman was found to have a hypoechoic 2x2 cm mass on ultrasound examination of the body of the pancreas. We performed laparoscopic spleen-preserving distal pancreatectomy for solid pseudopapillary tumour (SPT) of the pancreas. Blood loss was minimal, and operating time was 182 min. The other 5 cases were operated upon using the open method. All were female, with an average age of 54.8 years. The average blood loss was 387g. Operating time was 321 min. Laparoscopic pancreatic surgery is generally thought to be difficult owing to the need for lymph node resection, and because nerve plexus invasion occurs with malignant tumors such as pancreatic cancer. The present case series was reported to demonstrate the techniques that have evolved the safety of the operation and its future potential related to the minimally invasive nature of the surgery.