Enucleation of a pancreatic nonfunctioning endocrine tumor localized with intraoperative US and augmented reality

Pancreatic endocrine tumors (PETs) are uncommon but clinically challenging and fascinating tumors. Small, benign neoplasms are readily curable by surgical resection. This video presents the case of a 40-year-old woman with a tumor at the level of the pancreatic body. The patient’s virtual reconstruction is used during surgery to help the surgeon pinpoint the lesion accurately. A laparoscopic approach is used.

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Enucleation of a pancreatic nonfunctioning endocrine tumor localized with intraoperative US and augmented reality

Authors

B Dallemagne, L Soler, J Marescaux

Abstract

Pancreatic endocrine tumors (PETs) are uncommon but clinically challenging and fascinating tumors. Small, benign neoplasms are readily curable by surgical resection. This video presents the case of a 40-year-old woman with a tumor at the level of the pancreatic body. The patient’s virtual reconstruction is used during surgery to help the surgeon pinpoint the lesion accurately. A laparoscopic approach is used.

Classification

complex cases

Keywords

Enucleation, pancreatic nonfunctioning endocrine tumor, intraoperative US, augmented reality

Media type

Surgical video

Duration

09'54''

Publication

2009-09

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E-publication

WeBSurg.com, Sept 2009;9(09).
URL: http://www.websurg.com/doi-vd01en2723.htm

Enucleation of a pancreatic nonfunctioning endocrine tumor localized with intraoperative US and augmented reality

1. Clinical case presentation 00'10''

We present the case of a 40-year-old woman with a tumor at the level of the pancreatic body. Initially, the lesion measured 10mm, but during subsequent re-evaluations, we observed that its size had doubled. The endocrine and hormonal work-ups are normal, and the CT-scan of the abdomen does not reveal any metastatic lesions. The tumoral work-up is performed with the CT-scan, also used to perform the patient’s virtual reconstruction on which we can observe the endocrine tumor’s position and its connections to the Wirsung’s duct. We know that elective enucleations are difficult when the tumor is close to the Wirsung’s duct, due to the risk of canal injury and of secondary fistulas. The patient’s virtual reconstruction will also be used during the surgery to help the surgeon pinpoint the lesion accurately. A laparoscopic approach is used. Four trocars are placed in a typical fashion for an access at the level of the superior abdomen.

2. Access to the pancreatic cavity 01'30''

The pancreatic cavity is approached by dividing the gastrocolic ligament. A lateral grasper is used to retract the stomach cephalad in order to keep the pancreatic cavity constantly open. The gastrocolic ligament’s dissection is performed with the Ligasure device, a time-saving and reliable instrument.

3. Dissection of the stomach’s adhesions 02'14''

A few adhesions to the stomach’s posterior surface are freed to create a sufficient working space.

4. Virtual reconstruction and intraoperative ultrasound 02'30''

The patient virtual reconstruction is superimposed to the peroperative view to guide the tumor’s localization, but it is the intraoperative ultrasound that allows to localize it with certainty. This lesion cannot be seen on the pancreas’ surface, and there does seem to be very little space between the lesion and the Wirsung’s duct. The intraparenchymal localization on this picture allows to identify the tumor at the top of the screen and, in touch with it, the Wirsung’s duct.

5. Pancreatic incision 03'22''

The intraparenchymal localization of the lesion requires an incision of the pancreatic capsule and of the first few millimetres of the pancreatic parenchyma. Throughout this procedure, the peroperative ultrasound allows to precisely delimit the lesion. Here we see the superimposition of the patient’s virtual reconstruction that confirms this localization. The pancreatic parenchyma is incised according to the tumor’s position. This dissection is performed using a hook with monopolar electrocautery. The main retropancreatic vessels are identified and the incision of the pancreatic parenchyma will allow to uncover the lesion whose macroscopic aspect is typical, as it is markedly different to the aspect of the pancreatic parenchyma. At this level of the capsule’s incision, there is no risk of Wirsung’s duct injury. As soon as the lesion is identified, a stitch is placed to identify it; this stitch will also allow to mobilize the lesion during its dissection.

6. Nodule dissection 05'28''

We notice here the surface of the tumoral nodule: macroscopically, its aspect is different. In this patient, the dissection is made harder by the proximity with the Wirsung’s duct. The dissection should therefore be extremely accurate; it is performed with the hook as it allows to gradually expose the various adhesions of the tumoral lesion, as well as the vascular branches that irrigate it. Some surgeons use ultrasonic dissectors to delimit the tumor; however, here, the laparoscopic view allows a microscopic study of the tumor’s perimeter with identification of the Wirsung’s duct. An accurate cleavage plane can therefore be performed in relation to the canal. Only minute applications of monopolar coagulation are allowed as more substantial applications could burn the Wirsung’s duct, leading to subsequent fistulas: this dissection should therefore be extremely accurate. The alternative to this resection is a central pancreatic resection, but it requires two anastomoses on the pancreas, a more challenging procedure technically, so the first choice remains the elective enucleation.

7. Nodule extraction 07'42''

The lesion is placed in an extraction bag. The extraction site is checked, especially for potential pancreatic leakages, which is not the case here. The Wirsung’s duct is well identified.. The tumor’s macroscopic aspect is typical of an endocrine tumor. The histopathologic analysis confirms the lesion’s benign nature so that surgery will be restricted to this elective enucleation. To complete the hemostasis, some biological glue is applied into the depression left by the resection. We place a drain as there is a significant risk of pancreatic fistula. The postoperative period was notable for a biological pancreatitis with epigastralgia that was easily controlled with basic analgesics. The drain was left in place for 48 hours postoperatively. The immuno-histochemical analysis demonstrated cell positivity for chromogranine (DAK-A3 clone) and synaptophysine (polyclonal). The K167 (Sp6 clone) proliferation index is under 1%.