“单孔+1”荧光腹腔镜下保留十二指肠胰头切除术在胰头良性肿瘤中的应用

Application of "single-incision plus one port" laparoscopic duodenum-preserving pancreatic head resection for benign pancreatic head tumors

摘要:

背景与目的 随着对十二指肠壶腹部解剖的认知深入，保留十二指肠胰头切除术（DPPHR）得以出现。而伴随着微创腹腔镜技术的进步，单孔腹腔镜手术、腹腔镜保留十二指肠胰头切除术（LDPPHR）得以发展，但因操作难度巨大，“单孔”与“保留十二指肠胰头切除术”始终难以结合，故而笔者团队力求进行简化与改进，尝试单孔保留十二指肠胰头切除术（SILDPPHR）基础上通过在左肋缘下增加1个12 mm Trocar辅助操作，即SILDPPHR+1。本文主要为探讨荧光显影导航SILDPPHR+1的可行性及疗效。方法 回顾性分析2022年2月—2023年5月四川省医学科学院·四川省人民医院肝胆胰外科收治的行荧光显影导航SILDPPHR+1的8例患者临床资料。SILDPPHR+1的基本特点为：基于传统5孔法腹腔镜DPPHR、单孔腹腔镜手术的操作基础与技巧和吲哚菁绿胆道导航技术等较为成熟可行的技术进行融合、改良；合理运用缝线悬吊、交叉牵拉等方法以较少的操作空间做到最优暴露；重点关注胰十二指肠动脉弓、胆道胰腺段、十二指肠的保护，结合胰胃吻合技术减少术后并发症。结果 8例接受荧光显影SILDPPHR+1的患者均顺利完成手术，无术中改行5孔腹腔镜或中转开腹手术病例，手术时间为（360±68）min，术中出血（84±26）mL，术中均未输血。手术切除病理诊断5例为胰腺导管内乳头状黏液瘤、1例为浆液性囊腺瘤、2例为慢性胰腺炎。8例病例均实现了根治性切除，且术后未出现严重胃肠道功能障碍，平均5 d开始经口进食，术后住院时间为（9±2）d。随访（7.8±4.6）个月，8例患者均未出现肿瘤复发，均未发生胃肠道功能障碍，术后未出现胆汁漏、十二指肠缺血坏死，2例出现A级胰瘘，1例出现胆道狭窄。结论 选择合适病例，在经验较丰富的肝胆胰外科中心开展荧光显影导航SILDPPHR +1是安全可行的。

Abstract:

Background & Aims With a deeper understanding of the anatomy of the ampulla of Vater, the technique of duodenum-preserving pancreatic head resection (DPPHR) has emerged. Alongside advancements in minimally invasive laparoscopic techniques, single-incision laparoscopic surgery (SILS) and laparoscopic DPPHR have been developed. However, due to the inherent complexity of the procedure, combining "single-incision" with "preservation of the duodenal pancreatic head" has remained challenging. Therefore, our team sought to simplify and improve this approach by attempting single-incision laparoscopic DPPHR (SILDPPHR) with the addition of a 12 mm Trocar at the left rib margin, referred to as SILDPPHR+1. This study was primarily conducted to evaluate the feasibility and effectiveness of SILDPPHR+1 with fluorescence-guided navigation.Methods The clinical data of 8 patients who underwent SILDPPHR+1 with fluorescence-guided navigation in the Department of Hepatobiliary and Pancreatic Surgery of Sichuan Provincial People's Hospital between February 2022 and May 2023 were retrospectively analyzed. SILDPPHR+1 involved the integration and refinement of techniques, including traditional 5-port laparoscopic DPPHR, single-incision laparoscopic surgery, and indocyanine green cholangiography; techniques such as suture suspension and cross traction were applied to achieve optimal exposure within limited operating space; emphasizing the protection of the pancreaticoduodenal artery arch, bile duct-pancreatic segment, and the duodenum, along with the use of pancreaticojejunostomy techniques to reduce postoperative complications.Results All 8 patients who underwent fluorescence-guided SILDPPHR+1 completed the surgery successfully, with no intraoperative conversions to 5-port laparoscopic or open procedures. The average surgical duration was (360±68) min, and intraoperative blood loss was (84±26) mL, with no intraoperative transfusions required. Pathological examination revealed 5 cases of intraductal papillary mucinous neoplasm of the pancreas, 1 case of mucinous cystic neoplasm, and 2 cases of chronic pancreatitis. All 8 cases achieved radical resection, with no severe gastrointestinal dysfunction after operation. Oral intake was resumed after an average of 5 d, and the average length of hospital stay was (9±2) d. During a follow-up period of (7.8±4.6) months, none of the 8 patients experienced tumor recurrence or gastrointestinal dysfunction. There were no bile leaks or duodenal ischemic necrosis, but 2 cases developed grade A pancreatic fistula, and 1 case had biliary stricture.Conclusion In appropriately selected cases and within experienced hepatobiliary and pancreatic surgery centers, performing fluorescence-guided navigation SILDPPHR+1 is safe and feasible.