|Year : 2018 | Volume
| Issue : 4 | Page : 349-353
First robotic pylorus preserving pancreaticoduodenectomy for Frantz's tumour in an adolescent girl
Palanivelu Chinnusamy, Sumanta Dey, Bhushan Chittawadagi, Srivatsan Gurumurthy, Sandeep Sabnis, Senthilnathan Palanisamy
Deapartment of HPB and Minimal Access Surgery, GEM Hospital and Research Center, Coimbatore, Tamil Nadu, India
|Date of Submission||22-Jan-2018|
|Date of Acceptance||06-Feb-2018|
|Date of Web Publication||3-Sep-2018|
Dr. Sumanta Dey
GEM Hospital and Research Center, 45, Pankaja Mills Road, Ramanathapuram, Coimbatore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Solid pseudopapillary tumour (SPT) is one of the uncommon benign cystic neoplasms of pancreas occurring predominantly in young females. Being benign in nature, surgical resection is the treatment of choice with excellent 5-year survival. A 14-year-old girl presented with pain abdomen for 1 week. On evaluation, she was found to have a large SPT involving head and uncinate process of Pancreas She underwent robotic pylorus preserving pancreaticoduodenectomy (R-PPPD) with da Vinci® Si Robotic System (Intuitive Surgical, Sunnyvale, CA, USA). The total operating time was 480 min. Her postoperative recovery was uneventful and she was discharged on postoperative day 6.
In the era of minimally invasive surgery, robotic pancreatic resection and reconstruction are becoming more acceptable. Although the operating domain is small in younger age group, the precise movement of robotic arm and high quality magnified three-dimensional view allows the surgeons to perform PPPD on younger patients also. Young female patients suffering from SPTs can electively undergo R-PPPD with minimal morbidity and mortality. R-PPPD can become the treatment of choice for SPTs involving pancreatic head region even in paediatric and adolescent age group.
Keywords: Neoplasm, pancreas, pancreaticoduodenectomy, pseudopapillary, robotic
|How to cite this article:|
Chinnusamy P, Dey S, Chittawadagi B, Gurumurthy S, Sabnis S, Palanisamy S. First robotic pylorus preserving pancreaticoduodenectomy for Frantz's tumour in an adolescent girl. J Min Access Surg 2018;14:349-53
|How to cite this URL:|
Chinnusamy P, Dey S, Chittawadagi B, Gurumurthy S, Sabnis S, Palanisamy S. First robotic pylorus preserving pancreaticoduodenectomy for Frantz's tumour in an adolescent girl. J Min Access Surg [serial online] 2018 [cited 2021 Jan 16];14:349-53. Available from: https://www.journalofmas.com/text.asp?2018/14/4/349/231914
| ¤ Introduction|| |
Solid pseudopapillary tumour (SPT), also known as Frantz's tumour, is one of the uncommon and peculiar neoplasms of pancreas. It is found predominantly in women in younger age group. Most SPTs are benign in nature but some have the malignant potential. Here, we report a case of large SPT, detected in a 14-year-old girl who presented with pain abdomen and managed successfully by robotic pylorus preserving pancreaticoduodenectomy (R-PPPD).
| ¤ Case Report|| |
A 14-year-old girl reported to outpatient department with a history of pain abdomen for 1 week. There was no history of fever, vomiting, jaundice, blood in stool, weight loss or loss of appetite. There were neither associated co-morbid conditions nor significant family history. Her clinical examination did not reveal any significant abnormality. Her blood investigations were within normal limits including liver function tests. However, screening ultrasound of the abdomen demonstrated a lesion of size 8 cm × 7 cm × 6 cm having mixed echogenicity in head of pancreas with mild pancreatic duct dilatation. A contrast-enhanced computed tomography (CECT) scan of the abdomen [Figure 1] confirmed the mass with heterogeneous enhancement involving pancreatic head and uncinate process with main pancreatic duct diameter of 3.5 mm. Rest of pancreas and other abdominal organs were normal. No regional lymphadenopathy was noted and adjacent major vascular structures were free. Her CA 19-9 level was within normal limit. Considering the age of the patient and correlating the clinical and radiological findings, provisional diagnosis of SPT was made. After thorough preoperative check-up, she underwent R-PPPD. The operating time was 480 min with 120 ml intraoperative blood loss without any adverse events. Operative steps are described in the next paragraph. She was started on nasojejunal (NJ) tube feeding on postoperative day 1 (POD1). Injection octride (100mcg, Octerotide, Sun Pharmaceuticals Industries Ltd.) was given prophylactically till POD3 and stopped when there was no evidence of post-operative pancreatic fistula. She was allowed oral feeding from POD4 which she tolerated well and NJ feeding was tapered off. She was discharged on POD6. The histopathology report was confirmative of SPT [Figure 2] with no malignant features. The patient is under regular follow-up and leading normal life with no evidence of recurrence.
|Figure 1: Contrast enhanced computed tomography scan (pancreatic protocol) of abdomen showing (a) heterogeneous pancreatic head mass|
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|Figure 2: Histopathology slides (a) Slide showing 1- Duodenal wall with Brunner's glands, 2- Exocrine pancreas, 3- Tumour (b) Slide showing 4- Exocrine pancreas, 5- Tumour (c) Slide showing solid areas of SPT (d) Slide showing papillae with central vascular cores which are characteristic of Solid pseudopapillary tumour|
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The da Vinci® Si, HD robot (Intuitive Surgical, Sunnyvale, CA, USA) was used to perform this procedure. The patient is placed in the supine position with legs abducted at hip to allow for assistant surgeon to stand in between legs. Pneumoperitoneum is obtained with a Veress needle at the umbilicus. Port placement was done as shown in [Figure 3]. After initial inspection [Figure 3], the robot is brought into position (head end) and docked. At this time, the patient is placed in a reverse Trendelenburg position and operating table tilted right up. A percutaneous sling is used to lift up the falciform ligament and the gallbladder is tacked to the anterior abdominal wall with a loop ligature, in order to expose the porta hepatis. Due to bulky tumour, we have modified our technique from PPPD. We first mobilise the duodenojejunal flexure (DJF) by incising the peritoneum lateral to the DJF while carefully retracting the inferior mesenteric vein to the left, thus dividing the ligament of Treitz. This manoeuver frees traction on first jejunal vessels of superior mesenteric vascular pedicle which are responsible for troublesome bleeding during uncinate dissection. The right gastric and gastroepiploic vessels are dissected, sealed and divided using the robotic bipolar vessel-sealing device to enter into lesser sac, thus freeing the antrum and the duodenum from the pancreas and the tumour is visualised. The second surgeon utilises the assistant port to provide gentle, deliberate traction as needed, utilising the suction irrigator. The inferior border of the pancreas and the neck are dissected out and mobilised. A tunnel is created underneath the neck the pancreas [Figure 2], on top of the superior mesenteric and portal vein all the way to the superior aspect of the pancreas. An umbilical tape is passed underneath the pancreas Cattell–Braasch manoeuver is done and the hepatic flexure of the colon is taken down to expose the 2nd and 3rd part of duodenum. The uncinate process is mobilised away from the superior mesenteric vein and the superior mesenteric artery and uncinate process of the pancreatic head is separated from the superior mesenteric vascular pedicle. After transposing the upper jejunum to the right of the mesenteric pedicle, the loose connective tissue remaining anterior to the superior mesenteric artery is dissected. With this first stage of the procedure, the loose connective tissue around the superior mesenteric vascular pedicle is dissected en bloc. The proximal duodenum is divided distal to the pylorus using a laparoscopic Endo GIA™ stapler (Ethicon Endo surgery Inc, Cincinnati, USA) 60 mm stapler device with white cartridge, and the stomach is placed into the left upper quadrant for reconstruction later.
|Figure 3: Intra-operative images (a) Port positions (U-Umbilicus, C (Camera)-12 mm Camera port, R1-Robotic arm 1 R2-Robotic arm 2, R3-Robotic arm 3, A1-12 mm assistant port, A2-5 mm assistant port),(b)1-SPT, 2-Normal distal pancreas, 3-Stomach, 4-Gall bladder, (c) 5-Portal vein, 6-SPT, 7-Splenic vein, 8-Superior mesenteric vein, (d) 9-Pancreatic transection|
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The common hepatic artery is dissected out and a portal and celiac lymphadenectomy is performed. The gastroduodenal artery is identified, ligated, clipped and divided.
The jejunum is transected just distal to 1st jejunal vessels using Endo GIA™ stapler (Ethicon Endo surgery Inc, Cincinnati, USA).
Now, the entire specimen with transected duodenal and jejunal end are into right upper quadrant giving wide exposure for pancreatic neck transaction. Two haemostatic sutures are applied to the superior and inferior borders of the pancreatic body, to the left of the proposed transection plane. The neck of the pancreas is carefully divided all round using the robotic monopolar scissors in R1 coupled with bipolar vessel sealer in R2 with suction irrigation by assistant A2 [Figure 3], carefully avoiding sealing of pancreatic duct. Once PD is identified, it is cut with robotic scissor noting the clear pancreatic fluid exuding from the PD cut end.
Calot's triangle is dissected; the cystic artery and duct are ligated although gall bladder was not dissected of from liver bed at this stage. All the fibrofatty tissues along the common bile duct are swept down caudally. The common hepatic duct (CHD) is incised, the biliary tree is decompressed and a bulldog clamp applied to the cut end of the CHD.
Once this is done, specimen is lifted up and remaining tissue is separated off Gerota's fascia and specimen is free of all its tissue attachments.
The entire specimen [Figure 4] is then placed into a specimen retrieval bag and removed from suprapubic Pfannenstiel incision which was closed immediately after delivering the specimen.
|Figure 4: Specimen image, (a) pancreatic head mass, (b) duodenum, (c) cut section of the mass showing mixed solid and cystic areas|
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For the reconstruction phase of the procedure, the stapled end of the jejunum is brought alongside the transected surface of the pancreas (jejunum is already in supracolic compartment via DJ flexure). Pancreatic duct reconstruction was performed with a modified Blumgart technique. The anastomosis consisted of 3–4 interrupted horizontal transpancreatic mattress sutures of 4-0 polydioxanone sutures between the pancreatic parenchyma and the seromuscular layer of the jejunum. A duct-to-mucosa anastomosis is performed using interrupted 5-0 polydioxanone sutures [Figure 5]. The hepaticojejunostomy is performed approximately 10–15 cm downstream from the pancreaticojejunostomy using a 5-0 monofi lament sutures in a interrupted posterior layer and in running fashion over an anterior layer [Figure 5]. Finally, an antecolic end to side duodenojejunostomy is performed approximately 50 cm from the biliary anastomosis using a 2-0 polydioxanone suture in single layer anastomotic technique with intracorporeal sutures [Figure 5]. Twenty-four French drain placed in Morisson's pouch and another near pancreatic anastomosis. All the port sites are closed appropriately.
|Figure 5: Intra-operative images, (a) 1-Uncinate process,2-Inferior vena cava, 3-Abdominal aorta, 4-Portal vein, (b)pancreaticojejunostomy 5-Jejunal roux loop, 6-Transectedsurface of pancreas, (c) hepaticojejunostomy 7-Jejunal roux loop,8-Hepatic duct, (d) duodeno-jejunostomy 9-Roux loop of jejunum, 10-Stomach with first part of duodenum|
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| ¤ Discussion|| |
SPTs are one of the uncommon varieties (3%) of cystic neoplasm of pancreas. Patients typically present with abdominal pain or lump although some patients may remain asymptomatic until detected incidentally on clinical examination or radiological investigations. Solid pseudopapillary tumours may appear in any part of the pancreas but are more likely to be found in the distal body and tail as also noted in our study. Our patient has SPT involving head and uncinate process of pancreas. Ultrasound of abdomen is often the first-line investigation to detect SPTs. However, CECT abdomen will show large mixed solid cystic heterogeneously enhancing mass in pancreas which is typical feature of SPT. Most patients do not require further investigations to confirm. However, when imaging is not confirmatory, endoscopic ultrasound-guided cytology or biopsy can be done to confirm before surgery.,, SPT is generally considered as a tumour with low malignant potential. Although resection of the tumour provides a 5-year survival rate more than 95%, local recurrence or distant metastases can occur. Moreover, a minority of patients show locally advanced or metastatic disease at their initial presentation. Hence, the location of the tumour being in the head and uncinate process region, our surgical plan was pancreaticoduodenectomy preserving as much as normal pancreatic tissue. The feasibility of doing laparoscopic pancreaticoduodenectomy is now well established, still it is being performed by very few experienced minimally invasive surgeons. Being the latest invention of minimally invasive surgery, surgeons are performing robotic pancreaticoduodenectomy and showing better results when compared with its open or even laparoscopic counterpart. The degree of freedom of movement of robotic arm and magnified three-dimensional view allowing surgeons to perform pancreatic resections and reconstructions more comfortably. Our patient underwent R-PPPD and we followed ERAS protocol in postoperative period and she was discharged on POD6. On reviewing literature, we found very few evidences of doing R-PPPD in young females for SPT,, and according to our literature search, she is the youngest patient who underwent R-PPPD for SPT. We believe R-PPPD can be done in paediatric and adolescent age group with ease and faster postoperative recovery with equivalent oncological outcome. However for SPT patients, long-term postoperative follow-up is required though the recurrence rate is rare.
| ¤ Conclusions|| |
In this era of minimally invasive surgery, R-PPPD can be considered as treatment of choice in young patients with large SPTs with minimal morbidity and mortality and good oncological outcome.
Informed consent was obtained from the patient for this study.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given consent for images and other clinical information to be reported in the journal. The patient's parents understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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