Perioperative management - Left pancreatic resection, spleen-preserving, robotically assisted

Indications for Spleen-Preserving Distal Pancreatectomy

• Pathological changes limited to the pancreatic body or tail, excluding primary pancreatic carcinomas:
  • Benign solid and cystic lesions of the pancreatic tail and body
  • Pancreatic pseudocysts
  • Adenomas
  • Cystic tumors without suspicion of malignancy (suspected IPMN + MCN)
  • Neuroendocrine tumors
  • Metastases in the pancreatic tail
  • Focal chronic pancreatitis
  • Trauma
• Alternative procedures:
  • Distal pancreatectomy with splenectomy, especially in primary pancreatic carcinomas
  • Open distal pancreatectomy
  • Local excision (only for benign lesions)
• An oncological distal pancreatectomy with splenectomy is indicated for
  • All cystic and solid tumors with proven malignancy or suspicion of malignancy

Note: During the implementation phase of a robotics program, distal pancreatectomy is ideally considered as an "entry" into robotic surgery at pancreatic centers with prior laparoscopic experience due to its specific characteristics. After all, an isolated resection occurs without reconstruction. Initially, "uncomplicated" resections are recommended, for example, in benign findings. With initial experience, the spectrum can quickly expand to malignant tumors and resections in pancreatitis.

• Primary malignancies of the exocrine pancreas
• Also inflammatory changes extending to the splenic hilum
• Involvement of the pancreatic head then pancreatectomy
• Locally unresectable tumor with central vascular invasion
• Non-resectable distant metastases
• Portal vein thrombosis or other conditions with pronounced venous collateral circulation (liver cirrhosis).
• Splenic vein occlusion with pronounced collaterals and presence of gastric varices
• Acute pancreatitis
• Liver cirrhosis Child B and C
• Patients with severe cardiovascular comorbidities for whom anesthesia alone poses a risk (e.g., NYHA III constellation with high-grade carotid stenoses)

Medical history/Clinical Findings:

• No characteristic leading symptom, nonspecific with loss of appetite, feeling of fullness, digestive disorders, weight loss.
• Upper abdominal and back pain with localization in the body/tail area
• Newly onset diabetes mellitus due to destruction of the islets of Langerhans
• Obstructive pancreatitis, palpable tumor
• Previous surgeries

Laboratory Diagnostics

• Complete blood count, CRP, albumin, lipase/amylase, blood sugar, oral glucose tolerance test or HbA1c, blood group and possibly erythrocyte concentrates as per surgeon's discretion
• Tumor marker CA 19-9 (independent predictor of poorer overall survival)
• CEA (also and especially from endosonographically obtained cyst punctate)
• Genetics: PRSS1, SPINK1, PSTI, CFTR (in young patients to exclude hereditary genesis – strict indication due to high cost!)
• Hormone analysis if endocrine active neoplasms are suspected

Note: Pancreatic function diagnostics can employ the following tests (in processes in the body and tail, exocrine dysfunction is not assumed):

• Oral glucose tolerance test in previously unknown diabetes mellitus to assess endocrine pancreatic function
• HbA1c to assess endocrine pancreatic function
• Stool elastase for diagnosing exocrine pancreatic function

Imaging Diagnostics

• Transcutaneous Sonography: Basic diagnostics with good and non-invasive visualization of the pancreatic parenchyma, also allowing detection of pancreatic duct dilation. Additional assessment of the portal vein system through color Doppler sonography. Ultrasound contrast agents can contribute to differential diagnosis between inflammatory and tumorous, cystic tumor - pseudocyst. Furthermore, detection of cholestasis, cholecystolithiasis, liver metastases, ascites.
• CT Abdomen: For solid changes, a 4-phase CT of the abdomen is most suitable. CT can fundamentally assess pancreatic masses, lymph node enlargements, perfusion of the superior mesenteric vein, portal vein, superior mesenteric artery, and celiac trunk, distant metastases, pancreatic calcifications, pancreaticolithiasis, distant metastasis.
• MRI with MRCP (Magnetic Resonance Cholangiopancreatography): For cystic tumors, an MRI of the upper abdomen with MRCP is recommended, which is superior to CT in terms of diagnostic power. Additionally, MRI with MRCP better visualizes the spatial relationships between the tumor and pancreatic duct system. Furthermore, duct irregularities, stenoses, dilations, double-duct sign = simultaneous stenosis of the pancreatic duct and common bile duct, common bile duct stenosis, dilation, and pancreaticolithiasis can be detected.
• Possibly CT Thorax: to exclude pulmonary metastasis
• Possibly CEUS ultrasound (contrast-enhanced ultrasound) to assess liver lesions
• Possibly FDG-PET-CT: in suspected metastatic situation

Endoscopic/Invasive Diagnostics

• Possibly EGD with Endosono: Clarification of gastric collateral pathologies and further depiction of the pancreas through endosonography to assess mural changes in cystic neoplasms for type diagnosis of these changes as well as for cyst puncture or biopsy confirmation, examiner-dependent
• Possibly Laparoscopy in suspected peritoneal carcinomatosis and/or proven ascites -> puncture with cytology
• Possibly ERCP: Due to possible complications (pancreatitis, bleeding, perforation), preferably only for therapeutic intervention, otherwise MRCP or EUS.

Preoperative Functional Diagnostics

• ECG
• Lung function
• Chest X-ray
• Others depending on pre-existing conditions

Special Preparation

• Blood group determination
• Possibly provision of 2 cross-matched erythrocyte concentrates as per surgeon's discretion
• Possibly stabilization of coagulation (e.g., Konakion®)
• Possibly improvement of liver function (e.g., DHC stenting in jaundice)

Preoperative Preparation:

• Body care: shower the evening before
• Shaving: from jugulum to symphysis; legs in case of vein removal for vascular construction
• Preoperative nutrition: eat lunch the day before, then small intestine absorbable diet (SAD), in case of reduced general condition and nutritional status (albumin < 30mg/dL) additionally high-calorie nutrition (3 days preoperatively), human albumin, iron (Ferrinject), vitamin B12, folic acid
• Thrombosis prophylaxis: See guideline Prophylaxis of venous thromboembolism (VTE)
• Premedication: Epidural catheter. Intensive care unit registration. Central venous catheter
• Antibiotics: according to house standard, e.g., Cefuroxime 1.5g and Clont 500 mg or Rocephin 2g + Clont 500mg (repeat after 3 hours of surgery time)

General Risks

• Wound healing disorder
• Thromboembolism
• Lymphatic fistula
• Injury to internal organs (intestine, liver, stomach, spleen)
• Subsequent interventions
• Bleeding/Rebleeding: PPH = postpancreatectomy hemorrhage

Specific Risks

• Splenectomy.
• Pancreatic fistula: POPF = postoperative pancreatic fistula
• Acute pancreatitis
• Endocrine pancreatic insufficiency with diabetes mellitus (lifelong)
• Stomach wall injury
• Gastric emptying disorder: DGE = delayed gastric emptying

Definition and classification of PPH, POPF, and DGE by the International Study Group of Pancreatic Surgery (ISGPS), see literature references for this

• Intubation anesthesia
• Urinary catheter
• Perioperative antibiotic prophylaxis
• Intra- and postoperative analgesia with epidural catheter
• Nasogastric tube
• 2 large-bore IV cannulas
• If necessary, central venous catheter
• If necessary, arterial pressure monitoring

Follow this link to PROSPECT (Procedure specific postoperative pain management) or to the current guideline Management of acute perioperative and post-traumatic pain.

Positioning is done in the supine position on the large vacuum cushion. The left arm can be abducted. The use of the cushion can eliminate the need for additional supports.

After inserting the trocars, the operating table is tilted to approximately 15° Anti-Trendelenburg and approximately 5° right lateral position. The surgical robot is brought in and the robotic arms are docked.

Note:

Positioning is of particular importance due to docking the patient to the robot manipulator. There is a risk of injury if the patient slips.

Caution:

Vacuum cushions may have leaks. Check again before sterile draping.

• Surgeon at the console ideally also with the ability to view the patient and table assistant.
• The surgical robot (Patient Card) is brought to the patient from the left side of the patient. 
• The table assistant stands or sits on the right side of the operating table. 
• Anesthesia at the head of the patient
• Scrub nurse/OR nurse to the right of the table assistant

Robotic Instruments:

· Cardiere or Tip-Up Grasper,

· (Maryland bipolar Forceps),

· fenestrated bipolar Forceps,

· Camera (30°),

· monopolar Scissors,

· Vessel sealer,

· Linear stapler SureForm 60 with black cartridge

Trocars:

Robotic

• Three 8 mm robotic trocars
• One 12 mm robotic trocar

Laparoscopic

• One 5 or 12 mm assistant trocar

Basic Instruments:

• 11 scalpel
• Dissection scissors
• Langenbeck retractor
• Suction system
• Needle holder
• Suture scissors
• Forceps
• Compresses/Gauze pads
• Swabs
• Suture material for the abdominal wall fascia in the area of trocars from 10 mm Vicryl 0 with UCLX needle, for the retrieval incision PDS 0 or PDS 2/0. Subcutis (3-0 braided, absorbable), Skin (3-0 monofilament, absorbable)
• Possibly Veress needle
• Possibly Backhaus clamps
• Plaster

Additional Instruments

• Gas system for pneumoperitoneum
• Laparoscopic atraumatic grasper
• Laparoscopic swab on a stick
• Laparoscopic suction-irrigation system
• Specimen retrieval bag
• Alexis wound retractor size S
• Clip applier if not robotic
• Linear stapler if not robotic

Instrument Setting for "Two Left Hands"

Port 4 (8mm) far right: Cardiere or Tip-Up Grasper

Port 1 (8/12 mm): bipolar Forceps, (Linear stapler) (12 mm if robotic stapling is to be done)

Port 2 (8 mm): Camera

Port 3 (8 mm) far left: Scissors/Vessel sealer

Additionally:

Assistant trocar (12 mm):

Clip applier,

atraumatic bowel graspers,

Suction with irrigation,

Swab on a stick

Linear stapler (if laparoscopic stapling is to be done)

Note:

Postoperative care should be integrated into a fast-track concept as "enhanced recovery after surgery" (ERAS). The goal is rapid recovery and reduction of postoperative complications and hospital stay. Key points of the perioperative ERAS concept are:

·      preoperative eutrophy and normovolemia with fluid intake up to 2 hours preoperatively, 

·      contemporary anesthesia management and use of regional techniques, 

·      minimizing the use of drains and invasive accesses, 

·      as minimally invasive blood-sparing surgical technique as possible, 

·      postoperative pain management with reduction of opioid requirement, 

·      early mobilization, 

·      early nutritional build-up and 

·      timely discharge planning using discharge management.

Postoperative Analgesia:

Note: Various scales are available for quantifying postoperative pain, allowing the patient to determine their pain level multiple times a day, such as the NRS (numeric rating scale 0–10), the VAS (visual analog scale), or the VRS (verbal rating scale). 

Caution: Strive to minimize the use of opioids and NSAIDs (adverse effects on bowel motility and anastomotic healing)

• Epidural catheter by anesthesia pain service removed on the 3rd postoperative day
• Basic medication: Oral analgesia: 4x1g Novalgin/3x1 g Paracetamol, also combinable, e.g., fixed Novalgin and as needed Paracetamol up to 3x/day
• Administration of Novalgin: 1g Novalgin in 100 ml NaCl solution over 10 minutes as IV infusion, or 1 g as a tablet orally or 30-40 drops Novalgin orally
• Administration of Paracetamol: 1g IV over 15 minutes every 8h, or 1g suppository every 8h rectally (Caution: consider anastomosis height), or 1g as tablets orally

Caution: The basic medication should be tailored to the patient (age, allergies, renal function).

• As-needed medication: If VAS >= 4, as needed Piritramid 7.5 mg as IV infusion or SC, or 5 mg Oxigesic acute
• If pain persists postoperatively >= 4, administration of a sustained-release opioid (e.g., Targin 10/5 2x/day)

Note: If pain occurs only during mobilization, an as-needed medication should be given 20 minutes before mobilization.

Note: Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current guideline for the treatment of acute perioperative and post-traumatic pain and observe the WHO step scheme.

Postoperative Measures:

• Monitoring: post OP: Recovery room, avoid ICU/IMC if medically possible
• Venous accesses: Central venous catheter removed by the 1st postoperative day, leave one peripheral line, 
• Nasogastric tube removed at the end of the operation
• Urinary catheter: removed by the 1st postoperative day
• Drain removal: Target drain removed after determination of pancreatic enzymes and serum-equivalent values from the 3rd postoperative day 
• Mobilization: Early mobilization on the evening of the operation. Gradual resumption of physical activity, full load when symptom-free, e.g., on the day of the operation in the siesta chair, standing and walking in the room from the first day, mobilization in the corridor from the 2nd postoperative day
• Physical therapy
• Breathing exercises
• Nutritional build-up: Sip drinking + yogurt/high-calorie drink on the day of the operation, tea/soup/yogurt + high-calorie drink on the 1st postoperative day, light full diet from the 2nd postoperative day
• Infusion: 500-1000 ml on the first postoperative day, thereafter only if oral fluid intake is insufficient
• Antibiotics: Single-shot intraoperatively, no further administration required
• Thrombosis prophylaxis: In the absence of contraindications: for moderate thromboembolic risk (surgical procedure > 30 min duration): low molecular weight heparin in prophylactic (usually "Clexane 40"), possibly in weight- or disposition risk-adapted dosage until full mobilization is achieved, physical measures, compression stockings 

Note: Follow the link to the current guideline on prophylaxis of venous thromboembolism (VTE)

Caution: when administering heparin, consider: renal function, HIT II (history, platelet monitoring), 

• Possibly stool regulation/bowel activity: from the 1st postoperative day: Macrogol 1-3 sachets/day, the first bowel movement should occur by the 3rd day, maintain high-normal potassium, laxative regimen: 1. Tea with Laxoberal/Dulcolax suppository, 2. Prokinetics: MCP / Prostigmin IV, 3. Neostigmine SC or IV, possibly Relistor when opioids are administered
• Blood work: on the 1st postoperative day, and then every 2-3 days with normal progress until discharge, immediately if clinical deterioration occurs, 
• Blood glucose profiles
• Pancreatic enzymes from drainage secretion before drain removal, e.g., on the 3rd postoperative day
• Dressing every 2 days, with cutaneous suction dressing every 5 days
• Nutritional counseling
• Clips/sutures: if not absorbable, removed after 8-10 days
• Discharge: From the 5th postoperative day
• Sick note: Individually determined – based on the degree of recovery and the type of work, e.g., office work after 3 weeks post OP, physical work after 4 weeks post OP 
• Follow-up care:
  • Dependent on histological findings, usually no specific follow-up care required for benign conditions
  • For newly developed diabetes mellitus: diabetic management
• Discharge letter: The discharge letter should contain information about: Diagnosis, therapy, course, histology, comorbidities, current medication, continuation of VTE prophylaxis, postoperative nutrition
• Rehabilitation (AHB): if required/desired: register through social services

Intraoperative Complications

Injury to Adjacent Organs

• Stomach: very rare deserosation possible > suturing
• Intestine: rare deserosation possible > suturing
• Spleen: with spleen preservation: hemostasis using hemostatic agents or electrocoagulation
• Liver: rare bleeding or bile leak > electrocoagulation, liver suture

Vascular Injuries

• Portal vein/superior mesenteric vein: suturing, partial resection, and end-to-end anastomosis
• Splenic artery/vein: if necessary, vascular suture, possibly splenectomy
• Injury to the transverse mesocolon with perfusion disturbance of the transverse colon: very rare > resection of the ischemic bowel segment and end-to-end anastomosis

Avoidance of intraoperative complications through careful preparation!

Postoperative Complications

Pancreatic Fistula

• Common complication after left pancreatic resection
• Usually resolves spontaneously if well-drained
• Main cause of postoperative morbidity after left pancreatic resection

Especially with very soft pancreatic parenchyma (e.g., in benign, cystic neoplasms), the risk of developing postoperative pancreatitis and/or fistula is increased.

• Pancreatic Fistula (POPF = postoperative pancreatic fistula; definition and classification according to ISGPF)

In 2005, the International Study Group for Pancreatic Fistula (ISGPF) developed a definition based on the amylase concentration in the drainage fluid:

A postoperative pancreatic fistula exists with a threefold increase in amylase concentration in the drainage fluid (compared to the amylase concentration in serum) from the third postoperative day.

The clinical impact of the postoperative pancreatic fistula is classified into Grades A – C.

Grade A:

• Clinically inconspicuous patient, persistent fistula through the drainage, no intra-abdominal fluid collection (CT).
• No therapeutic consequences

Grade B:

• Clinically stable patient, peripancreatic fluid (CT) not completely drained by the existing drainage.
• Antibiotics, oral food restriction, leave drainage in place; possibly invasive intervention (ultrasound- or CT-guided drainage); usually prolonged hospital stay.

Grade C:

• Clinically unstable patient (sepsis)
• Intensive care unit, interventional drainage or re-laparotomy; frequent bleeding complications; significantly increased mortality!

Drainage Management

• With existing target drainage:
  • Leave drainage in place and ensure secure fixation.
• Possibly parenteral nutrition
• In case of infected pancreatic fistula, take a swab and administer antibiotics, initial therapy according to the antibiogram of the intraoperatively taken bile duct swab, adjust antibiotics if a new swab result is available.
• If the target drainage has already been removed:
  • CT-guided drainage placement or transgastric drainage, swab collection

In case of persistent pancreatic fistula Grade B/C, a CT angiography is recommended to exclude a pseudoaneurysm, which arises due to inflammatory vascular erosion on the basis of a pancreatic fistula. If an aneurysm is present, radiological embolization or placement of a covered stent should be considered via angiography. The last resort is a re-laparotomy.

An algorithm for the management of pancreatic fistulas can be found here: Pancreatic Fistula

Postoperative Bleeding (PPH = postpancreatectomy hemorrhage; definition and classification according to ISGPS) (2-10%)

• The erosion bleeding, where the visceral vessel wall is digested by pancreatic juice, represents a life-threatening and highly acute clinical picture that requires immediate intervention.
• The special feature of postoperative bleeding after partial pancreatic resection compared to bleeding after other surgical procedures lies in the numerous possible variations regarding cause, timing, location, and severity.
• The cause of early extraluminal bleeding is often insufficient intraoperative hemostasis. Late extraluminal bleeding, on the other hand, usually develops as a result of erosion of blood vessels or pseudoaneurysms. An important risk factor for late bleeding is the postoperative pancreatic fistula, and there are also associations with bile leak, intra-abdominal abscess, and sepsis.
  • Onset of Bleeding
    • Early = < 24 h postoperatively
    • Late = > 24 h postoperatively
• Location
  • Intraluminal (primarily into the intestinal lumen):
    Stress ulcer, anastomosis region, anastomosed pancreatic resection surface, pseudoaneurysm
  • Extraluminal/intracavitary (primarily into the free abdominal cavity):
    Pancreatic bed, resection area, liver, anastomosis region, severed vessels, pseudoaneurysm
  • Combined:
    Pseudoaneurysm → tryptic erosion of the vessel wall by pancreatic secretion with the formation of a perivascular hematoma, which can either decompress intra-abdominally (extraluminal) or find connection to the GI tract, e.g., via an insufficient anastomosis (intraluminal).
• Severity
  • Mild:
    minor to moderate blood loss, Hb drop < 3 g/dl, only slight impairment of the patient → no surgical intervention required, endoscopy and volume/RBC substitution sufficient (1-3 RBC units)
  • Severe:
    severe blood loss, Hb drop > 3 g/dl
    severe impairment of the patient (tachycardia, hypotension, oliguria, shock), substitution → 3 RBC units required
    invasive measures indicated: angiography with coiling or stenting, re-laparotomy

An algorithm for the management of late bleeding after pancreatic procedures can be found here: Late Bleeding

Gastric Emptying Disorder

→ Exclusion of intra-abdominal formation → symptomatic

• Leave or reinsert the gastric tube
• Prokinetics
• Parenteral nutrition