Page 32 - Read Online

Page 4 of 15 Donisi et al. Mini-invasive Surg 2021;5:38 https://dx.doi.org/10.20517/2574-1225.2021.55

intraoperative blood loss and shorter hospital stay than open surgery and comparable perioperative and
[16]
oncological outcomes. Gamboa et al. showed similar results and additionally reported a shorter operative
time than totally minimally invasive approach, a similar LOS, and a lower conversion rate, even though
patients undergoing hand-assisted distal pancreatectomy (HADP) had more comorbidities and a higher
number of previous abdominal operations. Kneuertz et al. reported the outcomes of laparoscopic DP
[42]
(LDP) at their institution over an 11-year period; a reduced use of hand-assistance was observed with
growing experience and a reduced LOS in TLS relative to HALS. A similar trend in reduction of HALS use
[44]
[43]
over time was reported by Jayaraman et al. and Nakamura et al. . A relevant piece of literature includes
HADP in the laparoscopic cases, and it is therefore difficult to extrapolate data on specific HADP
outcomes [45-52] . The current available literature on the topic is summarized in Table 1; articles where the
surgical technique is not specified were excluded. Placement of trocars and hand-port is shown in Figure 1.

Some reports have postulated a non-inferiority of the hand-assisted approach for PD relative to open, but its
usefulness has been questioned [29,30,62-64] . In PD, the advantage of hand assistance does not appear to be
striking. This is probably ascribable to the fact that the complex reconstruction phase, in HAPD, is
performed intracorporeally, and, if a surgeon has enough laparoscopic skills to perform the reconstructive
part, he conceptually should not need the help of the hand in the demolition phase . Accordingly, recent
[36]
literature reports a very limited adoption (0.6%) of the hand-assisted approach for PD . Some hybrid
[36]
approaches have been proposed, with the demolition phase performed with a hand-assisted approach and
the reconstruction phase with an open approach via a mini-laparotomy .
[65]

LAPAROSCOPIC-ASSISTED SURGERY
A similar but somewhat different hybrid approach that appeared to be more suitable for PD is laparoscopic-
assisted surgery (LAS). In LAS, the preparation and part of the demolition phase of the surgical operation is
managed via laparoscopy, while the reconstruction part is performed out of the body via a small
laparotomic incision . With this approach, we are able to take advantage of the improved vision of
[66]
secluded spaces given by the laparoscopy, sparing a large incision to the patient and granting a faster
postoperative recovery, while assuring an adequate anastomosis technique and hemostasis through a small
incision that can also be used for the retrieval of the resected specimen [67,68] . Several authors, in the initial
phase of approaching minimally invasive PD, used a laparoscopic-assisted PD (LAPD) approach and
reported their case series, proposing the feasibility of LAPD [69-74] . LAPD showed non-inferior results to open
surgery in terms of perioperative and oncological outcomes (comparable number of harvested lymph nodes
[75]
[76]
[77]
and higher R0 rates) . Similar results were also reported by Tan et al. and Mendoza et al. , who showed
no differences in oncological and perioperative outcomes between open PD and LAPD. Tian et al.
[68]
[67]
reported a lower estimated blood loss and shorter time to first flatus and Wang et al. described again a
lower intraoperative blood loss and a shorter LOS. Additionally, a lower rate of anastomosis related
complications has been reported compared to totally laparoscopic PD performed by experienced pancreatic
surgeons at the beginning of their learning curve . Similarly promising results were reported by
[78]
Deichmann et al. . No differences in intraoperative characteristics and postoperative outcomes were found
[79]
[81]
[80]
between LAPD and robotic-assisted PD by Piedimonte et al. . Patel et al. reported a shorter LOS and
lower severe morbidity rate and reoperation rate in LAPD compared to TLS, although a progressive shift
from LAPD to TLS was observed over time. Somewhat similar results were published by Wang et al. ,
[82]
reporting an increased operative time and blood loss in LAPD relative to TLS but similar LOS, morbidity
rate, and postoperative pancreatic fistula (POPF) rate, with LAPD adopted by more inexperienced surgeons.
In addition, Goh et al. reported a more frequent adoption of the hybrid technique during their early
[83]
[84]
experience to allow for a safer transition to totally MIS. van Hilst et al. compared postoperative outcomes
in LAPD and TLS without finding any significant difference; similar results were reported by