The sequential surgical path to the first laparoscopic resection with Mini- laparotomy anastomosis for pancreatico-duodenectomy (Whipple’s) in Sri Lanka

OBJECTIVE To map out the path way from open pancreatico duodenectomy to complete laparoscopic resection detailing the situations which necessitated conversion to the open surgery at different stages of the procedure. SUMMARY BACKGROUND DATA Laparoscopic assisted pancreatico-duodenectomy is an achievable alternative to open surgery which necessitates a steep, stepwise learning curve. The usefulness and progression to laparoscopic resection with hand assisted or hybrid adaptations has been reviewed 1 METHOD Open pancreatico duodenectomy was modified to complete laparoscopic surgery via a series of hybrid surgeries converting to open surgery at varying stages of the procedure. The Adaptation made and the stage at which conversion to open surgery was noted with the resultant success and complications RESULTS Twenty eight patients underwent surgery over two years. In 10 patients laparoscopic mobilization was possible until exposure of the portal vein .It was progressed to supraduodenal dissection in 11 patients and division of stomach and pancreas in 3. Complete resection was achieved in 4 patients. One patient developed pneumonia on the seventh post-operative day and succumbed eight days later. Other patients were discharged eight to ten days following surgery. Postoperative complications were minimal in all patients and none had anastomotic leaks or prolonged ileus. All pathological specimens revealed clear resection margins. CONCLUSION Laparoscopic pancreaticob duodenectomy poses a steep and challenging learning curve. Conversion to open surgery at varying stages of the procedure provides the confidence and improvement of the skills until successful completion.