The role of laparoscopy in pancreatic surgery is still controversial and must address the following potential applications: a) staging of pancreatic cancer; b) palliation of pancreatic cancer; c) pancreatic resection for benign and malignant disease; d) pancreatic drainage procedures.
Carcinoma of the pancreas is the fifth commonest cause of cancer death in the Western world. Its incidence is quite doubled in Europe among the last twenty years. In Italy 10-12 new cases per year/100.000 inhabitants are recorded. In most of cases it is ductal adenocarcinoma. The diagnosis carries a poor prognosis with a 5 year mortality rate of about 95-99%. Thus, the mortality related to this pathology is quite similar to its incidence. Surgery is the only therapeutical option of pancreatic cancer. Nevertheless, radical surgery requires good technical skill and can cause complications and operative mortality. Thus, it should be addressed to patients who can really benefit in terms of survival and quality of life. Less than 20% of pancreatic cancers are resectable for cure because of extrapancreatic involvement. In these case palliation should be provided.
A correct preoperative staging is necessary to identify patients with potentially resectable disease and those unresectable. There is still some concern about the management of pancreatic cancer and clear guidelines are yet not available. Radical surgery should be avoided in patients with extrapancreatic involvement, evidence of local vascular invasion (portal vein, superior mesenteric vein and artery, aorta and vena cava), metastatic disease(liver, peritoneum, lymphnodes), and in aged patients.
Up to few years ago, 65% of laparotomies performed in patients deemed resectable showed evidence of metastatic disease. Advances in dynamic spiral CT-scan decreased the number of unnecessary laparotomies. Diagnostic accuracy of CT scan is 95% in detecting local involvement, nodal and hepatic metastases, vascular invasion. Sensitivity of the technique is about 67% in detecting lesions up to 15 mm, 95-100% for lesions bigger than 15 mm.
As previously said, in the diagnostic-therapeutic protocol videolaparoscopy (VLS) is addressed to: a) staging; b) radical surgery; c) palliation.
