pancreatic resection is technically challenging due to anatomic factors such as the organ 's retroperitoneal location and close proximity to the duodenum and major vasculature . as a result , the application of laparoscopy to pancreatectomy has been slower than with other abdominal procedures .
the complication rates and oncologic outcomes of this method are similar to those of the open method .
i , n addition tlpd has some advantages , such as comparatively less time to return to daily activities , less scar formation and early initiation of adjuvant treatment .
this method requires experience not only in pancreatic surgery but also in the field of laparoscopic surgery .
therefore , the number of centres where this technique is regularly performed is limited . in particular , using robotic surgery at the time of reconstruction increases the possibility that the procedure can be completed entirely by the laparoscopic method .
we aimed to present the difficulties we experienced in the transition to laparoscopic surgery following 100 classic open whipple operations .
between december 2011 and april 2014 , 100 classic open pancreaticoduodenectomies were performed by the same surgeon .
the difficulties encountered in the transition to laparoscopic surgery are classified as preoperative , intraoperative and postoperative problems .
the most important difficulty encountered during this period was the selection of a suitable patient . in determining the eligibility of patients suitable for laparoscopy , the patients who had tumour size below 2.5 cm or who had intraductal papillary mucinous neoplasm ( ipmn ) and benign conditions were given priority .
advanced tumours and tumours with vascular invasion were excluded from the study . before the procedure ,
all patients were evaluated with triphasic computed tomography ( ct ) and endoscopic ultrasound for appropriate staging .
of 5 patients who underwent surgery , 2 had pancreatic head tumour , 2 had cystic neoplasms of the pancreas and 1 had a diagnosis of chronic pancreatitis .
five trocars of 10 - 12 mm were used , and 5-mm nathanson retractor was used for liver retraction , which was placed in the sub - xiphoid position .
subsequently , the superior mesenteric vein were dissected , a tunnel was opened from the posterior of the pancreas and the pancreas was hanged .
the first portion of the duodenum was transected by means of endostapler and the pancreas was transected by means of ultrasonic dissector .
the treitz ligament was dissected and the specimen was taken to the patient 's right .
the uncinate process of the pancreas and portopancreatic junction was dissected and pancreatic tissue was separated from the portal vein and superior mesenteric artery . during this period , we preferred the second trochar position [ figure 2 ] .
finally , cholecystectomy was performed ; the bile duct was cut and the specimen was put into an endobag .
an end - to - side pancreaticojejunostomy and duct - to - mucosa anastomosis was performed .
subsequently , an end - to side hepaticojejunostomy and end - to - side duodenojejunostomy were performed .
finally , the infraumblical trocar site was extended 5 cm and the specimen was removed [ figure 3 ] .
we can prepare gastrocolic ligament dissection , pancreatic head mobilisation , partial kocher manoeuvre and hilus dissection at this position , we prepare extended kocher manoeuvre and uncinate dissection . additionally , in the final step
the surgeon stand on the right side of the patient final step of our operation postoperative early enteral nutrition was started in a manner similar to classic open pancreaticoduodenectomy .
analgesia was provided with a patient - controlled pump for the early postoperative period of 3 days and with oral narcotic analgesics in the following period .
the patients were discharged on postoperative day 7 if they had an uneventful postoperative period .
the most important difficulty encountered during this period was the selection of a suitable patient . in determining the eligibility of patients suitable for laparoscopy , the patients who had tumour size below 2.5 cm or who had intraductal papillary mucinous neoplasm ( ipmn ) and benign conditions were given priority .
advanced tumours and tumours with vascular invasion were excluded from the study . before the procedure ,
all patients were evaluated with triphasic computed tomography ( ct ) and endoscopic ultrasound for appropriate staging .
of 5 patients who underwent surgery , 2 had pancreatic head tumour , 2 had cystic neoplasms of the pancreas and 1 had a diagnosis of chronic pancreatitis .
five trocars of 10 - 12 mm were used , and 5-mm nathanson retractor was used for liver retraction , which was placed in the sub - xiphoid position .
subsequently , the superior mesenteric vein were dissected , a tunnel was opened from the posterior of the pancreas and the pancreas was hanged .
the first portion of the duodenum was transected by means of endostapler and the pancreas was transected by means of ultrasonic dissector .
the treitz ligament was dissected and the specimen was taken to the patient 's right .
the uncinate process of the pancreas and portopancreatic junction was dissected and pancreatic tissue was separated from the portal vein and superior mesenteric artery . during this period , we preferred the second trochar position [ figure 2 ] .
finally , cholecystectomy was performed ; the bile duct was cut and the specimen was put into an endobag .
an end - to - side pancreaticojejunostomy and duct - to - mucosa anastomosis was performed .
subsequently , an end - to side hepaticojejunostomy and end - to - side duodenojejunostomy were performed .
finally , the infraumblical trocar site was extended 5 cm and the specimen was removed [ figure 3 ] .
we can prepare gastrocolic ligament dissection , pancreatic head mobilisation , partial kocher manoeuvre and hilus dissection at this position , we prepare extended kocher manoeuvre and uncinate dissection . additionally , in the final step
analgesia was provided with a patient - controlled pump for the early postoperative period of 3 days and with oral narcotic analgesics in the following period .
the patients were discharged on postoperative day 7 if they had an uneventful postoperative period .
seventeen cases were completed laparoscopically and 5 cases were converted to open surgical procedure . here , we have given some infomation about cases converted to open surgical procedures .
indications of the other 17 cases were head of pancreas cancer , periampullary tumour , ipmn and cancer doubt of chronic pancreatitis . during surgical procedure of the first five patients , even though the operations were started by laparoscopic method , 3 of them at various stages due to bleeding and 2 of them during the reconstruction of the pancreas , which was of bad quality , underwent conversion to open surgery . on the other hand , the next 17 patients had total laparoscopic pancreatectomy .
the data collected from the first 5 patients operations , which were converted to open surgery , were analysed .
conversion to open surgery was done due to bleeding during dissection of the first branch of the portal vein in 1 patient and due to bleeding during dissection of the uncinate process of the pancreas in 2 patients . in 2 patients , dissection
was completed laparoscopically and conversion to open surgery was done due to the soft quality of the pancreas . according to these early results , bleeding seems to be the most frequent cause of conversation to open surgery .
the bleeding of the first branch of the portal vein due to excessive traction was yet another reason for uncontrollable bleeding . at this stage
the most important preventive method is isolating and separating vessels properly and placing the clips if necessary .
the average length of hospital stay of the patients who had tlpd was 10 days ( 6 - 21 ) . estimated blood loss was 340 ml ( 250 - 440 ) .
we do not prefer to perform jejunostomy on the first day of surgery ; enteral nutrition is started by nasojejunal tube and increased daily . on day 3 or day 4
in the last 25 years , the most significant advance in pancreatic head tumour surgery has been the decrease of the mortality rate to below 1% . in parallel to developments in technical equipment , the use of minimally invasive surgery in pancreatic cancer is another significant advance over this same period .
tlpd , which requires high technical skill levels , is one of the most difficult kinds of laparoscopic surgery . nowadays ,
although there are many centres dealing with this issue , a large case series has not been made . in the initial period of tlpd , besides being a highly skilled pancreatic surgeon , it is necessary to have good skills in laparoscopic surgery . in recent years
, studies comparing open and laparoscopic pancreatectomy have begun to be published which have not revealed any superiority of tlpd to the classic open technique . however , having the same survival advantage compared with open surgery through a smaller incision is likely to be an advantage of this technique .
it is a fact that by performing tlpd in early - stage and cystic pancreatic tumours , better cosmetic results can be expected in this group of patients .
moreover , it is known that tlpd can provide an advantage in terms of earlier onset of patients to chemotherapy .
initially the surgeon has to reach a certain level of experience in pancreatic surgery in order to start performing tlpd because the problems of this technique in the start - up period are similar to the early - stage difficulties of open surgery ( more estimated blood loss , more operation time , more fistula , and the mortality rate ) .
thus , patient selection is very important in the initial phase . for initial cases ,
those with early stage tumours or tumour - like lesions such as ipmn should be selected . in these patients , although dissection can be performed in an easier way , the pancreaticojejunostomy may become problematic .
this is because the quality of the pancreas is softer in early - stage tumours .
according to our experience in the older patients who have early - stage tumours and no serious comorbidities , the pancreatic quality is better and this makes comfortable dissection possible . in tlpd , dissection is different from the classic open technique .
optionally in the conventional method , resection is clockwise : first stomach , then the common bile duct and pancreatic resection is performed whether the retro - pancreatic dissection is done in the last part of the dissection phase . in tlpd
optionally , the posterior pancreas around the superior mesenteric artery is dissected and finally common bile duct and gallbladder dissection is done .
one of the biggest advantages of tlpd including artery- first approach is that it allows the surgeon to evaluate the relationship between the tumour and surrounding arterial structures .
thus , determination of resectability of the tumor can be made at early stage of operation .
however , in our series , there was no patient with major vessel invasion including portal vein or mesenteric vascular structures due to meticulous selection of initial cases .
if there is any doubt about invasion of artery during open procedure , retropancreatic approach is reasonable to determine resectability as it is described in textbooks .
another advantage is that gallbladder can be used for traction of the liver upward . in general ,
in addition , 10-mm trocars are important because their use allows the camera to move , helping the surgeon by working in different angles [ figure 2 ] . in the reconstruction period ,
thus , after doing the back wall , the anterior wall can be complete from the incision which is done for removing the specimen .
the most important disadvantages of tlpd are longer operation time and higher cost compared to open procedures .
in conclusion , it can be suggested that tlpd is a safer procedure , while having comparable technique and oncologic outcomes to open surgery .
 background : recently , total laparoscopic pancreatectomy has been performed at many centres as an alternative to open surgery . in this study 
 , we aimed to present the difficulties that we have encountered in converting from classic open pancreaticoduodenectomy to total laparoscopic pancreatectomy.materials and methods : between december 2012 and january 2014 , we had 100 open pancreaticoduodenectomies . 
 subsequently , we tried to perform total laparoscopic pancreaticoduodenectomy ( tlpd ) in 22 patients . in 17 of these 22 patients 
 , we carried out the total laparoscopic procedure . 
 we analysed the difficulties that we encountered converting to tlpd in three parts : preoperative , operative and postoperative . 
 preoperative difficulties involved patient selection , preparation of operative instruments , and planning the operation . 
 operative difficulties involved the position of the trocars , dissection , and reconstruction problems . 
 the postoperative difficulty involved follow - up of the patient.results:according to our experiences , the most important problem is the proper selection of patients . 
 contrary to our previous thoughts , older patients who were in better condition were comparatively more appropriate candidates than younger patients . 
 this is because the younger patients have generally soft pancreatic texture , which complicates the reconstruction . 
 the main operative problems are trocar positions and maintaining the appropriate position of the camera , which requires continuous changes in its angles during the operation . 
 however , postoperative follow - up is not very different from the classic procedure.conclusion:tlpd is a suitable procedure under appropriate conditions . 
INTRODUCTION
MATERIALS AND METHODS
Preoperative period
Intraoperative period
Postoperative period
RESULTS
DISCUSSION
CONCLUSION
Financial Support and Sponsorship
Conflicts of Interest