Defining Precision Surgery: Totally Laparoscopic Transduodenal Ampullectomy : A Combined Approach Aims for Margin Resection Success.

Abstract

Adenomas are premalignant lesions of the ampulla of Vater and should therefore be resected.¹ Three approaches are accepted: pancreatoduodenectomy and surgical and endoscopic ampullectomy.^2,3 When endoscopic management is not amenable, a transduodenal minimally invasive ampullectomy is the less aggressive option. Complete resection is paramount to avoid local recurrence. We present a combined approach to maximize the precision of this demanding procedure. A 64-year-old female patient, following an episode of acute pancreatitis, was diagnosed with a lesion of the ampulla of Vater. An endoultrasound-guided biopsy revealed an ampullary adenoma with low-grade dysplasia. Its growth along the duct made it not amenable for endoscopic resection. Consequently, a laparoscopic ampullectomy was then proposed. To obtain optimal free margins, a combined strategy was designed: the use of a choledochoscope (allowing for a direct view of the lesion limits), intraoperative ultrasound (to rule out possible intramural tumor growth), and indocyanine green (used to identify the bile duct and also in the filling of a Fogarty Catheter² inserted in the common bile duct to do a traction of the tumor/ampulla to expose the free margins). Operative time was 416 min. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. Pathology reported a well-demarcated ampullary adenoma with low-grade dysplasia and free margins. Twenty-four months after surgery, the patient is asymptomatic with no evidence of recurrence. Transduodenal minimally invasive ampullectomy is a demanding procedure. The combined use of technologies herein presented warrants a precision surgery allowing for a free-margin anatomical resection.