Advanced Laparoscopic, Anti-Obesity Surgery, and Radical Surgery for Pancreatic, Gastric and Liver Cancer

Mr. Basil Ammori, Consultant Surgeon and Honorary Senior Lecturer

The laparoscopic approach has recognised advantages over open surgery, and recent advances in techniques and technology has enabled the adoption of this minimally invasive approach for the management of most benign conditions as well as the palliation of malignancies. The role of laparoscopy, however, in the radical resection of intra-abdominal cancers remains controversial.

Laparoscopic cholecystectomy and bile duct exploration is associated with a lesser risk of morbidity and mortality in the young (= or < 50 yr) and fit (ASA 1 & 2) patient compared with preoperative ERCP and subsequent laparoscopic cholecystectomy. Urgent laparoscopic cholecystectomy for acute cholecystitis avoids the risks of failure of conservative treatment (20%) and of relapse while awaiting surgery (20%), obviates the need for a second admission, reduces overall hospital stay and can be performed safely with minimal conversion rates (<1% in our experience with urgent surgery for ‘all comers’). Of the patients who undergo elective laparoscopic cholecystectomy, some 50% might be suitable for day-case surgery.

Several randomised controlled trials have demonstrated a reduction in postoperative pain and a more rapid return to activity following laparoscopic repair of inguinal hernias compared with open surgery. Most patients in our experience are suitable for surgery as a day-case procedure including those with bilateral hernias. We adopt the total extraperitoneal (TEP) approach recommended by the National Institute National Institute for Clinical Excellence (NICE) for its superior safety over the transabdominal approach (TAPP), and apply that for primary as well as recurrent hernias.

Laparoscopic anti-reflux surgery (Nissen fundoplication) is indicated for young patients with gastroesophageal reflux disease (GORD) who respond to treatment but do not wish to take long-term medical therapy (and is cost-effective), patients with complicated GORD (such as peptic oesophageal stricture) or those who fail to respond satisfactorily to treatment, patients with large (gross) volume reflux, large symptomatic sliding hiatus hernias, and those with paraoesophageal ‘rolling’ hiatus hernias. Some one-quarter of patients might be suitable for surgery as a day-case.

Our experience with laparoscopic drainage of pancreatic pseudocysts (cyst-gastrostomy or cyst-jejunostomy) demonstrates a more rapid recovery and a short postoperative hospital stay (1-3 days). Bilateral thoracoscopic splanchnotomy, a minimally invasive procedure that interrupts the lesser and greater splanchnic nerves and denervates pain pathways from the upper abdominal viscera, is an effective procedure for the palliation of intractable abdominal pain of chronic pancreatitis and advanced malignancies, and most of our patients seek discharge from hospital the following day. Laparoscopic gastric and biliary bypass is our preferred approach for the palliation of obstructive symptoms in patients with locally advanced inoperable periampullary and distal gastric cancer as it has the benefits of minimally invasive surgery and obviates the need for repeated endoscopic interventions.

Laparoscopic splenectomy is our approach of choice in patients with ‘benign’ and ‘malignant’ haematologic disorders, including patients with moderate splenomegaly (1 kg splenic weight). We also practice laparoscopic distal pancreatectomy or enucleation, and laparoscopic adrenalectomy for neuroendocrine tumours of the pancreas and adrenal glands respectively. Laparoscopic de-roofing of simple cysts of the liver and spleen is the management of choice for large symptomatic cysts.

Anti-obesity (bariatric) surgery has a recognised role in the management of patients with morbid obesity (BMI = or >35 kg/m2 with co-morbidity, or BMI = or >40 kg/m2), as it reduces their long-term risk of cardiovascular, respiratory, and skeletal co-morbidities as well as the risk of premature death, cures type-II diabetes, and is cost-effective. Orlistat and Reductil are licensed for no more than 2 years, have a limited effect (maximum of 10% weight loss) that is often short-lived, and suffer from significant side-effects particularly steatorrhoea and hypertension. Whilst we recommend laparoscopic gastric banding in such patients, we adopt the laparoscopic gastric bypass as a more effective, durable and metabolically safe procedure in the superobese patient (BMI = or >50 kg/m2) as well as in the ‘sweet-eaters’.

We adopt a radical approach to surgical resection of periampullary and gastric cancer with D2/D3 lymphadenectomy, and to Liver resection for metastatic colorectal cancer. Our expertise in these areas was derived, by enlarge, from the following sources:

A travelling fellowship to a specialist HPB unit at Teikyo University Hospital in Tokyo, Japan. Professor Tadahiro Takada, demonstrated elegant Japanaese-style radical surgery for pancreatic and other periampullary malignancies, as well as surgery for liver malignancies. The results achieved in Japan for periampullary cancer are superior to those achieved in the West with almost a doubling in survival rates, and although the role of extended resection and radical lymphadenectomy in improving survival remains controversial, it is highly likely that surgery may have a crucial role.
I have obtained my Higher Surgical Training in Leeds, and was mentored by Professor David Johnson and Mr. Henry Sue-Ling at the General Infirmary at Leeds, UK who adopted the Japanaese-style surgical approach to cancer. The results of radical resection for gastric cancer with D2 lymphadenectomy that were achieved at this unit mimicked those reported from Japan and were depicted in their nominal publication entitled "Gastric cancer: a curable disease in Britain".

I have also obtained Higher Surgical Training in liver surgery at St James's University Hospital in Leeds where I was mentored by Mr. Peter Lodge, a Consultant Hepatobiliary & Transplant Surgeon. Mr Lodge adopted a very aggressive approach to rsesection of liver tumours. Patients who underwent liver resection for colorectal metastases to both lobes of the liver, that are widely considered by most other surgeons to represent a contraindication to resection, achieved survival rates that were comparable to those with unilobar metastases. Furthermore, the survival rates achieved at St. James's in Leeds were considerably better than those of several other units, and were highly comparable to the results achieved in the best centres in the world, namely from France and Germany.


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