Distal Pancreatectomy

Published on 16/04/2015 by admin

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Chapter 15

Distal Pancreatectomy

Natalie E. Joseph

Introduction

Distal pancreatectomy is the term applied to resection of that portion of the pancreas extending to the left of the midline and not including the duodenum and distal bile duct. First described by Billroth in 1884, distal pancreatectomy is performed for various benign and malignant conditions involving the body and tail of the pancreas. These include inflammatory conditions such as chronic pancreatitis and symptomatic pseudocysts, pancreatic trauma, neuroendocrine tumors, pancreatic adenocarcinoma, solid neoplasms of indeterminate etiology, and cystic neoplasms of the pancreas. Because of the lower incidence of resectable malignant pancreatic neoplasms involving the body and tail of the pancreas, as well as the late appearance of clinical symptoms in this portion of the gland, distal pancreatectomy is performed less often than resection of the pancreatic head.

Preoperative Evaluation

The indication for distal pancreatectomy will dictate preoperative workup and also influence surgical decision making. Multidetector, dynamic, contrast-enhanced computed tomography (CT) is the preoperative imaging modality of choice for all indications and is essential to surgical planning. CT provides detailed images of the pancreatic pathology and its relationship to surrounding organs, major vasculature, and pancreatic ducts, as well as the presence of metastatic disease (Fig, 15-1). Other modalities, such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS), may also be helpful when a definitive mass is not well visualized.

FIGURE 15–1 Anatomy for preoperative evaluation of pancreas.

Surgical Approach

The standard approach to resection of the body and tail of the pancreas is through an upper midline incision from the xiphoid process to just below the umbilicus. Alternatively, a bilateral subcostal incision can be used. The surgical approach depends on the indication, with several different approaches available.

Open Retrograde Distal Pancreatectomy with Splenectomy

Retrograde distal pancreatectomy with splenectomy is the standard procedure for management of proven or suspected cancers in the body and tail of the pancreas, to ensure the adequacy of the lymph node dissection, or with tumors when the anatomic constraints dictate sacrificing the spleen (Fig. 15-2, A).

FIGURE 15–2 Open retrograde distal pancreatectomy with splenectomy.

The pancreas is approached by opening the lesser sac through the gastrocolic ligament below the gastroepiploic vessels (Fig. 15-2, B). The peritoneum overlying the inferior border of the pancreas is divided lateral to the superior mesenteric vessels toward the tail. The splenocolic and splenorenal attachments are divided to mobilize the spleen anteriorly and to the right, separating it from splenic flexure of the colon and from Gerota’s fascia (Fig. 15-2, C).

The short gastric vessels connecting the splenic hilum with the greater curvature of the stomach must be isolated and divided to facilitate mobilization of the tail of the pancreas. The dissection along the inferior margin of the pancreas is continued, and the inferior and posterior peritoneal attachments are divided. Care must be taken because there are numerous venous tributaries from the posterior aspect of the pancreas into the splenic vein. This dissection opens up the retroperitoneal window behind the pancreas.

Division of Splenic Artery and Vein

Understanding the vascular anatomy of the pancreas is essential to safe technique (Fig. 15-3, A). The splenic artery is identified at its origin from the celiac trunk and traced distally along the posterosuperior border of the pancreas. It is divided just distal to its origin. The splenic vein is then isolated and divided just proximal to its confluence with the portal vein, preserving the inferior mesenteric vein if possible (Fig. 15-3, B).

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