CHAPTER 11 Distal pancreatic resection
Step 1. Surgical anatomy
♦ The most common indications for performing distal pancreatectomy are benign or malignant neoplasm, complications of pancreatitis, and occasionally trauma.
♦ Although there has been extensive literature on the role of open distal pancreatectomy for malignant disease, there is only a nascent literature on the role of laparoscopic distal pancreatectomy.
♦ Laparoscopic distal pancreatectomy remains a procedure usually conducted for benign pancreatic disease. This chapter reviews the perioperative care and discusses the operative techniques for laparoscopic distal pancreatectomy.
Step 2. Preoperative consideration
Patient preparation
♦ A contrast-enhanced computed tomography (CT) scan utilizing a pancreatic protocol is obtained for preoperative assessment of pancreatic disease. This study provides images of the pancreas during arterial and venous phases to allow for a full evaluation of smaller lesions and to help delineate the relationship of the splenic vessels to the lesion.
♦ Patients with radiographic abnormalities of the body and tail of the pancreas usually undergo endoscopic ultrasound with or without FNA (fine needle aspiration) and cystic fluid sampling if indicated.
♦ In patients with a dilated pancreatic duct, an Endoscopic Retrograde Cholangiopancreatography (ERCP) may be useful for evaluating the papilla and ductal anatomy and its relationship to the lesion. Alternatively, Magnetic Resonance Cholangiopancreatography (MRCP) is also useful as a noninvasive means for elucidating pancreatic pathology and anatomy.
♦ In our institution, a pancreas protocol CT and EUS (Endoscopic Ultrasound) fully assess the majority of patients and obviate the need for additional studies.
♦ If splenectomy is anticipated, then preoperative vaccination against encapsulated bacteria (H. Influenza, Streptococcus, Meningococcus) should be given 7 to 10 days before surgery.
♦ Patients with functional pancreatic neuroendocrine tumors may require preoperative hospitalization to optimize physiologic status.
♦ Similar to other major abdominal surgeries, preoperative antibiotics and DVT (deep venous thrombosis) prophylaxis are provided per Surgical Care Improvement Project (SCIP) guidelines.
Equipment and instrumentation
♦ For a laparoscopic approach, a 30-degree and 45-degree laparoscope, ultrasonic dissector, 5-mm and 10-mm clip applier, blunt-tipped atraumatic bowel graspers, fine-tipped needle driver, articulating endoscopic stapler, fibrin glue with laparoscopic delivery device, and hand port should be available.
♦ In addition, a laparoscopic ultrasound should be available to help locate and characterize lesions intraoperatively. The ultrasound is often particularly useful for clarifying the spatial relationship of neuroendocrine tumors to the main pancreatic duct. In addition, intraoperative ultrasound may help explain other occult pathology, which may change intraoperative decision-making.
Anesthesia
♦ General anesthesia with endotracheal intubation and complete neuromuscular blockade is generally required for this operation.
♦ After intubation, a nasogastric (NG) tube should be placed to decompress the stomach during the operation and for patient care during the immediate postoperative period.
♦ A Foley catheter should be placed and standard preoperative antibiotics given per surgeon.
Room setup and patient positioning
♦ The patient is positioned in a 30-degree right lateral decubitus position using a beanbag or large gel rolls. This allows for rotation of the patient during mobilization of the pancreas and allows the use of gravity as a retractor during the case. The 30-degree lateral decubitus also provides for rotation into a horizontal position if conversion to an open procedure is required.
Step 3. Operative steps
♦ There are several technical variations that may be utilized based on surgeon preference and characteristics of the operative field.
♦ Pancreatic mobilization can be performed from lateral to medial or from medial to lateral. In general, the lateral-to-medial approach is often easier. However, this does not allow for early control of the splenic artery and vein.
♦ For extended distal pancreatic resections, we often prefer to proceed from medial to lateral, beginning with division of the neck of the pancreas. This facilitates later dissection by allowing early control of the splenic vessels. The medial-to-lateral approach is also useful to aid mobilization of the vessels when splenic preservation is considered. Complete splenic mobilization is not necessary unless the spleen is to be removed.
♦ We will describe laparoscopic distal pancreatectomy with en bloc splenectomy via a medial-to-lateral approach and follow this with a discussion of how splenic preservation can be done laparoscopically.
Access and port placement
♦ Pneumoperitoneum is achieved by either the Veress needle technique, with the needle placed through the umbilicus, or the open Hassan technique at the site of the operating laparoscope. The laparoscopic distal pancreatic resection is performed via four trocars.
♦ A critical component of any laparoscopic approach is port placement.
♦ The locations of these trocars may vary slightly depending on the body habitus of the patient. In general, the trocars should be triangulated around the body and tail of the pancreas with a working distance that allows sufficient range of motion.
♦ We have obtained the greatest flexibility by utilizing three 12-mm trocars and one 5-mm trocar.
