Laparoscopic ‘Spleen first approach’ for distal splenic vasculature and distal pancreatic lesions

Kumeran Ravindran, FRCS, Roopesh Khanna J, DNB, Shanmugam R P, Mch

Apollo Firstmed Hospitals, Chennai, India

Surgeries for splenic hilar and posteriorly placed distal pancreatic lesions are technically challenging. "Spleen first approach" enables this dissection laparoscopically. We present two case reports where the "Spleen first approach" was used successfully. First Case report – 42 year old female patient with symptomatic solitary neuro endocrine tumour (insulinoma) located postero-inferiorly in the tail of pancreas. Second case report – 55 year old female patient with distal splenic artery (hilar) aneurysm measuring 22 millimetres.

Both patients were operated in right semi lateral decubitus position. Veress pneumoperitoneum created at palmer’s point. Trocars inserted under vision. As the first step, spleen was mobilised by freeing the lieno-renal ligament and lieno colic ligament. Spleen was then flipped over medially and further dissection was done along the inferior border of the tail of pancreas to expose the avascular plane between the pancreas and the Gerota’s fascia. This facilitates the exposure of the posterior aspect of distal pancreas along with the splenic vasculature. Lesions in this region can be dealt-with comfortably with the weight of the flipped over spleen facilitating retraction of distal pancreas.

In case report -1, the neuro endocrine tumour was identified and enucleated. Spleen was preserved and pancreatic raw area was sutured. Spleen was flipped back to its original position with intact gastro-splenic ligament. In case report -2, after the "spleen first approach", the splenic vessels were easily identified and distally placed aneurysm was delineated. Aneurysmectomy was done after proximal and distal ligation. However splenectomy had to be performed due to subtotal infarction of the spleen.

We suggest "Spleen first approach" facilitates laparoscopic surgery for lesions in the posterior aspect of the tail of pancreas and splenic hilar region

Session: Poster Presentation

Program Number: ETP062

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