Laparoscopic subtotal pancreatectomy: the right edge of the distal resection

F Marchesi, MD, PhD, F Tartamella, MD, S Cecchini, MD, C.r. Ferrone, MD. Clinica chirurgica generale, Universita degli studi di Parma, Italy.

 Case
We report a case of an obese (BMI 30.) 48 year-old male patient who presented with recurrent upper abdominal pain. He was found to have a symptomatic cystic mass in the neck of the pancreas.. US demonstrated a 5 cm hypoechoic cystic mass of the pancreatic isthmus. Serum CA 19-9 was slightly elevated. CT and MRI findings were consistent with a mucinous cystoadenoma/cystoadenocarcinoma. EUS-FNAB diagnostic of a cystic lesion with no evidence of malignant cells. A 6-month follow up MRI scan demonstrated the lesion had increased in size, strengthening the suspicion for mucinous cystoadenocarcinoma. The patient underwent a laparoscopic subtotal pancreatectomy and splenectomy. The pancreatic transection was extended to the left side of the gastroduodenal artery. The surgical procedure was technically demanding due to the patient’s visceral obesity and the anatomical location of the lesion. The postoperative course was complicated by a grade B pancreatic leak, managed conservatively. The pathology report demonstrated a pancreatic lympho-epithelial cyst which was resected with a clear surgical margin.

Conclusions
Laparoscopic distal pancreatectomy and splenectomy for a pancreatic neck lesion can be extended to the left side of the gastroduodenal artery in order to obtain a clear resection margin. Even if obesity increased the techinical difficulty, it should not be considered a contraindication to laparoscopic approach.

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