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Standardization of surgical technique in laparoscopic distal pancreatectomy

Yuji Morine, MD, Mitsuo Shimada, Satoru Imura, Tetsuya Ikemoto, Shuichi Iwahashi, Yu Saito, Shinichiro Yamada. Department of Surgery, Institute of Biomedical Sciences, Tokushima University

Background: Recent advances of diagnostic tool could contribute to the increasing detection of cystic or solid benign tumors, and even early malignancy. Laparoscopic distal pancreatectomy (Lap-DP) is being accepted as a feasible and safe surgical alternative to open distal pancreatectomy (DP) especially for such benign tumor located in the pancreatic tail and body. However, the expertise in Lap-DP is more difficult to acquire than that in other laparoscopic procedures, it is important to standardize the technique for performing Lap-DP. Hence, we standardized a technique of Lap-DP, and demonstrated the surgical outcomes in this study.

Standardization: Trocar placement: In supine position, after the insertion of 12mm camera trocar on hypo-umbilical region, four other trocars are inserted into near bilateral costal arch (5mm) and bilateral flank region (10mm) in direct visualization.

Division of gastrocolic ligament: After retraction of liver left lobe, the omental bursa is opened, and splenocolic ligament is also dissected. Stomach is lifted and fixed to upper abdominal wall.
Individual division of splenic artery: after dissection of gastropancreatic fold, the splenic artery was identified and individually divided.
Dissection of inferior boarder of pancreas: The inferior border of pancreas is dissected from medial to left lateral, and retroperitoneum was dissected along lower level of the pancreas. The superior mesenteric vein (SMV) is exposed, and also the pancreas is mobilized over portal vein and SMV.
Division of pancreas: Transection site of pancreas is covered by NEOVEIL sheet®. After 5min clamping of transection site, pancreas was divided using autosuture device taking 5min, and then splenic vain (SpV) is divided individually. (If tumor is located in pancreas tail, pancreas division including SpV is done at the left side of gastropancreatic fold.) 
Pancreas and spleen mobilization: pancreas including tumor was dissected from retroperitoneum using anterior RAMPS (Radical antegrade modular pancreatectomy with splenectomy) method. (For malignant tumor, posterior PAMPS method is applied.)

Outcomes: Twenty-nine Lap-DP were performed for the following disease: IPMN (n=7), MCN (n=3), SCN (n=5), SPT (n=1), neuroendcrine tumor (n=5), others (n=4) and pancreas cancer (n=4). The median blood loss and operative time were 74 g and 277 min, respectively. Regarding short term surgical complication, grade C pancreatic fistula was observed in only one patients (3.4%).

Conclusion: Lap-DP is gaining acceptance as a standard approach for removal of various pancreatic diseases. Moreover, standardization of surgical procedure could establish Lap-DP as a safe and feasible procedure.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 93867

Program Number: P474

Presentation Session: Poster Session (Non CME)

Presentation Type: Poster

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