Laparoscopic Splenic and Vessels-Preserving Distal Pancreatectomy. An Alternative Minimaly Invasive Method for Benign and Low Malignant Potential Pancreatic Lesions.
Iswanto Sucandy, MD, Joseph Titano, MS, Gintaras Antanavicius, MD,
FACS, Christopher M Pezzi, MD, FACS
Department of Surgery
Abington Memorial Hospital
Abington, PA
Introduction: The use of minimally invasive surgery for distal pancreatic mass with benign or borderline malignancy has caused paradigm shift among surgeons. Although the spleen is often routinely resected, splenic preservation in younger patients has become preferable for various reasons, even though dissection around the splenic artery and vein can be very challenging. In this video, we demonstrate a laparoscopic distal pancreatectomy with preservation of both the spleen and the splenic vessels.
Methods: A 31 year old obese woman with BMI of 43 kg/m2 was found to have an incidental 4-cm cystic mass at the posterior margin of the body-tail of the pancreas on a transabdominal ultrasonography during preoperative work-up for bariatric surgery. This finding was confirmed on a CT scan. A transgastric endoscopic ultrasonography with fine needle aspiration of the lesion revealed proteinaceus cystic contents without malignant cells (CEA-Carcinoembryonic Antigen: 1072 ng/mL). Laparoscopic distal pancreatectomy with preservation of both the spleen and the splenic vessels was performed, followed by a vertical sleeve gastrectomy [for the purpose of this presentation, only the laparoscopic distal pancreatectomy part is demonstrated]. The total operative time for the distal pancreatectomy was 4 hours with 100 ml blood loss. The supraumbilical port site was enlarged to approximately 4 cm and used as an extraction port for the specimen. A closed-suction drain was placed near the pancreatic stump. No intraoperative complications occured. An oral diet was resumed on postoperative day 1 and the patient was discharged on postoperative day 3.
Results: Final pathology was consistent with a mucinous cystic neoplasm with low grade dysplasia. Four weeks postoperatively, the patient was readmitted for a small left upper quadrant abdominal collection consistent with pancreatic leak. This collection resolved with a percutaneously-placed drain by interventional radiology.
Conclusions: Laparoscopic splenic and vessels-preserving distal pancreatectomy for a mass with benign or borderline malignancy is safe and technically feasible. High level of experience in advanced laparoscopy is required for a success of this technically complex resection.
Points of interest:
case study–5 sec
CT scan–19 sec
endoscopic U/S–25 sec
procedure begins–34 sec
surgical summary–6:55
histopathology–7:09
Keyword(s): 5mm Endoclip, 5mm port, back pain, bariatric surgery, BMI, breast augmentation, case study, cephalad, confluence of the portal vein, CT scan, cyst wall, depression, EBL, endoscopic U/S, endosopic FNA bx, female, fibromyalgia, gastrocolic ligament, GERD, Harmonic scalpel, hemostasis, histopathology examination, hook electrocautery, hypercholesterolemia, incidentally discovered, inferior border of the pancreas, intact, laparoscopic linear stapler, laparoscopic splenic and vessel preserving distal pancreatectomy, left lobe of liver, liposuction, liver retractor, LOS, low grade dysplasia, major curvatur of the stomach, malignant cells, Maryland dissector, mucinous cystic neoplasm, mucinous epithelium, NG tube, non-enhancing cystic mass, operative time, pancreas, pancreas parenchyma, pancreatic cystic mass, pancreatic dissection, pancreatic transection, penrose drain, PMH, POD 3, posterior border of pancreatic body-tail, posterior pancreas connective tissue attachments, pre-op work-up, proximal and distal resection margins, proximal contral, PSH, pylorus, RUQ, specimen, splenic artery, splenic hilum, splenic vein, stomach, superior border of the pancreas, tissue dissection, tissue reinforcement material, tortuous, traction, U/S, uneventful recovery, vessel dissection, vessel loop
