Laparoscopic distal pancreatectomy

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Indications

Almost all lesions less than 7 cm in size that do not involve the celiac or mesenteric vessels should be considered for laparoscopic distal pancreatectomy. Absolute contraindications are lesions greater than 10 cm. Relative contraindications are, lesions ranging from 7 to 10 cm in size, multiple previous open upper abdominal operations, and a previous history of severe necrotizing pancreatitis. Splenic preservation should be attempted if there is no suspicion of malignancy, that is, surgery to remove a suspicious cyst. However, in cases in which malignancy is suspected or there is a strong a family history of pancreatic cancer, the surgeon should consider removing the spleen with the tail of the pancreas en bloc to achieve a wide resection.

Advances in the Operation

One challenge in approaching lesions of the distal pancreas is the difficulty in localizing the lesion. This is challenging for both open and laparoscopic techniques, but more so with the laparoscopic approach. The texture and appearance of tumors can be homogenous with the rest of the pancreas. Preoperative tattooing enables the surgeon to quickly identify the location of the tumor at the time of laparoscopy and provide guidance to the surgeon about where to divide the gland (Fig. 1). This can decrease intraoperative time while ensuring complete resection of more subtle and smaller masses.

Figure 1.

Tattoo to help localize a lesion at tail of the pancreas.

Under endoscopic ultrasound guidance before surgery, the pancreatic lesion is tattooed via an endoscopic transgastric technique. Using an endoscopic 22‐gauge needle, the surgeon injects a total of 5 mL of concentrated purified carbon particles (GI Spot dye; GI Supply, Camp Hill, PA) into the pancreatic parenchyma immediately proximal to the tumor. The dye is injected to create a vertical line deep in the pancreas parenchyma because the marking may need to be identified from the posterior aspect of the gland during the dissection.

Technique

The laparoscopic distal pancreatectomy steps (in order) are listed as follows and described afterwards:

• Perform staging laparoscopy.

• Open the lesser sac.

• Perform takedown of the splenic flexure of the colon.

• Distinguish the splenic vessels from the hepatic vessels.

• Divide splenic artery unless the spleen is preserved.

• Mobilize the distal pancreas and divide splenic vein if splenectomy is indicated.

• Extract specimen.

• Place a drain in the divided stapled pancreas.

Using the Hasson technique, the first port is placed infraumbilically. Two ports are placed in the upper midline (or right of midline) and one port in the left lower quadrant. Once local landmarks are identified, the gastrocolic omentum and short gastric vessels are divided, followed by takedown of the splenic flexure of the colon to achieve wide visualization of the lesser sac. Mobilization of the gland is easiest from the inferior border of the gland. Thus, beginning with the inferior approach facilitates dissection of the posterior aspect of the gland from the retroperitoneal bed. The splenic artery and vein branches can be visualized from underneath the pancreas. Alternating dissection of the splenic vessels from above and below the gland offers better visualization (Fig. 2). Once the pancreas is clear from the splenic vessels to allow for division of the gland, the gland is divided with a stapler with a size chosen on the basis of the pancreas thickness. The specimen is removed with an Endo Catch bag (Covidien), and a surgical drain is place at the cut end of the pancreas.

Figure 2.

Spleen preserving distal pancreatectomy: port site placement and vessel‐preserving technique.

Laparoscopic Distal Pancreatectomy With Splenectomy

When a malignancy is suspected (based on imaging or fine‐needle aspiration cytology) or a technical reason necessitates removal of the spleen, the best technique is to mobilize the spleen after individual division of the splenic artery, splenic vein, and gland. Dissection of the splenic artery toward the spleen is sometimes necessary to ensure that the splenic artery is not mistaken for the hepatic artery (Fig. 3). The splenic artery and the vein are each ligated in turn with a vascular stapler; sometimes these vessels are approached from the posterior aspect of the gland. The spleen is mobilized from its attachments as the last step of the operation. When the spleen is removed for nononcological reasons, one can divide the pancreas from the spleen to morcellate (liquefy) the spleen for easy extraction from the peritoneum. When the spleen is removed because of malignancy, this piecemeal extraction method is not applicable because an oncologic margin could be threatened by the intracorporeal separation of the pancreas and spleen. In this case, the specimen is removed en bloc in an Endo Catch bag, by extending the incision of the midline 12‐mm port site. A frozen‐section analysis is performed intraoperatively to confirm a negative and adequate margin of resection before the operation is completed. The indications of splenic preservation are the same for both laparoscopic and open procedures.

Figure 3.

(A and B) Laparoscopic dissection and exposure of splenic vessels.

At all times, an Endo GIA 2.5‐mm (vascular load) stapler is open, loaded, and ready to use in case of injury to the splenic vessels. Clips are avoided because stapling devices cannot engage on a clip. As a precaution, keep a fresh 10‐blade scalpel and curved heavy Mayo scissors ready at all times in case a rapid conversion to an open operation is needed to control bleeding.

Patient Outcomes

Patients are admitted to the surgical floor for a typical hospital stay of 3 to 5 days after surgery. In our experience, recovery time tended to be shorter in the octogenarian and frail patient populations compared with patients who had open resections. Wound complications are rare after the laparoscopic technique; however, the pancreatic leak rate for all types of laparoscopic pancreas surgery is similar to that for the open operation.

Multiples studies comparing laparoscopic with open distal pancreatectmoy showed that in the laparoscopic group there was: an increased rate of splenic preservation, a decreased rate of operative blood loss, a decreased rate of postoperative intra‐abdominal infections, shorter lengths of stay, and a decreased rate of delayed gastric emptying. However, operative times and perioperative mortality were similar among the two groups.