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INDICATIONS

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Laparoscopic resection of the body and tail of the pancreas is limited to certain pancreatic neoplastic diseases including pancreatic neuroendocrine tumors such as insulinomas, pancreatic cystic neoplasms, and pseudopapillary tumors. The approach is not recommended for chronic calcific pancreatitis. For adenocarcinoma of the body and tail of the pancreas, splenectomy should be performed. Splenic preservation is recommended and should be attempted in the absence of a malignant neoplasm.

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PREOPERATIVE PREPARATION

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The preparation is related to the preoperative diagnosis. As splenic preservation is not always possible, it is recommended to vaccinate the patient 2 weeks prior to the surgery against encapsulated organisms including pneumococcus, haemophilus influenza, and meningococcus.

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ANESTHESIA

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General anesthesia with endotracheal intubation is required.

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POSITION

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A cushioned beanbag should be placed on the operating table prior to bringing the patient into the room. After insertion of a bladder catheter, the patient should be positioned in a partial lateral position at about 45 degrees with the left arm crossing the chest and supported on an arm board or pillows (figure 1a). The right arm is placed on an arm board and an axillary roll is used. Liberal padding is used between and around both arms. The abdomen and flank area should be exposed. The left knee is flexed, with a padding of blankets or pillows between the legs. Alternatively, the patient may be positioned in a modified lithotomy position, also using a cushioned beanbag and taking care not to flex the thighs excessively so as to avoid interference with the range of motion of the instruments.

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OPERATIVE PREPARATION

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Hair removal is accomplished with skin clippers from the level of the nipples well out over the chest wall and down over the abdomen, including the flanks. The skin is prepared in the routine manner.

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INCISION AND EXPOSURE

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The surgeon stands on the patient’s right side similar to a laparoscopic left adrenalectomy (figure 1a). The camera operator stands to the right of the surgeon and the assistant on the left side of the patient. If the modified lithotomy position is employed, the surgeon is positioned between the legs and the camera operator to the patient’s right and the assistant to the patient’s left. Port placement is shown in figure 1b. A 10-mm 30-degree laparoscope is placed above the umbilicus using the open technique of Hasson as described in Chapter 11. The abdomen is insufflated to 15 mm Hg pressure. The laparoscope is introduced and all four quadrants of the abdomen are examined for metastatic disease. Two 5-mm ports are placed: one in the midline and one to the left side midway between the umbilicus and the xiphoid process at the midclavicular line. The ports are place about 5 to 8 cm apart in ...

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