- Distal pancreatic solid mass.
- Neuroendocrine tumor.
- Pancreatic adenocarcinoma.
- Solid neoplasm of indeterminate diagnosis.
- Distal pancreatic mucinous cystic neoplasms.
- Asymptomatic, ≥ 3 cm in size.
- Symptomatic, any size.
- Presence of a solid component.
- Dilated main pancreatic duct.
- Distal pancreatic symptomatic serous cystadenoma.
- Chronic calcific pancreatitis or small symptomatic pseudocyst limited to pancreatic tail (less common).
- Proximal mass requiring pancreatoduodenectomy.
- Known metastatic disease.
- Local invasion of structures that cannot be resected en bloc with the pancreas.
- Mass encasing mesenteric vessels, with loss of usual fat planes noted on preoperative imaging (CT, MRI, or endoscopic ultrasound [EUS]).
- Portal hypertension.
- Cardiopulmonary comorbidities.
- Splenic vein thrombosis.
- Surgical cure of a neoplasm in the distal pancreas.
- Prevention of malignant transformation of mucinous cystic neoplasms.
- Treatment of symptomatic benign disease.
- Surgical site infection, bleeding, and damage to adjacent structures.
- Removal of the spleen.
- Should this be necessary, patients are at risk for the rare complication of post-splenectomy sepsis.
- Complications unique to operations on the pancreas include:
- Postoperative pancreatitis.
- Pancreatic leaks.
- Pancreatic fistula formation.
- No special equipment is needed.
- A self-retaining retractor helps facilitate exposure of the operative field.
- A surgical energy device (eg, harmonic scalpel, LigaSure) is extremely useful.
- Depending on surgeon preference, a surgical stapler may be used to transect the pancreatic tail. In that case, a thoracoabdominal (TA) or gastrointestinal anastomosis (GIA) stapler is used.
- Thorough preoperative evaluation is essential before undertaking this procedure.
- For symptomatic patients, delineation of the presenting symptoms and correlation of these symptoms with the mass in the pancreatic tail or body is critical.
- Potentially useful tests include:
- Abdominal CT, ultrasonography.
- Endoscopic retrograde cholangiopancreatography (ERCP) or EUS.
- Magnetic resonance cholangiopancreatography (MRCP).
- For cystic neoplasms, cyst fluid is often obtained during EUS and analysis is performed to differentiate mucinous from serous cystic lesions and to determine cyst fluid CEA levels.
- Side branch versus main duct intraductal papillary mucinous neoplasms should be differentiated preoperatively using ERCP, MRCP, or EUS, if at all possible.
- Patients with persistent hypoglycemia and suspected insulinoma should receive glucose supplementation.
- Patients with refractory ulcers, elevated gastrin levels, and the suspicion of a gastrinoma should receive preoperative treatment for acid secretion and appropriate fluid and electrolyte supplementation.
- If splenectomy is planned, patients should undergo immunization for encapsulated organisms at least 2 weeks before surgery.
- The patient should be supine.
- The skin is prepared from the level of the nipples to the pubis, extending along the flank.
- The abdomen is entered through a midline incision.
- Alternatively, a bilateral subcostal incision may be used.
- Figure 16–1: Ligation of the short gastric vessels.
- For resection of the distal pancreas, the standard approach is through an upper midline incision.
- The pancreas is approached as in other pancreatic procedures through the lesser sac of the omentum....
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