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  • 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).

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Absolute

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  • 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.

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Relative

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  • Cardiopulmonary comorbidities.
  • Splenic vein thrombosis.

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Expected Benefits

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  • Surgical cure of a neoplasm in the distal pancreas.
  • Prevention of malignant transformation of mucinous cystic neoplasms.
  • Treatment of symptomatic benign disease.

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Potential Risks

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  • 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.

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  • 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.

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  • 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.

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  • 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.

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  • 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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