Plate 125
###### Figure 3

The more common indications for resecting the body and tail of the pancreas include localized adenocarcinoma in this area, islet cell adenomas, cysts, and chronic calcific pancreatitis. This procedure may be the initial approach for total pancreatectomy for carcinoma of the pancreas.

The preparation is related to the pre-operative diagnosis. If splenectomy is contemplated then vaccines for pneumococcus, haemophilus influenza, and meningococcus should be administered prior to the surgery.

The patient with an insulinoma, suggested by repeated fasting blood sugars of below 50 mg/dL, requires supplementary glucose by mouth or intravenously at regular intervals for 24 hours preceding surgery and intravenously during surgery.

When an ulcerogenic tumor is suspected, the fluid and electrolyte balance should be corrected, particularly if there have been large losses of gastric secretion or losses from enteritis. Serum gastrin levels may establish the diagnosis, and the patient may require a total gastrectomy in the future. Every effort should be made to localize one or more endocrine tumors by CT, MRI, somatostatin scintigraphy, or selective arteriography and selective arterial stimulation with either secretin (for gastrinoma) or calcium (for insulinoma).

General anesthesia with endotracheal intubation is used.

Supine position with the feet lower than the head.

The skin is shaved 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.

Either a long vertical midline or an extensive curved incision parallel to the costal margins, as described for pancreaticoduodenectomy (Plate 129).

When the procedure is carried out for an inflammatory lesion of the body and tail of the pancreas, a direct exploration of this region is performed. When the procedure is carried out for tumor, a thorough exploration of the abdomen, with particular reference to the liver and the gastrohepatic ligament in the region of the celiac plexus, should be made for evidence of metastasis. A possible microscopic diagnosis of adenocarcinoma is sought by biopsy before proceeding with a total pancreatectomy from the left-side approach. Since the adenomas can be distributed throughout the pancreas, the head of the pancreas must be thoroughly explored by visualization and palpation preliminary to a definitive type of procedure on the left half of the pancreas. Evidence of gastric hypersecretion, as indicated by increased vascularity and thickening of the gastric wall, along with a hyperemic and hypertrophic duodenum and an ulcer in the duodenum or beyond the ligament of Treitz, adds support to the potential diagnosis of gastrinoma tumor of the pancreas. ...

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