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INDICATIONS

The most common indications for laparoscopic resection of the body and tail of the pancreas are benign neuroendocrine neoplasms, benign cystic neoplasms, symptomatic pancreatic pseudocysts, and pancreatic duct strictures. The role of this procedure for pancreatic malignancy is ill defined, largely because of the lack of clinical data validating its oncologic equivalence to open resection.

PREOPERATIVE INVESTIGATION AND PREPARATION

A contrast-enhanced computed tomography (CT) scan using a pancreatic protocol is a necessary assessment tool. This study provides images of the pancreas during the arterial and venous phases. Patients with radiographic abnormalities of the body and tail of the pancreas should undergo endoscopic ultrasound with or without fine-needle aspiration (FNA) and cystic fluid sampling if indicated. In patients with a dilated pancreatic duct, endoscopic retrograde cholangiopancreatography (ERCP) is useful for evaluating the papilla and ductal anatomy in the head of the pancreas.

Preoperative medical evaluation to stratify operative risk is essential. Vaccination against encapsulated bacteria (Haemophilus influenzae, Streptococcus, Meningococcus) is routinely given preoperatively, preferably 7 to 10 days before surgery, as splenectomy is frequently required with distal pancreatectomy. Patients with functional pancreatic neuroendocrine tumors may require preoperative hospitalization to optimize physiologic status. Adequate fluid resuscitation, preoperative antibiotics, and deep venous thrombosis (DVT) prophylaxis are all indicated.

ANESTHESIA

General anesthesia with endotracheal intubation and complete neuromuscular blockade is required for this operation.

POSITION

Laparoscopic distal pancreatic resection can be performed with the patient in the supine position or in a right semilateral decubitus position. The upper and lower extremities are well padded and secured comfortably. If the patient is in the supine position, the surgeon stands between the patient’s legs and the assistant stands to the left of the patient (Figure 1).

OPERATIVE PREPARATION

After the induction of general anesthesia, a Foley catheter and a nasogastric tube are placed. The upper abdomen of the patient from the nipple line to the pubis is shaved with clippers, and the abdomen is sterilely prepped.

OPERATIVE PRINCIPLES

Laparoscopic distal pancreatic resection consists of a series of defined steps that include:

  1. Lesser sac exposure

  2. Splenic flexure and mesocolon mobilization from the spleen and the body of the pancreas

  3. Pancreatic mobilization

  4. Splenic artery and vein isolation and ligation

  5. Pancreatic transection

  6. Pancreatic stump management

  7. Specimen extraction

There are several technical variations that can be used based on surgeon preference and character of the lesion. Pancreatic mobilization can be performed from lateral to medial or from medial to lateral. In general, the lateral-to-medial approach is easier; however, this does not allow for early control of the splenic artery and vein. Complete splenic mobilization is neither ...

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