Plate 125

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. Likewise, the inner wall of the duodenum should be carefully palpated in the search for small adenomas extending into the lumen of the duodenum from the pancreatic side. Finally, a sterile ultrasound probe for intraoperative scanning of nonpalpable lesions is advocated by most surgeons.

After the abdomen has been explored and the region of the head of the pancreas evaluated, the greater omentum is reflected upward, and downward traction is maintained on the transverse colon as the omentum is separated by sharp dissection and the lesser sac entered (Figure 1). Usually, the stomach is easily separated from the pancreas, but sharp dissection may be required to separate it from the capsule of the pancreas, especially if there have been repeated bouts of acute inflammation. Sharp as well as blunt dissection is used to sweep the posterior gastric wall away from the pancreas, particularly in the region of the antrum, to make certain the middle colic vessels have not been angulated upward and attached to the posterior gastric wall. A clear view must be ensured of the entire pancreas and the first part of the duodenum all the way over to the hilus of the spleen (Figure 1). To avoid troublesome bleeding, it is usually desirable to divide the communicating vein between the right gastroepiploic vessels and the middle colic vein inferior to the pylorus. This permits better mobilization in the region of the antrum. Large S retractors can be used to retract the stomach upward as the transverse colon is either pulled downward outside the wound or returned to the abdomen and packed away. The pancreas should be inspected thoroughly and palpated to verify the pathology. It is safer and far easier to mobilize and remove the spleen rather than attempt to separate the pancreas from the splenic artery and vein running along the superior surface of the body and tail of this organ.

In carcinoma the tumor's mobility and the presence or absence of regional metastasis must be determined before a radical resection is planned. It is less uncommon to find a resectable carcinoma involving the tail or body of the pancreas. In insulinomas it is more common to find only one tumor; this may be enucleated without removing a large segment of the pancreas, depending on the adenoma's location and relationship to the major pancreatic duct and vessels. Finding a solitary gastrinoma of considerable size may tempt the surgeon to do a local excision only, followed by vagotomy, pyloroplasty, and proton pump inhibitor therapy postoperatively. Any enlarged lymph nodes around the pancreas are excised for frozen section examination searching for evidence of metastases. For gastrinoma, the duodenum must be opened and explored to search and remove a possible duodenal primary lesion.

When the lesion cannot be seen or palpated by digital examination of the anterior surface of the gland, the body and tail must be mobilized for direct palpation with the thumb and index finger and for visualization of the under-side of the pancreas. This is accomplished by incising the peritoneum along the inferior surface of the pancreas (Figure 2). Only a few small blood vessels are encountered. The inferior mesenteric vein should be identified, and the incision should avoid it as well as the middle colic vessels. After the inferior surface of the peritoneum has been incised, a finger can be introduced rather easily underneath the pancreas, and the substance of the gland can be palpated quite easily between the thumb and index finger (Figure 3). As a matter of fact, the finger can be inserted completely around the pancreas following the incision in the peritoneum just above the splenic artery and vein. Finally, a hand-held ultrasound unit is very useful in finding nonpalpable lesions within the pancreas.

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