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In the presence of a tumor that necessitates removal of the left half or all of the pancreas, steps should be taken to mobilize and remove the spleen. The splenic artery is doubly ligated with 00 silk near its point of origin. This tends to decrease the blood loss following manipulation of the spleen and permits blood to drain from this organ into the systemic circulation during the subsequent steps of its removal. The left gastroepiploic vessel is doubly clamped and ligated, and the short gastric vessels are then divided all the way up to the diaphragm. The blood supply on the greater curvature should be ligated by transfixing sutures that incorporate a bite of the gastric wall to prevent hemorrhage if gastric distention should occur and the ligature slip off the gastric side (Figure 4). Alternatively, the ultrasonic dissector can be used to coagulate and divide the short gastric vessels. The splenorenal ligament is divided as the surgeon pulls the spleen medially with his left hand (Figure 5). Blunt and sharp dissection may be carried out to free the tail of the pancreas, but this is rather easily done by finger dissection as the organ is reflected medially (Figure 6). The left adrenal and kidney are clearly visualized as well as a segment of the left renal vein. The inferior mesenteric vein is ligated and divided (Figure 6). at the inferior border of the pancreas. The splenic artery is divided near its point of origin and ligated and then transfixed distally with double ties of 00 silk. The splenic vein is cleared and separated from the posterior surface of the pancreas and is followed over to the point where it joins the superior mesenteric vein to form the portal vein (Figure 7). The splenic vein is gently freed from the pancreas, using blunt-nosed right-angle clamps (Figure 7). The vessel is ligated and is transfixed proximally to this tie to avoid any possible late hemorrhage. The spleen and body of the pancreas can then be mobilized sufficiently to be brought outside the peritoneal cavity.
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This approach is useful in performing a total pancreatectomy since it ensures a good exposure for the identification of veins coming off the medial aspect of the portal vein. The superior surface of the portal vein is free of venous tributaries. However, the resection may be restricted due to involvement of the portal vein by adenocarcinoma.
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