The stomach is grasped with an atraumatic laparoscopic clamp and retracted superiorly. The lesser sac is then entered using a harmonic scalpel to divide the omentum along the greater curvature of the stomach (Figure 2). The opening in the lesser sac should be generous and allow exposure of the body and tail of the pancreas. The lateral extent of the incision is carried to the level of the short gastrics. The short gastric vessels are not divided when planning splenic preservation. Medial exposure is essential; therefore, the opening in the omentum is carried to the right gastroepipolic vessels. 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. The surgeon must ensure a clear view of the entire pancreas and the first part of the duodenum all the way over to the hilus of the spleen (Figure 2). 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. The pancreas should be visually inspected to identify the pathology. Intraoperative ultrasound may be helpful.
The operation will be carried out in a medial to lateral direction, as opposed to the lateral to medial direction for an open distal pancreatectomy. An incision is made in the peritoneum along the inferior border of the body and tail of the pancreas (Figure 2). Gentle dissection along the neck of the pancreas will expose the superior mesenteric vein and the portal vein (Figure 3). The splenic vein is identified. An incision is then made along the superior edge of the pancreas to the left of the gastroduodenal artery and inferior to the hepatic artery. A plane between the portal vein and the neck of the pancreas is created by gentle blunt dissection in the inferior to superior direction with a blunt nose laparoscopic dissector (Figure 4). Once the opening is complete and the blunt tipped dissector can be seen protruding from the superior edge of the pancreas, a half inch Penrose drain shortened to 12 cm is placed into the abdominal cavity through the 12- or 15-mm port. It is then passed underneath the neck of the pancreas and the ends are secured with an endoloop (Figure 5). This will allow anterior traction of the pancreas, which is essential to dissecting the plane along the superior mesenteric vein and the neck of the pancreas, and will also facilitate mobilization of the splenic vein away from the proximal body of the pancreas. The assistant grasps the Penrose drain and pulls it superiorly and anteriorly. The surgeon then begins to gently dissect the mesenteric vessels and portal vein away from the neck. The splenic vein will come into view, and prior to division of the pancreas, small branches of the vein are divided with the ultrasonic dissector and larger branches are clipped. This dissection is carried out in the medial to lateral direction for 2 to 3 cm. It may be necessary to place a shortened vessel loop around the splenic vein to provide countertraction and proximal vascular control. Once 2 to 3 cm of the vein has been dissected free, the neck of the pancreas is divided. This is accomplished with a reticulated endoscopic stapling device with 3.8- or 4.8-mm staples. The staple line may be reinforced with a commercial material (Figure 6). Both the proximal and the distal staple lines are inspected for bleeding, and if bleeding is found, it is controlled with electrocautery or the ultrasonic dissector. The Penrose drain may be removed at this point, as retraction of the pancreas may be obtained by grasping the distal staple line. Once the pancreas is divided, the body of the pancreas is retracted superiorly (Figure 7). This will permit the branches of the splenic artery to be divided. The splenic artery will come into view superior to the splenic vein. Small braches of the splenic artery are then divided with the ultrasonic dissector and larger branches are clipped. (Figure 7). A second shortened vessel loop may be passed around the splenic artery in order to provide counter traction as well as proximal vascular control. Once the branches of the proximal splenic artery are divided, the remaining branches of the splenic vein are ligated. The distal pancreas is pulled downward to further expose the splenic artery (Figure 8). The branches of both the artery and the vein are very fragile and unavoidable avulsion will occasionally occur. For small braches, bleeding may be controlled with pressure. Larger branches should be grasped with a Maryland dissector to control the bleeding and then clipped if there is sufficient length or ligated with a 4-0 or 5-0 monofilament suture if there length is insufficient. The peritoneum is further divided along the inferior edge of the pancreas. The posterior margin of the dissection will be the splenic vein and artery. The proximal jejunum may be seen and should be retracted inferiorly. Defects in the mesocolon should be closed with sutures to prevent internal hernias. The peritoneum is also divided along the superior edge of the pancreas with the ultrasonic dissector. As dissection proceeds, the vein will next be seen as it exits the splenic hilum. Shortly thereafter, the artery will be seen entering the spleen. The distance between the end of the tail of the pancreas and the spleen is variable. The final attachments are divided with the harmonic ultrasonic dissector. The specimen is extracted from the abdominal cavity using a specimen retrieval bag or similar device (Figure 9). It is removed from the abdominal cavity from the umbilical port. Once it is removed, the abdomen is reinsufflated and the lesser sac exposed to permit inspection of the splenic artery and vein for bleeding. If vessel loops have been used, they are removed at this point.