Plate 128

Laparoscopic resection of the body and tail of the pancreas is limited to certain pancreatic neoplastic diseases including pancreatic neuroendocrine tumors such as insulinomas, pancreatic cystic neoplasms, and pseudopapillary tumors. The approach is not recommended for chronic calcific pancreatitis. For adenocarcinoma of the body and tail of the pancreas splenectomy should be performed. Splenic preservation is recommended and should be attempted in the absence of a malignant neoplasm.

The preparation is related to the preoperative diagnosis. As splenic preservation is not always possible, it is recommended to vaccinate the patient 2 weeks prior to the surgery against encapsulated organisms including pneumococcus, haemophilus influenza, and meningococcus.

General anesthesia with endotracheal intubation is required.

A cushioned beanbag should be placed on the operating table prior to bringing the patient into the room. After insertion of a bladder catheter, the patient should be positioned in a partial lateral position at about 45 degrees with the left arm crossing the chest and supported on an arm board or pillows (Figure 1A). The right arm is placed on an arm board and an axillary roll is used. Liberal padding is used between and around both arms. The abdomen and flank area should be exposed. The left knee is flexed, with a padding of blankets or pillows between the legs. Alternatively, the patient may be positioned in a modified lithotomy position, also using a cushioned beanbag and taking care not to flex the thighs excessively so as to avoid interference with the range of motion of the instruments.

Hair removal is accomplished with skin clippers 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.

The surgeon stands on the patient's right side similar to a laparoscopic left adrenalectomy (^6822858). The camera operator stands to the right of the surgeon and the assistant on the left side of the patient. If the modified lithotomy position is employed, the surgeon is positioned between the legs and the camera operator to the patient's right and the assistant to the patient's left. Port placement is shown in ^6822859. A 10-mm 30-degree laparoscope is placed above the umbilicus using the open technique of Hasson as described in Plate 91. The abdomen is insufflated to 15 mmHg pressure. The laparoscope is introduced and all four quadrants of the abdomen are examined for metastatic disease. Two 5-mm ports are placed: one in the midline and one to the left side midway between the umbilicus and the xiphoid process at the midclavicular line. The ports are place about 5 to 8 cm apart in the crainiocaudad orientation to permit bimanual operation without physical restriction. A 10-12 or 15-mm port is placed on the left side at the level of the umbilicus in the anterior axillary line. An additional 5-mm port is placed just below the right subcostal margin in the midclavicular line. A 15-mm port is required for an endoscopic stapler with 4.8-mm staples that may be used to divide a thicker pancreas, whereas a stapler with 3.8-mm staples or less will be able to be introduced through a 12-mm port.

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.

The specimen should be examined to determine that the pathology has been removed. A frozen section at the margin should be obtained for pancreatic cystic tumors and intraductal mucinous neoplasms. A closed-suction Silastic drain may be placed by passing the external portion of the drain through the 12- or 15-mm port and withdrawing from one of the 5-mm port sites. The 12- or 15-mm port site is closed with #1 absorbable suture. The umbilical port site is closed with #1 absorbable suture.

A nasogastric tube is not necessary. Crystalloids should be given in an adequate amount. Pain management will require intravenous narcotic analgesics for one to two days. Antibiotics are discontinued within 24 hours. Glucose monitoring should be performed as a transient diabetic state may occur. The hemoglobin and electrolytes should be checked on the first postoperative day and repeated as deemed necessary by the clinical course. An initial postoperative diet may be started on the first postoperative day. The drain amylase should be measured prior to removing the closed-suction drain. The drain should not be removed if the amylase is great than two times the upper limit of normal. Supplemental pancreatic enzymes are usually not necessary. The patient is discharged when tolerating a diet.