Laparoscopic distal splenopancreatectomy for mucinous tumor

This video presents the case of a 29-year-old female patient presenting with abdominal pain at the epigastrium. CT-scan and magnetic resonance imaging demonstrated a septated cystic lesion at the tail of the pancreas. This lesion is about 5cm in diameter. It is incarcerated in the hilum of the spleen. Echo-endoscopy confirmed the cystic nature of the lesion and fine-needle aspiration showed mucinous fluid with a clearly pathological CEA evocative of a mucinous cystic lesion. A laparoscopic distal splenopancreatectomy is demonstrated.

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Laparoscopic distal splenopancreatectomy for mucinous tumor

Authors

B Dallemagne, J Marescaux

Abstract

This video presents the case of a 29-year-old female patient presenting with abdominal pain at the epigastrium. CT-scan and magnetic resonance imaging demonstrated a septated cystic lesion at the tail of the pancreas. This lesion is about 5cm in diameter. It is incarcerated in the hilum of the spleen. Echo-endoscopy confirmed the cystic nature of the lesion and fine-needle aspiration showed mucinous fluid with a clearly pathological CEA evocative of a mucinous cystic lesion. A laparoscopic distal splenopancreatectomy is demonstrated.

Media type

Surgical video

Duration

16'45''

Publication

2011-09

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E-publication

WeBSurg.com, Sept 2011;11(09).
URL: http://www.websurg.com/doi-vd01en3364.htm

Laparoscopic distal splenopancreatectomy for mucinous tumor

1. Clinical case 00'11''

This video presents the case of a 29-year-old female patient presenting with abdominal pain at the epigastrium. CT-scan and magnetic resonance imaging demonstrated a septated cystic lesion at the tail of the pancreas. This lesion is about 5cm in diameter. It is incarcerated in the hilum of the spleen. Echo-endoscopy confirmed the cystic nature of the lesion and fine-needle aspiration showed mucinous fluid with a clearly pathological CEA evocative of a mucinous cystic lesion.

2. Pancreas exposure 00'56''

The laparoscopic approach is performed using 4 trocars. Exposure of the pancreas is facilitated by medial retraction of the stomach using a specific system, the Endograb®. This device allows to suspend the stomach and place traction on the gastrocolic ligament, which will be incised to access the pancreatic gland. A major technical trick should be observed here: the scope is placed at the umbilicus in order to allow sufficient access to the pancreatic region as a supraumbilical approach would not provide a sufficient view of the pancreatic gland.

3. Gastrocolic ligament dissection 01'52''

The gastrocolic ligament is incised while paying attention to preserve the gastro-epiploic arcade. In this patient, adhesions originating from a previous appendicular peritonitis may be observed. Mobilization of the gastrocolic ligament and adjustment of the gastric suspension provide sufficient views onto the entire pancreatic gland, without the need for any additional trocar. All trocars used during this procedure are truly active throughout the dissection. The pancreatic gland is exposed. The cystic lesion is not visible from the anterior aspect of the pancreas. However, the preoperative explorations clearly determined its position at the level of the splenic hilum, making an elective spleen-preserving resection impossible to achieve.

4. Inferior border dissection 02'57''

The inferior border of the pancreas is initially approached at the level of the mesenterico-portal axis.

5. Identification of portal vein 03'09''

The portal vein is identified and the retropancreatic channel posterior to the pancreas is progressively created. The incision of the left border of the pancreas is continued.

6. Retropancreatic region access 03'30''

The preoperative decision is made to perform a splenopancreatectomy. The approach to the retropancreatic region is necessary to achieve the vascular control of the portal axis while bearing in mind that the pancreatic resection will be most probably situated slightly to the left of the portal axis. Consequently, the pancreatic gland will be preserved as much as possible.

7. Superior border dissection 04'06''

Once the inferior border of the pancreas has been approached, its superior border is dissected in order to identify the vascular structures, and especially the splenic artery. Placing an umbilical drain renders this dissection easier. The umbilical drain will be found again at the superior border of the pancreas, thus allowing to identify the different dissection planes.

8. Pancreatc suspension 04'36''

The atraumatic suspension of the pancreas is useful since one of the main difficulties encountered in pancreatic surgery is the grasping of the gland that may rapidly induce small local bleedings obscuring the operative field. Suspension of the pancreas is therefore easy. It allows to identify the retropancreatic vascular axes, especially the splenic vein. A lymph node enlarged towards the origin of the hepatic artery will be sampled and sent for pathological analysis.

9. Coeliac trunk dissection 05'27''

Dissection is carried on at the level of the coeliac trunk and of the splenic artery, which will be dissected and identified.

10. Peroperative ultrasound 05'40''

Peroperative ultrasonography allows to confirm the position and the size of the lesion. It also allows to demonstrate a clear flattening of the splenic vein, hence confirming the impossibility to preserve the spleen. The whole dissection is facilitated by the bipolar Ligasure® device. However, some steps of the dissection are rendered easier by the use of a coagulating hook, which allows for a precise dissection, and especially so around the vessels.

11. Splenic artery division 06'39''

Since it has been decided to resect the spleen, the splenic artery will be controlled and divided at its origin. The division of the artery will be performed first so as to reduce the vascular supply at the level of the spleen, hence reducing its volume. This maneuver will be helpful in the final dissection as well as during the splenectomy. Control ultrasonography has allowed to localize the division line of the pancreas, which will be situated to the left of the mesenterico-portal axis in order to preserve as much of the pancreatic gland as possible. The origin of the splenic vein is identified. This splenic vein is compressed by the distal pancreas. This vein is controlled during the division of the pancreas by automatic stapling. The inferior mesenteric vein is also identified. The dissection is further pursued to the left of the mesenterico-portal axis in order to limit the pancreatic resection. The posterior dissection plane is progressively created. It will reach the plane previously created at the superior border of the pancreas. A sufficiently large window is created in order to allow for the introduction of the automatic stapler.

12. Pancreatic transection 09'22''

During dissection, a relatively inflammatory condition of the peripancreatic area and of the retroperitoneum is evidenced. The pancreatic gland in the portion involved is relatively compliant, and a stapling is performed. The splenic vein is controlled as well. In all pancreatic resections, the stapling line is systematically reinforced by an absorbable running suture. The pancreatic duct is not searched for electively but is included in this running suture for hemostasis and sealing of the pancreatic duct.

13. Gastroepiploic artery dissection 10'47''

The cystic lesion is evidenced in the posterior portion of the dissection. It is situated within the hilum of the spleen. Dissection is pursued towards the left of the gastrocolic ligament with division of the left gastroepiploic artery, thus allowing to progressively approach the inferior pole of the spleen. Tissues are particularly inflammatory, which is linked to the peripancreatic reaction. The superior pole of the renal capsule is also identified. The greater curve of the stomach is approached with division of the gastrosplenic short vessels.

14. Gastrosplenic vessels division 11'37''

The splenic artery and the splenic vein have been ligated. The gastrosplenic short vessels have been divided. Mobilization is carried out in relation with the anterior surface of the left kidney.

15. Phrenosplenic ligament division 12'02''

The phrenosplenic ligament is progressively divided.

16. Completion of dissection and specimen removal 12'06''

All external elements are removed from the operative field at the end of the procedure. A careful hemostatic control is performed at the level of the stump of the splenic artery and of the splenic vein. The specimen is removed through a suprapubic Pfannenstiel incision for esthetic reasons, as the patient is young. A Redon drain is placed at the level of the splenic bed, and it will be preserved till postoperative day 4. Amylase dosing of the drainage liquid allows to determine when the drain should be removed. The pathological examinations will confirm an intestinal mucinous cystadenoma with no carcinogenicity signs.