Laparoscopic left pancreatectomy with spleen preservation and splenic vessels resection

Authors

B Dallemagne, S Perretta, L Soler, J Marescaux

Abstract

This film demonstrates the laparoscopic resection of a pancreatic tumor in a 47-year-old woman who consulted for epigastric pain. The preoperative exam showed a tumor larger than 4cm situated at the body of the pancreas.

Keywords

Laparoscopic left pancreatectomy, spleen preservation, splenic vessels resection

Media type

Duration

23'00''

Publication

2010-06

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E-publication

WeBSurg.com, Jun 2010;10(06).
URL: http://www.websurg.com/doi-vd01en2877.htm

Laparoscopic left pancreatectomy with spleen preservation and splenic vessels resection

1. Clinical case presentation 00'18''

This film demonstrates the resection of a pancreatic tumor in a 47-year-old woman who consulted for epigastric pain. The preoperative exam showed a tumor larger than 4cm situated at the body of the pancreas. The use of 3D reconstruction based on the CT-scan images helps to precisely locate the tumor and to study its local relationships, especially with regards to the vascular network. This patient’s virtual image may be modulated according to the surgeon’s objectives. In the present case, the relationships between the splenic vessels and the tumor can be appreciated. In our case, the tumor’s location drives us to opt for the resection of the left pancreas by removing the splenic vessels.

2. Operative settings 01'25''

This intervention is carried out laparoscopically. The position of the surgical team in the operating room is fairly conventional. The surgeon stands between the patient’s legs, with an assistant on each side. The patient is placed in a supine position with her legs apart, with a slight reverse Trendelenburg tilt. A five-port approach is used. The supraumbilical port is used for the scope. Two lateral ports are used for the surgeon’s right and left hand. The ports situated on the lateral sides will be used by the assistants for retraction purposes. Once the gastrocolic ligament has been opened, the pancreas is approached. To do so, various adhesions between the posterior surface of the stomach and the pancreatic aspect are taken down. Considering the tumor’s location, it is essential to have access to the largest aspect of the pancreas since it was observed that the tumor slightly exceeded to the right of the mesentericoportal axis as shown on the reconstruction images. Most of the procedure is performed with the Ligasure® device.

3. Freeing of the gastrocolic ligament 03'03''

The gastrocolic ligament is freed in order to improve the vision, which is obtained on the anterior surface and the juxtacephalic portion of the pancreas. In our precise context, the preoperative exams are evocative of a potentially malignant tumor even if the malignant signs are neither evidenced by the preoperative imaging study nor by the use of tumoral markers. However, a sufficient resection margin should be respected at the level of the juxtacephalic portion of the resection.

4. Exposure of the anterior aspect of the pancreas and ultrasonography 03'49''

The anterior aspect of the pancreas is exposed. A peroperative ultrasonography will allow to define the limits of the tumor (although not demonstrated in this film). The left portion of the gastrocolic ligament is also freed, and the adhesions at the level of the transverse colon and of its splenic flexure are taken down. During this dissection, it is essential to preserve the left gastro-omental artery. Indeed, if a pancreatic resection is envisaged along with the resection of the splenic vessels and with spleen preservation, the left gastro-omental artery as well as the short gastrosplenic vessels should be preserved. As soon as the pancreas has been exposed, its dissection can be initiated.

5. Dissection of the inferior border of the pancreas 05'03''

The inferior border of the pancreas is incised in order to gain access to the mesentericoportal axis. The pancreatic capsule is incised. The mesenteric axis will be progressively identified. This identification may be slightly uneasier in adipose patients; however, when respecting the usual margins, the location is routinely identified. The laparoscopic approach helps to obtain a much more interesting view onto this axis than in open surgery. Actually, it offers a perfect visualization of the superior border of the mesentericoportal axis, especially during the dissection of this retropancreatic channel.

6. Identification of portal vein and splenic vein 06'18''

The portal vein and the origin of the splenic vein are identified. The dissection is progressively extended to the superior border of the pancreas. No blind maneuver is performed throughout the different steps of this dissection. The stump of the splenic vein is identified. In order to facilitate the identification of the superior border of the pancreas and of the portal trajectory, a tape is placed in the channel. The superior border of the pancreas is then approached in order to identify the superior limit of the retropancreatic channel. The placement of this tape facilitates this identification since the pancreas will be suspended to open up the space where the splenic vessels are situated. The left gastric vein is also identified during this dissection in order to be preserved. In this current case, given this voluminous tumor, the preservation of the spleen along with the division of the origin of the splenic vessels is decided upon.

7. Division of the splenic artery 08'02''

The origin of the splenic artery is dissected. It will be clipped and divided. In this technique, the spleen’s vascularization will be ensured by the left gastro-omental artery and by the short gastrosplenic vessels. This technique offers a good alternative to others in which the splenic vessels are preserved over their entire length. This technique is certainly used for benign lesions. In this case, a malignancy is possible, and as a result, it necessitates an “en bloc” resection of the left pancreas. The splenic vein is also clipped and divided. In this patient, the left gastric vein will be preserved during the dissection. After this vascular step, the division of the pancreas comes next. There are several technical modalities available to divide the pancreas. Electrocautery can be used with the help of a hook for instance. Division through ultrasound or division through the stapler can also be performed. In the present case, we wrongly opted for a division using the surgical stapler. In fact, the pancreatic gland is inflamed. The pancreas is hard, and as we will see, this will cause some problems during the stapler’s application.

8. Freeing of the superior border of the pancreas 11'34''

The superior border of the pancreas is freed along the hepatic artery so that the stapling can be applied as close as possible to the pancreatic head, hence respecting the resection margins that had been defined during the peroperative ultrasonography. The gastroduodenal artery as well as the common hepatic artery are identified in turn. Not only does this wide dissection of the superior border of the pancreas allow for access to the division line, but also allows for a lymph node dissection at the level of the common hepatic pedicle, if need be. The right border of the portal vein is also freed in order to divide the pancreas as close as possible to the isthmus and to the head of the pancreas.

9. Division of the pancreas with the stapler 13'16''

The stapler is applied. As mentioned earlier, the pancreas presents signs of chronic inflammation and it soon becomes evident that the surgical stapler does not have sufficient power to crush and staple the parenchymal pancreatic tissue. From then onwards, the pancreatic division will be pursued initially with the Ligasure® device, which however cannot crush the pancreatic parenchyma. This division will be finalized with ultrasonic scissors. This anarchic division induces a few bleedings at the level of the dorsal pancreatic branches, which will be systematically controlled by a bipolar cautery forceps. The various studies on the means of control and prevention of pancreatic fistula after left pancreatectomy that have been undertaken suggest that the different division systems are secured by the application of an additional running suture, and by all means, when this division is not accompanied by a stapling as it is the case in this patient. From then on, at the end of this intervention, the pancreatic division slice will be secured by a running suture. The pancreas is divided. The left gastric vein that will be preserved and the stump of the splenic vein can be seen.

10. Mobilization of the pancreatic body 15'32''

The body of the pancreas will be progressively mobilized from right to left. The vascular stumps that have been clipped can be identified here. The dissection of this posterior aspect of the pancreas is easy since no particular vascular structure is encountered during this retroperitoneal approach.

11. Dissection of the pancreatic tail 16'10''

The dissection is progressively extended towards the pancreatic tail where the terminal portion of the splenic vein and artery should be respected according to the selected approach. The origin of the left gastro-omental artery should be preserved too. This artery along with the short gastrosplenic vessels will ensure the spleen’s vascular supply. The end of the dissection of the pancreatic tail should be performed cautiously in order not to injure the left gastro-epiploic artery. In this patient, the precise identification of the pancreatic parenchyma is uneasy within this adipose mass. The position of the left gastro-epiploic artery and of the pedicle is controlled. The dissection of the terminal portion of the pancreatic tail helps to distally re-identify the splenic artery and the proximal extremity of the splenic vein in the hilum of the spleen. These two vascular structures will be dissected and clipped separately. In the present case, the traction maneuver on the pancreas causes the rupture of the splenic artery but as this artery has been ligated at its origin, there is obviously no consequence.

12. Running suture on the pancreatic division slice 19'22''

As mentioned earlier, the pancreatic division slice is ensured by a running suture of absorbable monofilament material. The Wirsung’s duct is not systematically searched. Certain authors recommend the elective ligation of the Wirsung’s duct in addition to this hemostatic running suture. A large running suture is probably sufficient to incorporate the Wirsung’s duct and therefore prevent postoperative fistulas from occurring. We hardly ever use biological glue at the level of these pancreatic sutures. We hardly ever use somatostatin-like substances prophylactically. Such substances would only be used in case of complications such as postoperative fistulas. This left pancreas surgery requires a systematic drainage considering the high amount of postoperative fistulas, which fluctuate between 10 and 60% according to different series. The drainage is used as a rule of thumb. The stomach is not drained; no nasogastric tube is placed. The patient is allowed to drink in the evening of the intervention and depending on her recuperation, a progressive return to food intake is initiated. No specific radiological control is performed postoperatively, except if the patient develops a less favorable clinical condition. In this patient, the pathological findings will reveal the presence of an Intraductal Papillary Mucinous Neoplasm with low-grade dysplasia.

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