Laparoscopic spleno-pancreatectomy for cancer

Laparoscopic spleno-pancreatic resection performed for adenocarcinoma in the tail of the pancreas. This case demonstrates how a complex resection can be undertaken laparoscopically using a stepwise approach. Difficulty was encountered with division of the pancreas and the management of this problem is discussed. The surgeon stands between the patient's legs with the table in the reverse Trendelenburg position. The authors place three 10-mm ports across the upper abdomen with additional 5-mm ports in the left subcostal epigastric area. The camera is placed in the supraumbilical port. The laparascopic approach provides superior visualization, and tactile assessment of the pancreas. Mobility of the tumor is important to determine feasibility of resection. Laparoscopic ultrasound can delineate the tumor and surrounding structures.

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Laparoscopic spleno-pancreatectomy for cancer

Authors

B Dallemagne, L Soler, J Marescaux

Abstract

Laparoscopic spleno-pancreatic resection performed for adenocarcinoma in the tail of the pancreas. This case demonstrates how a complex resection can be undertaken laparoscopically using a stepwise approach. Difficulty was encountered with division of the pancreas and the management of this problem is discussed.

The surgeon stands between the patient's legs with the table in the reverse Trendelenburg position. The authors place three 10-mm ports across the upper abdomen with additional 5-mm ports in the left subcostal epigastric area. The camera is placed in the supraumbilical port. The laparascopic approach provides superior visualization, and tactile assessment of the pancreas. Mobility of the tumor is important to determine feasibility of resection. Laparoscopic ultrasound can delineate the tumor and surrounding structures.

Media type

Surgical video

Duration

15'46''

Publication

2006-12

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E-publication

WeBSurg.com, Dec 2006;6(12).
URL: http://www.websurg.com/doi-vd01en2037.htm

Laparoscopic spleno-pancreatectomy for cancer

1. Clinical information and CT scan 00'11''

This is the case of a solid tumor arising in the tail of the pancreas of a 75-year-old Caucasian male. Pneumococcal vaccination was administered prior to surgery. Preoperative CT-scanning demonstrates clearly a mass in the tail of the pancreas. Of note, the splenic vein can be seen passing adjacent to the mass. Also, the posterior surface of the stomach is closely applied to the tumor. No lymphadenopathy metastases are identified preoperatively.

2. 3D virtual reality 00'40''

A 3D virtual reconstruction clearly demonstrates the location of this tumor mass and its relationship to surrounding organs and blood vessels. These augmented reality images provide more information than a standard 3D CT-scan reconstruction. Using digital subtraction technology and rotation of the images, the lesion can be analysed in great detail. The entire operative strategy can be planned in advance. The virtual images can also be superimposed onto the monitor during this surgery to aid the performance of key steps in the procedure. Trocar placement can be planned and discussed with the patient prior to surgery using this technology. For the surgery, the patient is placed in a supine position with legs apart.

3. Exploration 01'39''

The surgeon stands between the legs. The table is tilted to the head up reverse Trendelenburg position for the dissection. Four to 5 ports can be used. Three 10mm ports are placed across the upper abdomen as shown with additional 5mm ports in the left subcostal and epigastric area for retraction as necessary. Surgery was initiated with a camera placed in the supra-umbilical port. Thorough visualization of the abdominal cavity is one of the advantages of the laparoscopic approach. Graspers may be used to provide tactile assessment of the pancreas. Mobility of the tumor is important to determine feasibility of resection. In addition, laparoscopic ultrasound can be performed to delineate the tumor and surrounding vital structures.

4. Entering the lesser sac 02'45''

The lesser sac is entered first by dividing the greater omentum along the greater curvature of the stomach. The plane of division is lateral to the gastroepiploic vessels. With retraction of the stomach anteriorly and superiorly, it is possible to then inspect the pancreas directly. The pancreas is a difficult organ to approach because of its posterior location in the abdomen. It is retroperitoneal and closely applied to a number of vital structures. The body of the pancreas is related to the stomach anteriorly, the coeliac branches superiorly, the spleen laterally, the splenic flexure of the colon and kidney inferiorly, and the left adrenal and splenic veins posteriorly. In the case of malignancies in the tail of the pancreas, it is often technically easier as well as oncologically meaningful to remove the spleen during a distal pancreatectomy.

5. Exposure of superior border of pancreas 03'50''

After exposing the anterior surface of the pancreas, we proceed to delineate the superior border. Here we can observe the division of congenital adhesions that occur between the posterior body of the stomach and the anterior surface of the pancreas. As we proceed more medially, the peritoneal fold contains the left gastric artery and careful dissection is essential not to injure this vessel. The stomach must be retracted superiorly and the hook and scissors can be used in turn to divide the peritoneal reflections. Here we observe the dissection of the peritoneal reflection between the stomach and the pancreas. Within this, it’s where we can find the left gastric artery and sometimes event the origin of the splenic artery. If it is identified early at this stage, it makes the dissection easier because we can control the vessels from this point onwards.

6. Exposure of inferior border of pancreas 05'34''

The inferior border of the pancreas is now exposed by dividing the peritoneal reflection at the base of the transverse mesocolon. Once the inferior edge of the pancreas is exposed for a few centimetres, it is retracted anteriorly so that a plane can be developed posteriorly by blunt dissection.

7. Control of the pancreas 06'00''

At the superior end of this dissection, the splenic vessels are visualized. At this point, a nylon tape can be passed around the body of the pancreas. This is an effective way of retracting the pancreas to complete the posterior dissection which will be done later.

8. Exposure of the spleen 06'49''

At this point, we first completely open the lesser sac by dividing the gastrocolic ligament, which brings us to the gastrosplenic ligament, which is the same anatomical structure, part of the greater omentum. It only bears a different name because of its location. The short gastric arteries run in this ligament and they are taken individually between clips.

9. Division of the pancreas 08'09''

Once the spleen is completely freed on its medial aspect, we then proceed to divide the pancreas. With strong anterior retraction on the nylon tape, it is then possible to inspect posteriorly the pancreas and make sure that all the structures have been divided. It is important to have good visualization in this space and also to create a wide tunnel. We can observe at the end of this tunnel the splenic vessels. It is important to control these vessels because once we pass the stapler there is a possibility that these vessels could be injured by the tip of the stapler. We therefore place clips in order to secure hemostasis prior to passing the stapler to do the pancreatic division. With appropriate traction on the nylon tape, a linear intestinal stapler is applied across the body of the pancreas. In this case, you can see that the pancreas is very hard and it is impossible to close the stapler completely. Not only that, the pancreas slips out of the jaws of the stapler, and this results in a lot of bleeding and incomplete division of the pancreas. At this point, it is important to stop the procedure and control the hemostasis. For this purpose, we use 2/0 braided absorbable sutures. Alternatively, it is possible to use an energy device to apply a coagulation current across the pancreas in order to seal the blood vessels as well as the pancreatic duct. In our experience, the most effective technique of achieving hemostasis as well as closure of the duct is with sutures. After achieving reasonable hemostasis with sutures, we then proceed to complete the division of the pancreas with an energy device.

10. Division of splenic vessels 10'55''

After the pancreas has been completely divided, we can have very good visualization of the vessels which run in the superior border of the pancreas. Once we confirm that these are indeed the splenic vessels, we can then proceed to ligate and divide both the splenic artery and vein as we have already determined that we will perform a splenectomy together with the pancreatectomy. In very large spleens, it is useful to ligate the splenic artery some minutes prior to the vein. This is to allow the spleen to empty. In this case, however, it makes little difference.

11. Posterior mobilization of the pancreas 11'41''

Once all the vascular divisions are completed, the pancreas and spleen can now be removed “en bloc”. With appropriate retraction anteriorly and superiorly, this can easily and rapidly be accomplished with a combination of electrocautery, scissors and the energy device.

12. Division of splenic attachments 12'15''

Once the pancreas is well mobilized posteriorly, we then proceed to divide the splenocolic and lienorenal ligaments in order to mobilize the spleen.This is a relatively avascular plane. The parietal attachments of the spleen are divided last. In this approach, it is useful to leave them inside to up to this point because they provide good retraction to the spleen.

13. Hemostasis of pancreatic stump 13'13''

One of the problems with distal pancreatectomies is the management of the stump of the pancreas. Bleeding and leakage from the main pancreatic duct of Wirsung contribute to fistula formation. In this case as mentioned previously, figure of 8 sutures are placed to secure hemostasis. Although it was not possible to identify the pancreatic duct, it is still useful to place these sutures running from anterior to posterior in order to seal any possible leak from the pancreas. If it is possible to identify the main duct, then direct closure of this duct can be carried out with sutures or tissue glue.

14. Extraction 14'13''

The specimen is placed in a strong large bag for extraction. Histopathology confirmed the pancreatic exocrine adenocarcinoma at stage pT3 and 1. Postoperatively the patient recovered well and was discharged on the 9th postoperative day.