Laparoscopic radical antegrade pancreatosplenectomy

Benign inflammatory lesions, cystic neoplasms, and neuro-endocrine tumours in the body and tail of the pancreas are considered good indications for laparoscopic distal pancreatectomy and/or en-bloc pancreatosplenectomy. Laparoscopic resection of malignant neoplasms has raised concern about the radicality of resection and oncological outcomes. This video demonstrates the technique of laparoscopic radical antegrade pancreatosplenectomy (lap-RAP), which achieves a radical resection with clear circumferential margins. The resection proceeds from right to left to include a coeliac lymphadenectomy, early division of the splenic artery, splenic vein and neck of pancreas, and medial to lateral mobilization of the pancreas posterior to Gerota's fascia to ensure an adequate posterior oncological clearance. Lap-RAP extends the benefits of laparoscopic pancreatectomy to include malignant lesions in the body and tail of the pancreas. This video is recommended for experienced laparoscopic surgeons.

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Laparoscopic radical antegrade pancreatosplenectomy

Authors

I Tait, FM Polignano, GD Adamson

Abstract

Benign inflammatory lesions, cystic neoplasms, and neuro-endocrine tumours in the body and tail of the pancreas are considered good indications for laparoscopic distal pancreatectomy and/or en-bloc pancreatosplenectomy. Laparoscopic resection of malignant neoplasms has raised concern about the radicality of resection and oncological outcomes.
This video demonstrates the technique of laparoscopic radical antegrade pancreatosplenectomy (lap-RAP), which achieves a radical resection with clear circumferential margins. The resection proceeds from right to left to include a coeliac lymphadenectomy, early division of the splenic artery, splenic vein and neck of pancreas, and medial to lateral mobilization of the pancreas posterior to Gerota's fascia to ensure an adequate posterior oncological clearance.
Lap-RAP extends the benefits of laparoscopic pancreatectomy to include malignant lesions in the body and tail of the pancreas.
This video is recommended for experienced laparoscopic surgeons.

Catégorie

basic techniques

Mots-clés

laparoscopy, radical antegrade pancreatosplenectomy

Type de vidéo

Vidéo chirurgicale

Durée

09'40''

Publication

2008-11

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Nov 2008;8(11).
URL: http://www.websurg.com/doi-vd01en2464.htm

Laparoscopic radical antegrade pancreatosplenectomy

1. Clinical case presentation 00'14''

The procedure demonstrated in this video is the laparoscopic approach for radical antegrade pancreatosplenectomy. Cross-sectional imaging identified an 8cm mass lesion in the tail of the pancreas consistent with a neuro-endocrine tumor, and biochemical testing confirmed this to be a glucagonoma.

2. Pancreatic tissue exposure and tumor identification 00'39''

The gastrocolic ligament is first divided, in this case, with the Harmonic scalpel to widely expose, the neck, body and tail of the pancreas. Here we see normal pancreatic tissue and the view of the anterior aspect of the glucagonoma. The pancreas is exposed along the entire length to the splenic hilum and the gastrocolic ligament is widely opened to include the short gastric vessels right up to the upper pole of the spleen. The stomach is elevated and the adhesions between the stomach and anterior border of the pancreas are divided to expose the left gastric vein, the celiac axis and the origin of the splenic artery. The left gastric vein together with the celiac axis, the caudate lobe of the liver and the inferior vena cava are now demonstrated.

3. Celiac axis dissection 01'43''

The 2nd step of the operation is to dissect the celiac axis to expose and isolate the splenic artery at its origin. The peritoneum over the celiac axis and splenic artery is divided by Harmonic scalpel and hook dissection. The left gastric vein is exposed and this determines the medial extent of this dissection.

4. Splenic artery dissection and division 02'12''

The splenic artery is freed from the superior border of the pancreas using hook diathermy dissection, and the associated soft tissue lymphatics are resected and sent separately for histology. Once the splenic artery is fully mobilized, it is divided at its origin using the Endo-GIA vascular stapler. The common hepatic artery is seen to the left of the stapler curving away towards the head of the pancreas.

5. Pancreatic posterior dissection 02'49''

Following the division of the splenic artery, the lower border of the pancreas is mobilized by division of the peritoneum, and this dissection is continued posteriorly to develop the tunnel beneath the neck of the pancreas. This areolar tissue can be divided by hook dissection and the Harmonic scalpel, and the neck of the pancreas gradually elevated to identify and expose the superior mesenteric vessels. The superior mesenteric artery is identified first and dissection to the left side of the superior mesenteric artery identifies the 3rd part of the duodenum. The posterior pancreatic attachments are divided to fully expose the 3rd part of the duodenum, and this tunnel is gently developed towards the celiac axis.

6. Superior mesenteric artery identification 03'21''

The superior mesenteric artery is mobilized away from the neck of the pancreas using hook dissection, and the dissection continued towards the right side of the SMA to identify the superior mesenteric vein.

7. Superior mesenteric vein identification 04'07''

As this fascia is divided, the superior mesenteric vein comes into view and is clearly demonstrated here with the suction. Here we see the superior mesenteric vein and the superior mesenteric artery, and to the left side of these vessels, the 3rd part of the duodenum is exposed. The neck and body of the pancreas are gently elevated and the posterior pancreatic attachments are divided using the Harmonic scalpel. This dissection continues in a cephalad direction towards the origin of the splenic artery and the celiac axis. Next, the neck and body of the pancreas are gently rotated upward to identify the splenic vein embedded in the posterior border of the gland. The superficial layer of the fascia is gently divided by hook diathermy to release the splenic vein. Small venous tributaries from the pancreas are divided by hook diathermy, and the larger branches are divided using the Harmonic scalpel.

8. Splenic vein dissection 05'35''

Once the splenic vein is fully isolated from within the pancreas, it is ready for division either by endo-clips or avascular stapler. It is our preference to divide the splenic vein using the Endo-GIA vascular stapler. Following division of the splenic vein, it is possible to see the divided splenic artery just beyond in the tunnel beneath the neck of the pancreas.

9. Division of pancreas 06'05''

Next, the neck of the pancreas is divided at the level of the splenic artery using the Endo-GIA vascular stapler. This typically requires 2 firings of the Endo-GIA 45mm stapler.

10. Pancreas retraction for dissection 06'24''

The neck of the divided pancreas is grasped and reflected laterally towards the spleen and the posterior retroperitoneal attachments of the pancreas are then divided from medial to lateral. The plane demonstrated here is immediately anterior to the adrenal gland as there is no demonstrable posterior infiltration with this tumor. If there is concern about posterior invasion, the dissection would include the adrenal gland. The pancreas and tumor are retracted upward to delineate the lower margin of the tumor and the inferior mesocolic attachments to the tumor are divided to mobilize and release the lower edge of the tumor. During this dissection, care is taken to ensure that a layer of soft tissue is left between the lesion and the plane of dissection. The fascia anterior to the adrenal gland is gently divided to mobilize the tumor upward. The pancreas is reflected downwards and the posterior peritoneal attachments that tether the superior border of the body and tail of the pancreas to the retroperitoneum are divided along a line between the celiac axis and the left crus of the diaphragm. In this case, the plane of dissection is anterior to the left adrenal gland, but deep to Gerota’s fascia, which is included with the resected specimen. It is important that Gerota’s fascia is removed en bloc to ensure the posterior margin is clear of tumor and to achieve a satisfactory R0 resection.

11. Division of splenocolic ligament 08'20''

Once the body and tail of the pancreas have been mobilized off the left kidney, the inferior splenocolic attachments are divided to release the inferior pole of the spleen.

12. Division of splenophrenic ligament 08'36''

This dissection is continued laterally and upward to divide the splenophrenic ligament. With this approach, the spleen is the last organ to finally be released from the retroperitoneum. The remaining posterior attachments at the upper pole of the spleen to release the specimen, which is placed into a retrieval bag, and extracted through either a small vertical midline laparotomy at the umbilicus or a small gridiron incision in the iliac fossa.

13. Operative site inspection and day 2 post-op scan 09'18''

After removal of the specimen, the operative site is inspected. This final still image demonstrates the posterior plane of dissection, which is anterior to the left adrenal gland, but includes removal of Gerota’s fascia behind the pancreas to expose the posterior surface of the left kidney. This photograph is on the 2nd postoperative day after laparoscopic antegrade pancreatosplenectomy.