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Laparoscopic distal pancreatectomy with spleen and vessel preservation

This is the case of a female patient presenting with a 12mm endocrine tumor located at the pancreatic isthmus. To manage this case, a distal pancreatectomy is decided upon. This tumor measures 16mm in its transverse diameter and it is located just above the portal vein. The CT-scan and its 3D reconstruction helps us to plan the surgical intervention. The whole pancreas along with the splenic vessels (splenic vein and artery) are reconstructed. The objective is to precisely locate the tumor in order to determine the resection modalities. A distal pancreatectomy with preservation of the splenic vessels is therefore decided upon.

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Laparoscopic distal pancreatectomy with spleen and vessel preservation

Autores

D Mutter, L Soler, J Marescaux

Resumen

This is the case of a female patient presenting with a 12mm endocrine tumor located at the pancreatic isthmus. To manage this case, a distal pancreatectomy is decided upon. This tumor measures 16mm in its transverse diameter and it is located just above the portal vein. The CT-scan and its 3D reconstruction helps us to plan the surgical intervention. The whole pancreas along with the splenic vessels (splenic vein and artery) are reconstructed. The objective is to precisely locate the tumor in order to determine the resection modalities. A distal pancreatectomy with preservation of the splenic vessels is therefore decided upon.

Palabras clave

Laparoscopic distal pancreatectomy, spleen and vessel preservation

Tipo de medio

Vídeo quirúrgico

Duración

17'42''

Publicación

2010-04

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WeBSurg.com, Apr 2010;10(04).
URL: http://www.websurg.com/doi-vd01en2926.htm

Laparoscopic distal pancreatectomy with spleen and vessel preservation

1. Introduction 00'15''

This is the case of a female patient presenting with a 12mm endocrine tumor located at the pancreatic isthmus. To manage this case, a distal pancreatectomy is decided upon. This tumor measures 16mm in its transverse diameter and it is located just above the portal vein. The CT-scan and its 3D reconstruction helps us to plan the surgical intervention. The whole pancreas along with the splenic vessels (splenic vein and artery) are reconstructed. The objective is to precisely locate the tumor in order to determine the resection modalities. A distal pancreatectomy with preservation of the splenic vessels is therefore decided upon. Indeed, the tumor’s location should help us to carry out this resection without any splenic resection. The resection is simulated. From the start, it is clearly visible that the pancreatic division line is situated at the right border of the portal vein. The pancreatic dissection strategy consists in a primary vascular approach.

2. Abdominal cavity exploration 02'10''

The exploration of the peritoneal cavity reveals nothing out of the ordinary.

3. Lesser sac exposure and dissection of anterior aspect of pancreas 02'14''

In this patient, the first operative step is the exposure of the lesser sac. The ultrasonic scalpel will be a useful instrument to carry out the whole of this preparation. It allows for a fine dissection of the connective and vascular structures while permitting a very easy identification of the entire anatomical elements. The gastro-omental vessels are preserved. The entire stomach is mobilized at the level of its posterior surface in order to free the whole of the anterior aspect of the pancreas. A port placed in the left hypochondrium will help to retract the stomach throughout the entire procedure. Other exposure systems could also be used. The gastric mobilization helps to immediately identify the anterior aspect of the pancreas. As the vascular approach is decided upon, the first step is to approach the inferior border of the pancreas.

4. Pancreas inferior border dissection 03'26''

The dissection of the inferior border of the pancreas is carried out in close contact to it in order to leave both the splenomesaraic trunk and the splenic vein posterior to the pancreas. The dissection area exceeds the duodenojejunal flexure towards the pancreatic tail. The dissection is carried out progressively using the ultrasonic scalpel.

5. Freeing of pancreatic isthmus 03'49''

The pancreatic isthmus is freed at its inferior pole and at its superior pole. The gastro-omental vein is the next element in the dissection, which is pursued until the Henle’s gastrocolic trunk; retraction of the stomach and of the first duodenum can be achieved without any risk of vascular injury. This also allows to rapidly identify the Henle’s gastrocolic trunk as well as the portal vein at the inferior border of the pancreas. A small pancreaticoduodenal branch is immediately identified. These are the essential vascular risks in this surgery. Indeed, a tear of such vessels may lead to a massive bleeding in the operative field.

6. Usefulness of augmented reality 04'41''

The use of augmented reality allows to confirm the local anatomy. Here the portal vein is clearly in contact to the pancreas. The splenic vein courses cranially in the operative field; it is in contact to the pancreas. As a result, the inferior border of the pancreas can be safely dissected. The reconstruction using augmented reality allows to locate the tumor just above the portal vein although this vein is not visible. Macroscopically, we feel that it is situated slightly distally. Small pancreatico-portal vessels are controlled using bipolar cautery. Posteriorly, the origin of the splenic vein can be seen. Its dissection is painstaking since this is an extremely vascularized area. Dissection is carried out progressively using the ultrasonic scalpel.

7. Peroperative ultrasonography 05'51''

In order to confirm the tumor’s position, a per-operative ultrasonography completes the procedure. It confirms the tumor’s isthmic position very close to the tumor’s dissection area and confirms that its size is slightly over 1cm. The area that was palpated macroscopically was not the tumor. The pancreatic isthmus should be further dissected slightly at the pancreatic head’s level. Once again, the dissection in contact to the gastro-omental pedicle is performed progressively millimeter by millimeter in order to avoid a hemorrhage that would be difficult to control at this level. Since the dissection of the inferior border of the pancreas has been completed and since the portal vein and the posterior aspect of the pancreas have been exposed, the division area will be confirmed. No adhesions is shown at the level of the portal vein. Dissection will be carried out at the level of the superior border of the pancreas.

8. Control of splenic artery 06'48''

Indeed, for safety reasons, we prefer to dissect the origin of the splenic artery early. This artery can then be placed on a loop to be clamped urgently in case of acute bleeding. The left gastric artery is also identified and left slightly to the left of the operative field. The dissection is carried on on the right border of the pancreas. Just above the pancreatic isthmus, the origin of the splenic artery becomes visible. It will be controlled using a right-angle clamp and a loop is placed to clamp it urgently, if necessary. This loop is maintained by 2 clips. Augmented reality confirms that the vessel that has been clipped is indeed the splenic artery at its origin. Dissection in contact to the origin of the splenic vein is pursued. Another small posterior pancreaticosplenic or pancreatico-portal branch is here demonstrated. It is also clipped. Indeed, without the successive control of this small branch, it would not be possible to separate the pancreas from the splenic vein. As said earlier, the objective is to perform a distal pancreatectomy with preservation of the splenic vessels. Another small branch in contact to the splenic vein is identified. It is controlled using the Ligasure® device. Indeed, the accumulation of clips at this level may entail a risk of tearing during excessive manipulation throughout the dissection. The pancreatic isthmus is then totally dissected. At this level, it seems necessary to envisage the division of the pancreatic isthmus in order to facilitate the mobilization of the entire body of the pancreas.

9. Division of pancreas 09'16''

The division area will be carried out at the thinnest portion of the isthmus more than 1cm distal to the tumor. The dissection is begun with the ultrasonic scalpel, which achieves a very satisfying division of the pancreatic parenchyma. A few vessels that may bleed at this level are controlled with bipolar cautery. When the pancreatic slice is not thick, which is the case of the isthmus here, we prefer to divide it using linear staples of the GIA type. It ensures an effective control of the Wirsung’s duct. This maneuver can only be performed in the presence of a thin and non-dilated pancreas. Since the pancreatic vessels may be hemorrhagic following the stapler’s application, they can be controlled using bipolar cautery. The pancreatic slice can then be perfectly controlled. A last small segment will be divided by an additional blue stapler. Hemostasis is perfect and the pancreatic slice is controlled. The division in contact to the hepatic artery will be completed using ultrasonic cautery. It will then be possible to progressively dissect the splenic vein and its small pancreaticosplenic attachments at the posterior aspect of the pancreas. The splenic artery will be dissected in a similar fashion. This dissection is performed very progressively. Indeed, small and permanent blood oozing renders the identification of direct vessels between the splenic vessels and the posterior aspect of the pancreas difficult. However, this meticulously performed approach can perfectly be controlled, mostly using bipolar cautery. From time to time, a right-angle forceps allows to control the entire vessel in its thickness. Once again, bipolar cautery (through the use of a Ligasure® device) helps to ensure that the hemostasis of the pancreatic slice at its posterior aspect is complete. One of the difficulties lies in performing a complete dissection of the artery because of its branches. Dissection is successively carried out inferiorly, anteriorly, and posteriorly to the pancreatic gland. Here the posterior inferior dissection is performed without any difficulties. Indeed, there are no posterior adhesions. The dissection is then continued between the pancreas and the splenic vein. Small branches sometimes previously coagulated by the bipolar forceps are cut here by the ultrasonic dissector. The dissection of the artery now reaches the area that had been previously dissected with a loop placement.

10. Pancreatic tail dissection 12'49''

The dissection is now carried on towards the pancreatic tail. In this case, the pancreatic tail is relatively short and does not drain into the splenic hilum, which will facilitate the dissection as well as the preservation of the splenic pedicle. One of the difficulties lies in the exposure of the pancreas. Here a small atraumatic peanut swab mounted on a forceps is used in order to retract the pancreas without injuring it. It is essential to avoid parenchymal pancreatic injuries that would lead to bleeding during the dissection. Occasional bleeders are controlled using the bipolar forceps. Here we can see that a fairly rapid dissection originated in the tearing of a small pancreatic branch.

11. Distal dissection 14'01''

The dissection along the artery is simpler, even though the latter follows twists and turns that are sometimes complicated, making the anatomy difficult to follow with the endoscopic camera. A loop of the splenic artery can be seen here with small direct pancreatic branches that will be coagulated. Due to the continuing hemorrhage of a small venous lesion caused by the uprooting of a branch, a clamping of the pancreatic artery is decided upon using the loop that was placed previously. Bipolar coagulation does not allow to stop the bleeding. The bleeding’s source is identified, it is a small lateral lesion of the splenic vein, which will be controlled using intracorporeal Prolene 4/0 sutures. It is the only way to carry on the procedure; without this control, a conversion or a splenectomy with division of the splenic vessels would be required. The suture in contact to the splenic vein will allow a complete control of this small hemorrhage. The dissection of the pancreas’ posterior surface will be continued along the splenic vein. The distal section of the pancreatic tail is entirely freed at the level of the splenic vein. The freeing of the artery at the level of one of its loops still remains to be performed. Here again, the dissection is performed very gradually. The direct pancreatic arterial branches must be controlled using bipolar cautery. The body and tail of the pancreas are now completely detached of their parenchymal attachments.

12. Specimen extraction 16'30''

The pancreas is introduced in a bag for extraction from the abdomen. The security margin needs to be checked: it is over 1cm from the distal division, and the pathological findings confirm the existence of a well-differentiated endocrine tumor with one mitosis for fifty fields. The procedure is concluded by another check of the pancreatic slice.

13. TachoSil application 17'07''

The latter is well divided, extra stitches are decided against and the hemostasis is completed by applying a TachoSil gauze that entirely surrounds the pancreatic gland.

14. Suction drain placement 17'18''

A suction drain is left in place in the dissection area and will be removed after 48 hours. The postoperative follow-up is uncomplicated and the patient is discharged on the 8th postoperative day.