PANCREATECTOMIA DISTAL

Current Procedures: Surgery > Chapter 16. Distal Pancreatectomy >

Indications Distal pancreatic solid mass. Neuroendocrine tumor. Pancreatic adenocarcinoma. Solid neoplasm of indeterminate diagnosis. Distal pancreatic mucinous cystic neoplasms. Asymptomatic, 3 cm in size. Symptomatic, any size. Presence of a solid component. Dilated main pancreatic duct. Distal pancreatic symptomatic serous cystadenoma. Chronic calcific pancreatitis or small symptomatic pseudocyst limited to pancreatic tail (less common).

Contraindications Absolute Proximal mass requiring pancreatoduodenectomy. Known metastatic disease. Local invasion of structures that cannot be resected en bloc with the pancreas. Mass encasing mesenteric vessels, with loss of usual fat planes noted on preoperative imaging (CT, MRI, or endoscopic ultrasound [EUS]). Portal hypertension. Relative Cardiopulmonary comorbidities. Splenic vein thrombosis.

Informed Consent Expected Benefits Surgical cure of a neoplasm in the distal pancreas. Prevention of malignant transformation of mucinous cystic neoplasms. Treatment of symptomatic benign disease. Potential Risks Surgical site infection, bleeding, and damage to adjacent structures. Removal of the spleen. Should this be necessary, patients are at risk for the rare complication of post-splenectomy sepsis. Complications unique to operations on the pancreas include: Postoperative pancreatitis. Pancreatic leaks. Pancreatic fistula formation.

Equipment No special equipment is needed. A self-retaining retractor helps facilitate exposure of the operative field. A surgical energy device (eg, harmonic scalpel, LigaSure) is extremely useful. Depending on surgeon preference, a surgical stapler may be used to transect the pancreatic tail. In that case, a thoracoabdominal (TA) or gastrointestinal anastomosis (GIA) stapler is used.

Patient Preparation Thorough preoperative evaluation is essential before undertaking this procedure. For symptomatic patients, delineation of the presenting symptoms and correlation of these symptoms with the mass in the pancreatic tail or body is critical. Potentially useful tests include: Abdominal CT, ultrasonography. Endoscopic retrograde cholangiopancreatography (ERCP) or EUS. Magnetic resonance cholangiopancreatography (MRCP). For cystic neoplasms, cyst fluid is often obtained during EUS and analysis is performed to differentiate mucinous from serous cystic lesions and to determine cyst fluid CEA levels. Side branch versus main duct intraductal papillary mucinous neoplasms should be differentiated preoperatively using ERCP, MRCP, or EUS, if at all possible. Patients with persistent hypoglycemia and suspected insulinoma should receive glucose supplementation. Patients with refractory ulcers, elevated gastrin levels, and the suspicion of a gastrinoma should receive preoperative treatment for acid secretion and appropriate fluid and electrolyte supplementation. If splenectomy is planned, patients should undergo immunization for encapsulated organisms at least 2 weeks before surgery.

Patient Positioning The patient should be supine. The skin is prepared from the level of the nipples to the pubis, extending along the flank. The abdomen is entered through a midline incision. Alternatively, a bilateral subcostal incision may be used.

Procedure Figure 16–1: Ligation of the short gastric vessels. For resection of the distal pancreas, the standard approach is through an upper midline incision. The pancreas is approached as in other pancreatic procedures through the lesser sac of the omentum. The peritoneal covering along the inferior border of the pancreas is divided from the superior mesenteric vessels laterally toward the tail. Vessels encountered in this space should be ligated and divided or sealed with the surgical energy device. If concern exists for malignancy, then splenectomy is always performed; however, if pancreatectomy is being performed for benign disease, then spleen-preserving distal pancreatectomy is possible and the decision regarding splenectomy will be up to the surgeon. If splenectomy is to be performed, the spleen is mobilized anteriorly and to the right, and off of the left kidney in the retroperitoneum (Gerota's fascia). To mobilize the tail of the pancreas, the short gastric vessels that connect the splenic hilum with the greater curvature of the stomach must be isolated and divided. This can be done either via standard division and ligation with fine silk sutures, or with the use of the surgical energy device. Figure 16–2: Division of the splenocolic ligament. Once the spleen, still attached to the distal pancreas, has been liberated from the greater curvature of the stomach, its peritoneal attachment to the splenic flexure of the colon, the splenocolic ligament, must be divided. The spleen is rotated gently to the right and clamps are placed across the splenocolic ligament, as shown. The ligament itself is then divided sharply and the ends ligated. Figure 16–3: Mobilization of the spleen. Once the splenocolic ligament has been divided, the spleen (attached to the tail of the pancreas) is rotated to the right. Figure 16–4: Dissection along the inferior pancreatic margin. The inferior and posterior peritoneal attachments of the pancreas are sharply divided. The inferior mesenteric vein, if identified during this step, may be ligated and divided. Figure 16–5: Mobilization of the spleen and pancreatic tail. Once the posterior peritoneal attachments have been divided and the tail of the pancreas freed, the entire distal portion of the organ may be rotated medially. Figure 16–6: Division of the splenic artery and vein. The splenic artery is identified at its origin from the celiac trunk and traced distally along the posterior aspect of the gland. It is encircled, then doubly clamped and ligated. The proximal (celiac) portion is transfixed with a suture ligature. The splenic vein is then isolated, and its confluence with the portal vein is carefully identified. The vein is then divided between clamps, and the proximal (remaining) portion is oversewn with a 5-0 Prolene suture. Figure 16–7: Division of the pancreas. The pancreas is rotated medially via traction on the splenic tail into the operative field. A TA (shown) or GIA stapler can be used to divide the pancreas. If a TA stapler is used, the pancreas is then divided sharply using a scalpel. The duct should be oversewn and transfixed with a suture if visible. Figure 16–8A, B: Suturing the remainder of the pancreas. If the pancreas is thick and a stapler cannot be used, it can be divided sharply with a scalpel or with a surgical energy device. The duct is then transfixed with a suture (Figure 16–8A). A row of interrupted mattress sutures is placed through the body of the residual pancreas and tied (Figure 16–8B). Additional bites should be taken at sites of bleeding. Depending on surgeon preference, a drain can be left in the left upper quadrant near the transected pancreas, whether stapled or oversewn. Figure 16–1 Figure 16–2 Figure 16–3 Figure 16–4 Figure 16–5 Figure 16–6 Figure 16–7 Figure 16–8A–B

Postoperative Care Nothing by mouth with nasogastric tube decompression. Oral diet is resumed following removal of the nasogastric tube and resolution of postoperative ileus.

Potential Complications Pancreatic leak. Pancreatic fistula. Pancreatitis. Surgical site infection. Bleeding.

Pearls and Tips Intraoperative ultrasound can be useful if there is difficulty identifying the mass (cystic or solid) in the pancreas at the time of operation. To avoid inadvertent injury to the common hepatic artery, trace the splenic artery back to its origin from the celiac axis and visualize all branches prior to ligation of the splenic artery. For benign lesions, spleen-preserving distal pancreatectomy is possible and a medial-to-lateral approach is preferred.

References Bell RH Jr, Rikkers LF, Mulholland MW. Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott-Raven Publishers; 1996. Doherty GM, Way LW. Pancreas. In: Doherty GM, Way LW, eds. Current Surgical Diagnosis and Treatment, 12th ed. New York, NY: McGraw-Hill; 2005. Riall TS, Yeo CJ. Neoplasms of the Endocrine Pancreas. In: Mulholland MW, Lillemoe KD, Doherty GM, et al, eds. Greenfield's Surgery: Scientific Principles and Practice, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.