Distal Pancreatectomy

Chapter 15


Distal Pancreatectomy




Introduction


Distal pancreatectomy is the term applied to resection of that portion of the pancreas extending to the left of the midline and not including the duodenum and distal bile duct. First described by Billroth in 1884, distal pancreatectomy is performed for various benign and malignant conditions involving the body and tail of the pancreas. These include inflammatory conditions such as chronic pancreatitis and symptomatic pseudocysts, pancreatic trauma, neuroendocrine tumors, pancreatic adenocarcinoma, solid neoplasms of indeterminate etiology, and cystic neoplasms of the pancreas. Because of the lower incidence of resectable malignant pancreatic neoplasms involving the body and tail of the pancreas, as well as the late appearance of clinical symptoms in this portion of the gland, distal pancreatectomy is performed less often than resection of the pancreatic head.




Surgical Approach


The standard approach to resection of the body and tail of the pancreas is through an upper midline incision from the xiphoid process to just below the umbilicus. Alternatively, a bilateral subcostal incision can be used. The surgical approach depends on the indication, with several different approaches available.



Open Retrograde Distal Pancreatectomy with Splenectomy


Retrograde distal pancreatectomy with splenectomy is the standard procedure for management of proven or suspected cancers in the body and tail of the pancreas, to ensure the adequacy of the lymph node dissection, or with tumors when the anatomic constraints dictate sacrificing the spleen (Fig. 15-2, A).



The pancreas is approached by opening the lesser sac through the gastrocolic ligament below the gastroepiploic vessels (Fig. 15-2, B). The peritoneum overlying the inferior border of the pancreas is divided lateral to the superior mesenteric vessels toward the tail. The splenocolic and splenorenal attachments are divided to mobilize the spleen anteriorly and to the right, separating it from splenic flexure of the colon and from Gerota’s fascia (Fig. 15-2, C).


The short gastric vessels connecting the splenic hilum with the greater curvature of the stomach must be isolated and divided to facilitate mobilization of the tail of the pancreas. The dissection along the inferior margin of the pancreas is continued, and the inferior and posterior peritoneal attachments are divided. Care must be taken because there are numerous venous tributaries from the posterior aspect of the pancreas into the splenic vein. This dissection opens up the retroperitoneal window behind the pancreas.



Division of Splenic Artery and Vein


Understanding the vascular anatomy of the pancreas is essential to safe technique (Fig. 15-3, A). The splenic artery is identified at its origin from the celiac trunk and traced distally along the posterosuperior border of the pancreas. It is divided just distal to its origin. The splenic vein is then isolated and divided just proximal to its confluence with the portal vein, preserving the inferior mesenteric vein if possible (Fig. 15-3, B).


Related posts:

  1. Nissen Fundoplication
  2. Mastectomy
  3. Abdominoperineal Resection
  4. Radical Prostatectomy

Stay updated, free articles. Join our Telegram channel
Tags:
Aug 12, 2016 | Posted by in ANATOMY | Comments Off on Distal Pancreatectomy

Full access? Get Clinical Tree
Get Clinical Tree app for offline access