Distal Pancreatectomy

Chapter 36 Distal Pancreatectomy



Kiran K. Dhanireddy, MD, Thomas M. Fishbein, MD



INTRODUCTION


Distal pancreatectomy is performed for a variety of benign and malignant indications. The tail of the pancreas can be resected for lesions that are to the left of the superior mesenteric vessels. The procedure can be performed with or without splenic preservation, depending on the initial indication and intraoperative findings. Pancreatic malignancy generally requires splenectomy, whereas benign indications for distal pancreatectomy allow for splenic preservation. Although the ultimate outcome of the procedure depends on the underlying disease process, the complications associated with distal pancreatectomy are readily avoided through an intimate knowledge of pancreatic anatomy and meticulous surgical technique. The most discussed complication of pancreatic surgery is pancreatic leak and fistula1–3; however, several additional pitfalls to be avoided in the course of executing distal pancreatectomy will also limit postoperative morbidity and mortality. Whereas laparoscopic distal pancreatectomy with or without splenic preservation is currently possible, specific discussion of the laparoscopic aspects of this operation are beyond the scope of this chapter.4–7



INDICATIONS



• Pancreatic adenocarcinoma

• Benign cystadenoma

• Cystadenocarcinoma

• Neuroendocrine tumor

• Traumatic pancreatic duct disruption

• Pancreatic pseudocyst

• Chronic pancreatitis

• Acute pancreatic necrosis


OPERATIVE STEPS



Step 1 Incision

Step 2 Entry into lesser sac and exposure of pancreas

Step 3 Dissection of inferior border of pancreatic tail


Distal Pancreatectomy with Splenectomy



Step 4a Splenic mobilization

Step 5a Medial rotation of spleen and tail of pancreas

Step 6a Ligation of splenic vessels


Splenic Preservation



Step 4b Vascular control of splenic vessels medial to lesion

Step 5b Ligation of perforating branches of splenic vein and artery

Step 7a/6b Pancreatic division

Step 8a/7b Drain placement and closure of abdomen


OPERATIVE PROCEDURE



Incision


The patient should be in the supine position on the operative table in slight reverse Trendelenburg. Either an upper midline or a left subcostal incision may be used because both provide excellent exposure of the pancreas. The midline incision may be preferable when the patient has a narrow costal arch, whereas the subcostal incision is superior in patients in whom the costal arch is wide.



Entry into the Lesser Sac and Exposure of the Pancreas


To enter the lesser sac, the gastrocolic ligament is divided in a relatively avascular area. The anterior surface of the pancreas is then fully exposed. Occasionally, the inferior short gastric vessels must be ligated to facilitate full exposure of the tip of the pancreatic tail. This has no implication for splenic function if the spleen is preserved.



Hemorrhage from the Veins Communicating between the Right Gastroepiploic Vessels and the Middle Colic Vein


Occasionally, a branch of the right gastroepiploic vessels will communicate with the middle colic vessels inferior to the pylorus. In the process of elevating the stomach, this vein may be torn.



• Consequence



Unnecessary blood loss can obscure the operative field and prolong the course of the operation.

Grade 1 complication


• Repair



Ligation of the torn ends of the vessel.


• Prevention



Prior to elevating the antrum and pylorus of the stomach, all vascular attachments should be identified and ligated using silk or Vicryl ties of the appropriate caliber. Entering through the gastrocolic omentum in the correct avascular plane and continuing toward the short gastric vessels to the spleen will help avoid this complication.


Dissection of the Inferior Border of the Pancreatic Tail


After the pancreas has been fully exposed, the peritoneum overlying the inferior margin of the pancreatic tail is incised. This maneuver allows for superior reflection of the pancreas and exposure of the splenic vessels.



Injury to the Middle Colic Vein or the Inferior Mesenteric Vein


The middle colic vein runs in the transverse mesocolon in close proximity to the inferior border of the pancreas. This vein may be encountered during the medial portion of the dissection. Similarly, the inferior mesenteric vein may be encountered more laterally as it drains into the splenic vein.



• Consequence



Unnecessary blood loss and increased operative time are the consequences of unrecognized middle colic and inferior mesenteric vein injury.

Related posts:

  1. Isolated Limb Perfusions and Extremity Amputations
  2. Lateral Pancreaticojejunostomy (Puestow) Procedure
  3. Left Colectomy: Open and Laparoscopic
  4. Bronchial and Vascular Sleeve Lobectomy

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Jun 21, 2017 | Posted by in GENERAL SURGERY | Comments Off on Distal Pancreatectomy

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