In the era of minimally invasive surgery, there are fewer indications for open distal pancreatectomy than ever before. Whenever possible, minimally invasive techniques for distal pancreatectomy should be pursued. Indications for open distal pancreatectomy are dictated either by the clinical circumstance mandating resection or by a comorbidity or contraindication to laparoscopy. Both can be identified during a thorough history and physical (Table 1). Patients suffering ductal rupture as a result of trauma or those with extensive adhesions or anatomic anomalies resulting from prior surgery are two such examples. Other conditions include a history of peripancreatic inflammation in the setting of acute or chronic pancreatitis or a malignant diagnosis with known vascular involvement. Local advancement into the retroperitoneum without evidence of distant spread is yet another indication.

In an elective practice, the majority of distal pancreatectomies will be precipitated by suspicion for malignancy,¹ and those being performed open will likely have been selected as such, secondary to local extension of disease. This chapter will thus focus on oncologic principles of resection.

A relevant history and physical examination in the setting of potential malignancy should include a detailed past medical history with discussion of known pancreatic cancer risk factors such as family history of pancreatic cancer, chronic pancreatitis, history of diabetes, obesity, and smoking. Character, duration, and mitigating factors of any abdominal or back discomfort or sensations should be discussed and considered carefully to guide differential diagnosis.

Medical comorbidities as well as cardiovascular and pulmonary functional status should be evaluated, and any relevant testing needed for preoperative clearance such as stress echocardiograms or pulmonary function tests should be performed in accordance with anesthesia guidelines.²

A detailed past surgical history and special attention to family history can help identify patterns of hereditary malignant disease, which can in turn guide preoperative decision making, postoperative surveillance, and genetic testing of the patient and their families. If a neuroendocrine tumor is suspected, symptoms of functional tumors such as rash, diabetes, diarrhea, hypoglycemia, and signs of peptic ulcer disease should be discussed.

A thorough physical exam should evaluate for any abdominal abnormalities such as organomegaly. Splenomegaly should raise concern for segmental portal hypertension, which could be precipitated by tumor thrombosis or vascular invasion. Hepatomegaly can imply the presence of hepatic metastases. Special attention should also be paid to a patient’s nodal basins, specifically left supraclavicular and periumbilical nodes to evaluate for any palpable nodal metastases that would prompt a workup.

The nature of preoperative testing depends heavily on the nature of the diagnosis. Most conditions will warrant further definition with laboratory evaluations and contrasted, cross-sectional imaging, at times, in conjunction with endoscopic ultrasound for tissue diagnosis and for definition of a pancreatic lesion as it relates to surrounding structures.

Laboratory testing should include a complete blood count and a comprehensive metabolic panel, including evaluation of liver enzymes and amylase. A preoperative carbohydrate antigen 19-9 (CA 19-9) level is important for postoperative surveillance and can contribute to decision making when neoadjuvant therapy is being considered. When an endocrine tumor is suspected, functional urine and relevant hormone stimulation tests should be performed. If a patient has experienced substantial weight loss, a prealbumin level can be helpful in establishing nutritional status and can guide recommendations for perioperative supplemental alimentation, if appropriate.

Preoperative workup of a pancreatic mass or injury should almost always include a contrasted, cross-sectional imaging study. Although there is some debate regarding the optimal choice of imaging modality, the most common standard is a computed tomography (CT) “pancreas protocol,” which is a triple-phase CT that allows evaluation of arterial, pancreatic, and portal venous phases, and is critical to determining resectability and to establishing an appropriate operative plan. Three-dimensional reconstruction, where available, can also add insight regarding resectability. FIG 1 demonstrates a lesion with adrenal involvement that would be appropriate for radical antegrade distal pancreatectomy.

In the case of cystic neoplasms of the pancreas, many surgeons use magnetic resonance cholangiopancreatography (MRCP) in order to assess cystic nature and communication with the main pancreatic duct or side branch ducts in order to further characterize risk of cystic lesion.

Endoscopic ultrasound (EUS) is another available tool that can elucidate possible lymph node metastases and confirm spatial relationships between a mass and peripancreatic vasculature. EUS can also secure a tissue biopsy of the mass and any suspicious lymphadenopathy as relevant. EUS is not always needed if surgical planning can be completed with cross-sectional imaging, and the results of the EUS would not change the surgical plan. Multidisciplinary collaboration between surgeons and gastroenterologists is important to ensure the appropriate information is gathered and conveyed.

The role of positron emission tomography (PET)-CT in pancreatic cancer staging for consideration of resection is currently poorly defined and is not currently considered standard of care.