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Dallemagne B, Perretta S, Soler L, Marescaux J. Laparoscopic left pancreatectomy with spleen preservation for a suspicion of IPMN. Epublication: WeBSurg.com, Feb 2010;10(2). URL: http://www.websurg.com/ref/doi-vd01en2864.htm

B Dallemagne (France), S Perretta (France), L Soler (France), J Marescaux (France)

English - 19'27''
February 2010
TOC link: 
General and digestive > Pancreas

Laparoscopic distal pancreatectomy is suitable for benign and premalignant neoplasms located in the body and tail of the pancreas. Spleen preservation following distal pancreatectomy is known to be safe. There are two distinct approaches to preserve the spleen during the dissection of the distal pancreas. The classic design is to identify, isolate, and preserve the splenic artery and vein. Alternatively, the splenic artery and vein are ligated with the pancreas, and perfusion of the spleen is assured by the short gastric vessels. Both are accepted as appropriate techniques to address a mass in the tail of the pancreas. This video demonstrates a left pancreatic resection with spleen preservation and ligation of the splenic artery and vein.

Keywords: intraductal papillary mucinous neoplasm of pancreas, IPMN, laparoscopic left pancreatectomy, spleen preservation

00'08'' Clinical case presentation
In this video, we present a patient in which we perform a left pancreatectomy with preservation of the spleen. It is a 50-year-old woman who presents to the emergency room for pain in the right hypochondrium. A complete follow-up was performed using ultrasonography, which initially detected a lesion of the Wirsung’s canal. Then a CT-scan is performed with an echo-endo-US because of a suspicion of intrapancreatic mucinous neoplasm. On the CT and the reconstruction of the CT using a special software to create a virtual model of the patient, we can see a very sharp limit between the normal pancreas on the right side and the dilated pancreas on the left side.
In front of this suspicion of IPMN, we decide to perform a distal pancreatectomy or left pancreatectomy and also we decide to preserve the spleen during this operation.
We use a conventional laparoscopic approach with 5 trocars. The optical system is a 30 degree placed at the level of the umbilicus in order to be able to work on the gastrocolic ligament.
02'04'' Gastrocolic ligament opening
The main step of the operation is performed with the Ligasure® device; we are dividing the gastrocolic ligament in order to get access to the pancreatic tissue.
As we have decided to try to preserve the spleen but dividing the splenic vein and artery, we have to try as much as possible to respect the left gastro-epiploic artery, which will provide some vascularization for the spleen.
02'58'' Pancreas exposure
The first step of the operation is to try to get an optimal access to the pancreas. This step is important before trying to localize the disease with the use of intraoperative endo-sonography. The main problem in this approach is usually to keep this window open and usually we are using some forceps to open this area. And in this patient, we will use special devices for internal retraction, and with such devices, we keep this window open during all the procedure.
The anterior surface of the pancreas is exposed prior to the intraoperative use of ultrasound. Macroscopically, we can see a clear difference between the proximal part of the pancreas and the distal part where dilatation and aspects of chronic pancreatitis can be observed.
04'21'' Use of laparoscopic internal retractors
These laparoscopic internal retractors are quite useful in different procedures and in this patient we suspend the gastric wall in order to maintain the opening on the pancreas open during all the operation. One of the advantages of this internal retracting device is that all the laparoscopic instruments are used for surgery and not only for retraction so the system avoids the need for additional trocars used only for retraction.
05'12'' Intraoperative ultrasound
The intraoperative ultrasound confirms the dilatation of the pancreatic duct, which can be seen on the upper part of the screen and the relationships between the duct, the pancreas parenchyma and the vessels are defined with the ultrasonic probe. On the picture, we can see a frank demarcation between the dilated pancreas and the normal proximal parenchyma, and this aspect leads to the suspicion of an intramucinous pancreatic tumor. So we decide to do a left hemi-pancreatectomy.
06'00'' Lower pancreas dissection
The lower part of the pancreas is dissected in order to get access to the portal vein and the neck of the pancreas is first dissected. The bipolar forceps type Ligasure® is very interesting for this dissection; it is very precise.
06'24'' Portal vein dissection
It’s blunt and the anterior aspect of the portal vein is dissected in a usual fashion. The plan for this operation is to identify both the splenic vein and artery and to divide them and clip them at their origin while keeping the short gastric vessels and the left gastro-epiploic artery to vascularize the spleen.
The superior border of the pancreas is then dissected in order to identify the splenic vessels.
07'45'' Splenic artery dissection
Once the splenic artery has been identified and most important the common hepatic artery has also been identified, then the splenic artery is clipped and eventually divided.
08'12'' Umbilical tape application
Once the superior and inferior border of the pancreas have been dissected, the channel posterior to the neck of the pancreas is clearly dissected and we use one umbilical tape to fix and to surround this neck of the pancreas: this is quite helpful when we want to retract and mobilize this part of the pancreas, mostly when we are working on the main splenic vessels.
The dissection is continued on the splenic artery and the artery will be clipped and divided. The artery has to be divided before the vein in order to let the spleen empty before ligation of the splenic vein.
10'40'' Splenic vein dissection and division
Once the splenic artery has been divided, the dissection is continued on the splenic vein, which will also be dissected and divided on the proximal part. In this very accessible part of the vein, we only use clips, not a stapler. The stapler will be used in the distal part of the vein, just next to the spleen, where the dissection is not as easy.
11'47'' Pancreas division
The intraoperative ultrasound confirms the level of the pancreas’ division; this is done with a blue cartridge Endo-stapler and in this patient, because of the normal aspect of the proximal part of the pancreas, this division is quite clear, hemostasis is performed using a bipolar forceps. We are used to putting a running suture on the staple line. Usually, the pancreatic duct is not identified and this large running suture is supposed to saw the pancreatic duct while ensuring a good hemostasis of the stump of the pancreas. This stage of the operation is usually quite hemorrhagic because of the bleeding on the divided part of the pancreas, but usually with sutures only, the operative field can be controlled quite easily.
13'49'' Pancreas mobilization
Mobilization of the pancreas is then continued on the lateral side, starting on the medial part and progressing towards the tail of the pancreas and the spleen. When approaching the spleen and the tail of the pancreas, attention is paid to the perfect identification of the splenic vessels, mostly the splenic vein, the idea being to preserve the left gastro-epiploic pedicle as it will help in the vascularization of the spleen together with the short gastric vessels, which have also been preserved. That is a condition to preserve the spleen while having divided the splenic vein and artery at the medial side. The splenic side of the artery and the vein is progressively identified. The origin of the left gastro-epiploic artery is also identified and will be preserved, if possible, during the distal division of the splenic vessels. This division will be performed using an endoscopic stapler, vascular cartridge, because of the difficulty in getting a good exposure of the distal part of these vessels just next to the spleen. The veins are isolated before stapling and division, and the left part of the pancreas is removed. A careful hemostasis is done. The vascularization of the spleen is controlled; in this patient we can see different areas with different vascularization. The upper pole of the spleen is well vascularized, probably due to the short gastric vessels, while the upper part is more congestive, but this is quite a usual aspect after this technique and in this patient, it doesn’t lead to any postoperative problems. Of course, there is a rule for pancreatic distal resections; we will leave drainage in the area of the pancreatic stump. Analyses will be checked regularly during the postoperative days before the removal of this drainage. The patient is allowed to drink the day after surgery. Drainage, as mentioned, will be kept until the 4th or 5th day after surgery and if amylasemia is normal within the liquid, then usually the patient is discharged at day 5 or 6 after surgery. In this patient, the pathology excluded the IPMN, but concluded to a multi-cystic lesion of the left pancreas with multiple dilatations of the exocrine duct of the pancreas, and in some of these dilatations, the pathologist found some areas of local and focal dysplasia. In this patient, the postoperative outcome was completely normal and the patient was discharged on day 6 after surgery.
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Bernard Dallemagne 

Silvana Perretta 

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