Spleen Preserving Laparoscopic Distal Pancreatectomy for a Solid Pseudopapillary Tumor

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Author: Bestoun Ahmed
Published:
Specialties: General Surgery
Schools: University of Florida-Jacksonville
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Basic Info

Contributors:  Bestoun Ahmed

Spleen preservation is advisable if feasible during distal pancreatectomy for benign pancreatic tumors. A 31 year old patient had a blunt abdominal injury. Computed Tomography (CT) scan showed an incidental tumor in the body of the pancreas. EUS-guided cytology revealed a solid pseudopapillary tumor with benign features.This video demonstrates the technical details during a minimally invasive excision of a rare tumor of the pancreas in a male patient. Very few cases have been reported in males.

Editor Recruited By: Jeffrey B. Matthews, MD

DOI: http://dx.doi.org/10.17797/cc7ot3ymd8

Advanced

Procedure

Diagnostic laparoscopy is performed and confirms the preoperative findings. Division of gastrocolic omentum is performed up to the area of fundus, safeguarding the short gastric vessels.. The pancreas is exposed and laparoscopic ultrasonography helps to delineate the tumor borders and its proximity to the underlying splenic vessels. Release of the splenic flexure of the colon is accomplished to expose the distal aspect of the body and the tail of the pancreas. The dissection of the pancreas is performed using a linear vessel sealing device (LigaSure¢¢) and the hook electrocautery in a clockwise fashion by dissecting its lower border, then the peritoneum covering the anterior aspect of the normal pancreas, 2 cm proximal to the tumor border, followed by dissection of the superior border of the pancreas safeguarding the tortuous splenic artery. A plane is created between the splenic vessels and the inferior surface of the pancreas proximal to the tumor. Transection of the body of the pancreas is accomplished using reinforced linear staple loads. Separation of the entire body and tail of the pancreas from the splenic vessels is performed, controlling all branches to the pancreas. The specimen is placed in a pouch and extracted. Operative time: 170 minutes. Blood loss: 50 ml. The patient tolerated food on postoperative day 2 and was discharged on postoperative day 4. Pathology: 6x5 cm benign solid pseudopapillary tumor with clear margins.

Indications

Indications (for spleen preserving approach):
1.Chronic pancreatitis
2.Persistent pseudocyst
3.Serous Cystadenoma
4.Neuroendocrine tumors
5.Solid pseudopapillary tumor (Franz tumor)

Contraindications

1.Pancreatic cancer
2.Vascular invasion
3.Pancreatitis involving the entire pancreas
4.Contraindications of general anesthesia like severe cardiac and pulmonary failure.

Instrumentation

Setup

The patient is placed in right semi-lateral position. The surgeon stands on the patient¢s right side and two assistants on the left side. A Veress needle is placed in the upper abdomen and CO2 pneumoperitoneum is obtained. Four trocars are placed in a crescent fashion along the left costal margin. A 5mm trocar in the epigastric area, a 10 mm trocar midway between xiphisternum and umbilicus, a10 mm trocar at the left midclavicular area and a 5 mm trocar at the left anterior axillary line.

Preoperative Workup

1.CT scan of the abdomen, pancreas protocol
2.Endoscopic ultrasonography (EUS) and Fine needle aspiration (FNA) cytology
3.Tumor markers (CA19-9 and CEA)
4.General labs including complete blood count, serum electrolytes, creatinine, glucose, albumin and prealbumin

Anatomy and Landmarks

1.Spleen preservation may not be possible if the tumor is invading or inseparable safely from the splenic vessels.
2.Sacrificing splenic vessels can be done in cases of uncontrollable bleeding or invasion provided short gastric vessels stay intact during dissection. Intact short gastric vessels can preserve blood supply to the spleen (Warshaw approach).
3.Robotic assisted approach is an alternative method of doing the procedure
4.Conversion to open approach is vital in case of uncontrollable bleeding, unstable patient and failure of laparoscopic approach.

Advantages/Disadvantages

Advantages:
1. Laparoscopic approach has specific benefits over open approach: less intraoperative blood loss, less pain, cosmetic benefit (smaller incisions), less incidence of incisional hernia, less incidence of wound infection, earlier return to normal activities of daily living
2. Preserving the spleen has a possible immunological benefit over splenectomy
Disadvantages:
1.Laparoscopic approach has longer operative time. Likewise, spleen preservation adds more time to the procedure
2.Laparoscopic approach is not advisable in patients with borderline intraoperative vital parameters

Complications/Risks

Intraoperative:
1.Bleeding when not easily controllable with laparoscopic means should be converted to exploratory laparotomy and possible ligation of main splenic vessels and splenectomy
2.Inability to preserve spleen due to tumor invasion or devascularization. This necessitates distal pancreatosplenectomy
Early postoperative:
1.Bleeding which could be treated by blood transfusion with or without operative hemostasis according to the amount of blood loss
2.Pulmonary complications such as atelectasis and pneumonia which may necessitate admission to the ICU and treatment accordingly
Late postoperative:
1.Pancreatic fistula. Incidence is approximately 5-8% and varies in severity. Minor leaks can be treated by drainage with expectant management. Moderate leaks require NPO with either TPN or nasointestinal feeding beyond the ligament of Treitz, and possibly somatostatin infusion. Major leaks that do not respond to the above methods may require ICU support and exploratory laparotomy for better drainage and possibly necrosectomy
2.Mortality is approximately 1% and depends upon age, comorbidities and response to treatment
3.Intraabdominal abscess collection (4-5%). This is mostly due to leak which can be treated by drainage with or without debridement.
4.Re-exploration incidence is 1-6%. This is usually for bleeding, debridement or better drainage.
5.Long hospital or ICU stay. Average stay is 6-9 days.

Disclosure of Conflicts

none

Acknowledgements

References

1.Papavramidis T, Papavramidis S. Solid pseudopapillary tumors of the pancreas: review of 718 patients reported in the English literature. J Am Coll Surg. 2005;2:965¢72.
2.Yu PF, Hu ZH, Wang XB, et al. Solid pseudopapillary tumor of the pancreas: a review of 553 cases in Chinese literature. World J Gastroenterol. 2010 Mar 14;16(10):1209-14.
3. Speer AL, Barthel ER, Patel M. Solid pseudopapillary tumor of the pancreas: a single-institution 20-year series of pediatric patients. J Ped Surg. 2012;47: 1217¢1222.
4.Morikawa T, Onogawa T, Maeda S, et al. Solid pseudopapillary neoplasms of the pancreas: an 18-year experience at a single Japanese Institution. Surg Today. 2013 Jan;43(1):26-32.
5.Kleeff J, Diener M, Z'graggen K, et al. Distal Pancreatectomy, risk Factors for Surgical Failure in 302 Consecutive Cases. Ann Surg. 2007 Apr;245(4): 573¢582.
6.Shoup, M, Brennan M, McWhite K, et al. The Value of Splenic Preservation with Distal Pancreatectomy. Arch Surg. 2002; 137(2): 164-168.
7.Lillemoe KD, Kaushal S, Cameron J, et al. Distal Pancreatectomy: Indications and Outcomes in 235 Patients. Ann Surg. 1999 May;229(5): 693.

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