Technique of Laparoscopic Distal Pancreatectomy with Splenectomy

Laparoscopic pancreatectomy is done for lesions in the body and tail of the pancreas. Indications of distal pancreatectomy with or without splenectomy.

• Pancreatic cancer
• Pancreatic cystic neoplasms
• Neuroendocrine tumours of pancreas
• IPMN

The patient is laid supine and in a reverse Trendelenburg position. The camera port is placed just above the umbilicus. 2 working ports are placed on the right side and one on the left. The surgeon here is operating from the right side.

• Omentum is pushed down, and the lesser sac is entered by dividing the gastrocolic omentum. We can see the posterior wall of the stomach.
• Some of the attachments of the stomach to the anterior surface of the pancreas are divided.
• All the short gastric vessels are carefully divided.
• The fundus of the stomach is separated from the spleen and diaphragm. We must be careful here not to injure the stomach with the energy device as the stomach wall is very close here.
• The remaining attachments of the stomach to the anterior surface of the pancreas are divided.
• Dissection is moved to the inferior border of the pancreas. Mesocolon is dissected away from the pancreas. We can see a glimpse of the portal vein here.
• The splenic artery is identified on the superior border of the pancreas to the left of the celiac axis
• The tumour here was adherent to the transverse mesocolon and part of it was excised En block with the tumour.
• Dissection is continued on the inferior border of the pancreas.
• A large collateral vessel going into the tumour was clipped and divided.
• Pancreas is lifted off the retroperitoneum.
• Distal transverse colon and splenic flexure are dissected off the tail of the pancreas and spleen.
• The superior mesenteric vein is identified and dissected.
• A tunnel is developed over it.
• Tissue is freed from the superior mesenteric vein and splenic vein.
• The splenic vein is dissected all around.
• The splenic artery is dissected at the origin. It is clipped and divided.
• The splenic vein is clipped and divided.
• The superior border of the pancreas is freed.
• Stapler with a vascular reload is used to divide the Pancreas at the neck. We should ensure that its tip not holding any major vascular structure, preferably keeping it lateral to the celiac axis.
• Slow progressive compression is given over a few minutes to prevent fracture of the pancreas.
• The specimen is retrieved through a Pfannenstiel incision.