Surgery for Tumours of Body and Tail of Pancreas

The pancreas is divided into the head, body and tail. The head of the pancreas is on the right side of the abdomen nestled in the curve of the duodenum. The body is in the middle, and the tail is on the left side near the spleen. A distal pancreatectomy is a surgical procedure to remove the body and tail of the pancreas.

The spleen sits close to the tail of the pancreas. It is often removed along with the body and tail of the pancreas (distal pancreaticosplenectomy). However, the spleen can be preserved in select cases (spleen-preserving distal pancreatectomy).

Distal pancreatectomy is performed for various conditions affecting the body and tail of the pancreas:

• Pancreatic cancer — Adenocarcinoma of the body or tail of the pancreas is the most common indication.
• Pancreatic neuroendocrine tumours (PNETs) — Insulinomas, glucagonomas, and other neuroendocrine tumours located in the body or tail.
• Pancreatic cysts — Mucinous cystic neoplasms (MCN), intraductal papillary mucinous neoplasms (IPMN), and other cystic lesions.
• Chronic pancreatitis — When there is a mass or stricture in the body or tail causing pain or obstruction.
• Pancreatic trauma — Severe injury to the body or tail of the pancreas.
• Metastatic tumours — Cancers from other organs (e.g., kidney, lung, breast) that have spread to the pancreas.

Distal pancreatectomy can be performed through different surgical approaches. The choice depends on the nature of the disease, size and location of the tumour, and the surgeon's expertise.

Open distal pancreatectomy

In open surgery, a single long incision is made in the upper abdomen. This approach provides excellent exposure and is preferred for large tumours or when there is concern about involvement of surrounding structures.

Laparoscopic distal pancreatectomy

Laparoscopic distal pancreatectomy is performed through several small incisions (ports) in the abdomen. A camera and specialized instruments are inserted through these ports to perform the surgery. This approach results in less postoperative pain, shorter hospital stay, faster recovery, and better cosmetic outcomes compared to open surgery.

Laparoscopic distal pancreatectomy is now considered the standard approach for most benign and malignant lesions of the body and tail of the pancreas. Studies have shown comparable oncological outcomes to open surgery for appropriately selected patients.

Robotic distal pancreatectomy

Robotic surgery combines the precision of robotic technology with the expertise of the surgeon. The robotic system provides a 3D high-definition view, wristed instruments with greater dexterity, and tremor filtration. This approach is particularly beneficial for spleen-preserving distal pancreatectomy where precise dissection of the splenic vessels is required.

The procedure is performed under general anaesthesia and typically takes 2–4 hours. The steps include:

• The abdomen is explored to assess the extent of disease and rule out metastases.
• The pancreas is mobilized by dividing the attachments to surrounding organs.
• The splenic artery and vein are carefully identified and divided.
• The pancreas is divided at the neck or body using a stapler or cautery.
• The pancreatic stump is carefully inspected and reinforced if needed.
• A drain is placed near the cut end of the pancreas to monitor for leaks.

In spleen-preserving distal pancreatectomy, the splenic vessels are carefully preserved, and the spleen is left in place to maintain its immune function. The Warshaw technique involves dividing the splenic vessels while preserving the short gastric vessels to maintain blood supply to the spleen.

Recovery after distal pancreatectomy depends on the surgical approach and the patient's overall health. For laparoscopic or robotic surgery, most patients stay in the hospital for 3–7 days. Open surgery typically requires a longer stay of 5–10 days.

• Pain is managed with medications, and early mobilization is encouraged.
• A liquid diet is started gradually, advancing to solid food as tolerated.
• The drain is removed once the output is low and there is no evidence of a pancreatic leak.
• Most patients can resume normal activities within 4–6 weeks.
• Follow-up imaging and tumour marker monitoring are scheduled as needed.

As with any major surgery, distal pancreatectomy carries certain risks. Your surgeon will discuss these with you before the procedure.

• Pancreatic leak (fistula) — Leakage of pancreatic fluid from the cut end of the pancreas. This is the most common complication and occurs in 10–30% of cases. Most leaks resolve with conservative management.
• Bleeding — May occur during or after surgery.
• Infection — Surgical site infection or intra-abdominal abscess.
• Splenic infarction — If the spleen is preserved, there is a risk of reduced blood supply.
• Delayed gastric emptying — Difficulty in tolerating food after surgery.
• Pancreatic insufficiency — Rare after distal pancreatectomy as the head of the pancreas is preserved.

Minimally invasive approaches (laparoscopic and robotic) offer several advantages over open surgery:

• Less postoperative pain and reduced need for pain medications.
• Smaller incisions with better cosmetic results.
• Shorter hospital stay and faster return to normal activities.
• Reduced blood loss during surgery.
• Lower rates of wound complications and infections.

Studies have shown that laparoscopic distal pancreatectomy is safe and effective, with oncological outcomes comparable to open surgery for pancreatic cancer. The choice of approach should be made in consultation with an experienced pancreatic surgeon.