Journal of Gastrointestinal Surgery

, Volume 18, Issue 8, pp 1445–1451 | Cite as

Laparoscopic Spleen-Preserving Distal Pancreatectomy: The Technique Must Suit the Lesion

  • David J. Worhunsky
  • Yulia Zak
  • Monica M. Dua
  • George A. Poultsides
  • Jeffrey A. Norton
  • Brendan C. Visser
Original Article


Splenic preservation is currently recommended during minimally invasive surgery for benign tumors of the distal pancreas. The aim of this study was to evaluate the outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy, with particular attention paid to the technique used for spleen preservation (splenic vessel ligation vs preservation). A review of consecutive patients who underwent laparoscopic distal pancreatectomy with the intention of splenic preservation was conducted. Patient demographics, operative data, and outcomes were collected and analyzed. Fifty-five consecutive patients underwent laparoscopic distal pancreatectomy with the intention of splenic preservation; 5 required splenectomy (9 %). Of the remaining 50 patients, 31 (62 %) had splenic vessel ligation, and 19 (38 %) had vessel preservation. Patient demographics and tumor size were similar. The vessel ligation group had significantly more pancreas removed (95 vs 52 mm, P < 0.001) and longer operative times (256 vs 201 min, P = 0.008). Postoperative outcomes, complication rates, and splenic viability were similar between groups. Laparoscopic spleen-preserving distal pancreatectomy is a safe operation with a high rate of success (91 %). Vessel ligation was the chosen technical strategy for lesions that required resection of a greater length of pancreas. We found no advantage to either technique with respect to outcomes and splenic preservation. Operative approach should reflect technical considerations including location in the pancreas.


Minimally invasive surgery Pancreas surgery Laparoscopic pancreatectomy Spleen-preserving distal pancreatectomy 


  1. 1.
    Kooby DA, Gillespie T, Bentrem D, Nakeeb A, Schmidt MC, Merchant NB, Parikh AA, Martin RC, 2nd, Scoggins CR, Ahmad S, Kim HJ, Park J, Johnston F, Strouch MJ, Menze A, Rymer J, McClaine R, Strasberg SM, Talamonti MS, Staley CA, McMasters KM, Lowy AM, Byrd-Sellers J, Wood WC, Hawkins WG. Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches. Ann Surg 2008; 248: 438-446.PubMedGoogle Scholar
  2. 2.
    Vijan SS, Ahmed KA, Harmsen WS, Que FG, Reid-Lombardo KM, Nagorney DM, Donohue JH, Farnell MB, Kendrick ML. Laparoscopic vs open distal pancreatectomy: a single-institution comparative study. Arch Surg 2010; 145: 616-621.PubMedCrossRefGoogle Scholar
  3. 3.
    Limongelli P, Belli A, Russo G, Cioffi L, D'Agostino A, Fantini C, Belli G. Laparoscopic and open surgical treatment of left-sided pancreatic lesions: clinical outcomes and cost-effectiveness analysis. Surg Endosc 2012; 26: 1830-1836.PubMedCrossRefGoogle Scholar
  4. 4.
    Kooby DA, Hawkins WG, Schmidt CM, Weber SM, Bentrem DJ, Gillespie TW, Sellers JB, Merchant NB, Scoggins CR, Martin RC, 3rd, Kim HJ, Ahmad S, Cho CS, Parikh AA, Chu CK, Hamilton NA, Doyle CJ, Pinchot S, Hayman A, McClaine R, Nakeeb A, Staley CA, McMasters KM, Lillemoe KD. A multicenter analysis of distal pancreatectomy for adenocarcinoma: is laparoscopic resection appropriate? J Am Coll Surg 2010; 210: 779-785PubMedCrossRefGoogle Scholar
  5. 5.
    Eom BW, Jang JY, Lee SE, Han HS, Yoon YS, Kim SW. Clinical outcomes compared between laparoscopic and open distal pancreatectomy. Surg Endosc 2008; 22: 1334-1338.PubMedCrossRefGoogle Scholar
  6. 6.
    Taylor C, O'Rourke N, Nathanson L, Martin I, Hopkins G, Layani L, Ghusn M, Fielding G. Laparoscopic distal pancreatectomy: the Brisbane experience of forty-six cases. HPB (Oxford) 2008; 10: 38-42.CrossRefGoogle Scholar
  7. 7.
    Velanovich V. Case-control comparison of laparoscopic versus open distal pancreatectomy. J Gastrointest Surg 2006; 10: 95-98.PubMedCrossRefGoogle Scholar
  8. 8.
    Schwartz PE, Sterioff S, Mucha P, Melton LJ, 3rd, Offord KP. Postsplenectomy sepsis and mortality in adults. JAMA 1982; 248: 2279-2283.PubMedCrossRefGoogle Scholar
  9. 9.
    Cullingford GL, Watkins DN, Watts AD, Mallon DF. Severe late postsplenectomy infection. Br J Surg 1991; 78: 716-721.PubMedCrossRefGoogle Scholar
  10. 10.
    Holdsworth RJ, Irving AD, Cuschieri A. Postsplenectomy sepsis and its mortality rate: actual versus perceived risks. Br J Surg 1991; 78: 1031-1038.PubMedCrossRefGoogle Scholar
  11. 11.
    Shoup M, Brennan MF, McWhite K, Leung DH, Klimstra D, Conlon KC. The value of splenic preservation with distal pancreatectomy. Arch Surg 2002; 137: 164-168.PubMedCrossRefGoogle Scholar
  12. 12.
    Govil S, Imrie CW. Value of splenic preservation during distal pancreatectomy for chronic pancreatitis. Br J Surg 1999; 86: 895-898.PubMedCrossRefGoogle Scholar
  13. 13.
    Mellemkjoer L, Olsen JH, Linet MS, Gridley G, McLaughlin JK. Cancer risk after splenectomy. Cancer 1995; 75: 577-583.PubMedCrossRefGoogle Scholar
  14. 14.
    Kimura W, Inoue T, Futakawa N, Shinkai H, Han I, Muto T. Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. Surgery 1996; 120: 885-890.PubMedCrossRefGoogle Scholar
  15. 15.
    Warshaw AL. Conservation of the spleen with distal pancreatectomy. Arch Surg 1988; 123: 550-553.PubMedCrossRefGoogle Scholar
  16. 16.
    Carrere N, Abid S, Julio CH, Bloom E, Pradere B. Spleen-preserving distal pancreatectomy with excision of splenic artery and vein: a case-matched comparison with conventional distal pancreatectomy with splenectomy. World J Surg 2007; 31: 375-382.PubMedCrossRefGoogle Scholar
  17. 17.
    Fernandez-Cruz L, Orduna D, Cesar-Borges G, Lopez-Boado MA. Distal pancreatectomy: en-bloc splenectomy vs spleen-preserving pancreatectomy. HPB (Oxford) 2005; 7: 93-98.CrossRefGoogle Scholar
  18. 18.
    Rodriguez JR, Madanat MG, Healy BC, Thayer SP, Warshaw AL, Fernandez-del Castillo C. Distal pancreatectomy with splenic preservation revisited. Surgery 2007; 141: 619-625.PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Adam JP, Jacquin A, Laurent C, Collet D, Masson B, Fernandez-Cruz L, Sa-Cunha A. Laparoscopic spleen-preserving distal pancreatectomy: Splenic vessel preservation compared with the Warshaw technique. JAMA Surg 2013; 148: 246-252.CrossRefGoogle Scholar
  20. 20.
    Song KB, Kim SC, Park JB, Kim YH, Jung YS, Kim MH, Lee SK, Seo DW, Lee SS, Park do H, Han DJ. Single-center experience of laparoscopic left pancreatic resection in 359 consecutive patients: changing the surgical paradigm of left pancreatic resection. Surg Endosc 2011; 25: 3364-3372.PubMedCrossRefGoogle Scholar
  21. 21.
    Beane JD, Pitt HA, Nakeeb A, Schmidt CM, House MG, Zyromski NJ, Howard TJ, Lillemoe KD. Splenic preserving distal pancreatectomy: does vessel preservation matter? J Am Coll Surg 2011; 212: 651-657; discussion 657-658.PubMedCrossRefGoogle Scholar
  22. 22.
    Butturini G, Inama M, Malleo G, Manfredi R, Melotti GL, Piccoli M, Perandini S, Pederzoli P, Bassi C. Perioperative and long-term results of laparoscopic spleen-preserving distal pancreatectomy with or without splenic vessels conservation: a retrospective analysis. J Surg Oncol 2012; 105: 387-392.PubMedCrossRefGoogle Scholar
  23. 23.
    Hamilton NA, Porembka MR, Johnston FM, Gao F, Strasberg SM, Linehan DC, Hawkins WG. Mesh reinforcement of pancreatic transection decreases incidence of pancreatic occlusion failure for left pancreatectomy: a single-blinded, randomized controlled trial. Ann Surg 2012; 255: 1037-1042.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: 205-213.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138: 8-13.PubMedCrossRefGoogle Scholar
  26. 26.
    Weber SM, Cho CS, Merchant N, Pinchot S, Rettammel R, Nakeeb A, Bentrem D, Parikh A, Mazo AE, Martin RC, 3rd, Scoggins CR, Ahmad SA, Kim HJ, Hamilton N, Hawkins W, Max Schmidt C, Kooby DA. Laparoscopic left pancreatectomy: complication risk score correlates with morbidity and risk for pancreatic fistula. Ann Surg Oncol 2009; 16: 2825-2833.PubMedCrossRefGoogle Scholar
  27. 27.
    Magge D, Gooding W, Choudry H, Steve J, Steel J, Zureikat A, Krasinskas A, Daouadi M, Lee KK, Hughes SJ, Zeh HJ, Moser AJ. Comparative effectiveness of minimally invasive and open distal pancreatectomy for ductal adenocarcinoma. JAMA Surg 2013; 148: 525-531.PubMedCrossRefGoogle Scholar
  28. 28.
    Bruzoni M, Sasson AR. Open and laparoscopic spleen-preserving, splenic vessel-preserving distal pancreatectomy: indications and outcomes. J Gastrointest Surg 2008; 12: 1202-1206.PubMedCrossRefGoogle Scholar
  29. 29.
    Kang CM, Yang WI, Lee YH, Choi GH, Lee SW, Kim KS, Choi JS, Lee WJ, Kim BR. A case of spleen-preserving laparoscopic distal pancreatectomy and concomitant cholecystectomy in male patient with solid pseudopapillary neoplasm of the pancreas and gallstone. J Laparoendosc Adv Surg Tech A 2008; 18: 259-265.PubMedCrossRefGoogle Scholar
  30. 30.
    Yoon YS, Lee KH, Han HS, Cho JY, Ahn KS. Patency of splenic vessels after laparoscopic spleen and splenic vessel-preserving distal pancreatectomy. Br J Surg 2009; 96: 633-640.PubMedCrossRefGoogle Scholar
  31. 31.
    Ferrone CR, Konstantinidis IT, Sahani DV, Wargo JA, Fernandez-del Castillo C, Warshaw AL. Twenty-three years of the Warshaw operation for distal pancreatectomy with preservation of the spleen. Ann Surg 2011; 253: 1136-1139.PubMedCrossRefGoogle Scholar
  32. 32.
    Tien YW, Liu KL, Hu RH, Wang HP, Chang KJ, Lee PH. Risk of varices bleeding after spleen-preserving distal pancreatectomy with excision of splenic artery and vein. Ann Surg Oncol 2010; 17: 2193-2198.PubMedCrossRefGoogle Scholar
  33. 33.
    Inama M, Butturini G, Bassi C. Warshaw's technique: what's the point? HPB (Oxford) 2012; 14: 279.CrossRefGoogle Scholar
  34. 34.
    Yu W, Choi GS, Chung HY. Randomized clinical trial of splenectomy versus splenic preservation in patients with proximal gastric cancer. Br J Surg 2006; 93: 559-563.PubMedCrossRefGoogle Scholar
  35. 35.
    Csendes A, Burdiles P, Rojas J, Braghetto I, Diaz JC, Maluenda F. A prospective randomized study comparing D2 total gastrectomy versus D2 total gastrectomy plus splenectomy in 187 patients with gastric carcinoma. Surgery 2002; 131: 401-407.PubMedCrossRefGoogle Scholar
  36. 36.
    Venkat R, Edil BH, Schulick RD, Lidor AO, Makary MA, Wolfgang CL. Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis. Ann Surg 2012; 255: 1048-1059.PubMedCrossRefGoogle Scholar
  37. 37.
    Fernandez-Cruz L, Martinez I, Gilabert R, Cesar-Borges G, Astudillo E, Navarro S. Laparoscopic distal pancreatectomy combined with preservation of the spleen for cystic neoplasms of the pancreas. J Gastrointest Surg 2004; 8: 493-501.PubMedCrossRefGoogle Scholar
  38. 38.
    Corazza GR, Ginaldi L, Zoli G, Frisoni M, Lalli G, Gasbarrini G, Quaglino D. Howell-Jolly body counting as a measure of splenic function. A reassessment. Clin Lab Haematol 1990; 12: 269-275.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2014

Authors and Affiliations

  • David J. Worhunsky
    • 1
  • Yulia Zak
    • 1
  • Monica M. Dua
    • 1
  • George A. Poultsides
    • 1
  • Jeffrey A. Norton
    • 1
  • Brendan C. Visser
    • 1
  1. 1.Division of Surgical Oncology, Department of SurgeryStanford University Medical CenterStanfordUSA

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