Introduction

Distal pancreatectomy (DP) consists of standard DP (with or without splenic preserving) and Radical antegrade modular pancreatosplenectomy (RAMPS). The former is also called DP. The latter is indicated for malignant or suspected malignant tumors. Both can be performed via laparoscopic or open approach.

Laparoscopic distal pancreatectomy (LDP) was first described and reported in 1996 by Alfred Cuschieri et al. [1]. LDP was initially indicated for chronic pancreatitis. After that, the indication was expanded to other benign and premalignant lesions located in body and tail of pancreas. In recent years, LDP has not only been developed in plenty of countries but its indication is also expanded to body and tail of pancreatic cancers [2, 3]. However, application of standard LDP for pancreatic adenocarcinoma has still been controversial, especially for medium and large tumors. It is lack of evidence in this condition [4]. This chapter’s purpose is to describe technically standard laparoscopic distal pancreatectomy.

Procedure

Generally, standard LDP consists of LDP with splenectomy and laparoscopic spleen preserving distal pancreatectomy (LSPDP), also called SSLDP (spleen sparing laparoscopic distal pancreatectomy)

Operating Room Setup, Patient Positioning, and Surgical Team

Patient is placed in supine reverse Trendelenburg position. The arms should be tucked at the patient’s sides. The legs are abducted.

10 mm laparoscope of 30° or 45° is used.

The main surgeon and scrub nurse are positioned on the patient’s right side. The first assistant’s (cameraman) position is between patient’s legs and second assistant stands on the left side. The back table is set up on the right side of patient, above the scrub nurse (Fig. 1).

Fig. 1
An illustration of a surgical unit with the position of each person during the surgery to maintain their respective jobs.

Personnel setup

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Surgical Technique

In this chapter, we technically describe procedure of LDP step by step. We describe both LDP with and without splenectomy. There are six main steps during procedure apart from general steps which are present in most laparoscopic surgeries. They are [1] exposure of pancreas and infra-pancreatic superior mesenteric vein, [2] mobilization of transverse mesocolon and splenic flexure of colon, [3] posterior dissection and splenic vessel exposure, [4] upper border of pancreatic neck and celiac trunk dissection, [5] pancreatic neck transection, and [6] separating specimen. LDP with splenectomy and LDP without splenectomy differ from each other at last step. The description with details will be presented below.

Trocar Placement

First trocar is 12 mm in size which is placed at infra-umbilicus by close technique or Hasson technique. One 12 mm trocar and two or three 5 mm trocars are placed as in Fig. 2.

Fig. 2
The illustration of an abdomen with a 12 millimeter trocar on the left side. 3 trocars of 5 millimeters on the right side. Slight organization of the stomach, liver on the right, and intestines can be visualized.

Trocar position

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Inspection

Staging is very important in case of malignant or suspected malignant lesions. This is a mandatory step. Abdominal inspection is performed to assess liver, peritoneal, and mesenteric metastases. Beside this, we can assess the resectability of tumor.

Pancreatic Exposure and Infra-pancreatic Superior Mesenteric Vein Exposure

After abdomen is carefully explored and signs of advanced stage are not found, the lesser sac is entered by dividing gastrocolic ligament below level of gastroepiploic vessels. Gastrocolic ligament should be divided bilaterally to duodenum and splenic flexure of colon to completely expose body and tail of pancreas. This can cause injuries to transverse mesocolic vessels, duodenum, and transverse colon, especially at the site of pancreatic head. Some tips which can help avoiding these consequences are meticulous dissection and following landmarks such as gastroepiploic vessels and duodenum. Greater omentum can become ischemic after dividing gastrocolic ligament but there is mostly no need to resect it.

Next is mobilization of the stomach. Then suturing posterior wall of stomach against anterior abdominal wall is done by 2.0 absorbable suture. We prefer to use vicryl. The direction for pulling stomach is cranial and medial. As a result, superior border of pancreas and celiac trunk may be well accessed as we act at below steps. Pancreatic lesion is also inspected.

Infra-pancreatic superior mesenteric vein (SMV) is dissected at inferior pancreatic border. Right gastroepiploic and middle colic vein are important landmarks. SMV is covered by a thin layer called adventitial tissue and loose thin connective tissue outer. Dissector forceps can be useful to dissect and enter the loose thin connective tissue around SMV to expose SMV. Middle colic vein can drain separately or join with gastroepiploic vein to SMV. We prefer to leave middle colic vein unless it impedes such as in SMA first approach or some variations.

SMV and portal vein (PV) exposure (Fig. 3) is slowly developed upward till superior border of pancreas. This work is recommended under viewing. Expanding our dissection to the left of SMV facilitates this work. During expanding dissection, we need to consider vessels near SMV.

Fig. 3
The image from the surgery with two retraction devices which have managed to expose the pancreas in the abdomen of the patient.

SMV and PV exposure

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Transverse Mesocolic and Splenic Flexure of Colon Mobilization

Mobilization of transverse mesocolon is separating it from inferior border of pancreas. Transverse mesocolon consists of two peritoneal leaves. One passes on retroperitoneum in cranial at anterior surface or inferior border of pancreas; another runs downward. We need to incise the former at the site of inferior border of pancreas for mobilizing. Incision is usually started below pancreatic body. After that blunt forceps should be applied to identify the right plane. That is avascular plane. Mobilization will progress in left direction and then splenic flexure of colon is mobilized by dividing splenocolic omentum. Mobilized colon is retracted inferiorly to well expose both inferior border of pancreas and spleen. During mobilizing route, there are some small vessels going across dissection plane. Hence, an energy device has been usually used to provide a clean view.

Posterior Dissection and Splenic Vessel Exposure

Following right dissection plane of previous step, posterior dissection of pancreatic body and tail occurs. The aim of this step is separation of distal pancreas from retroperitoneal structures and facilitating splenic vessel exposure (Fig. 4). In open surgery, authors have begun exposing splenic vessels with anterior view from cranial border of pancreas. Splenic artery is prior exposed because splenic vein is located deeper and in caudal which is covered by pancreatic parenchyma. With laparoscopic surgery, this is preferably done with posterior view after pancreas is taken away from retroperitoneum and lifted. By doing this, splenic vein is first dissected. Circulating these vessels is usually combined with anterior dissection later in the next step.

Fig. 4
The image from the surgery with two retraction devices that have managed to expose the pancreas in the abdomen of the patient. The splenic vessel as indicated by an arrow can be visualized in the abdomen.

Splenic vessel exposure

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Upper Border of Pancreatic Neck and Celiac Trunk Dissection

Dissection is started at the upper border of pancreatic neck and then proceeded left laterally. The fat and lymph nodes along common hepatic artery (CHA), left gastric artery, and splenic artery are dissected in case of malignancy. Partly exposed splenic artery of the previous step is more dissected and encircled at the site of the planned line of pancreatic transection. Then, splenic vein is dissected and encircled.

In LDP with splenectomy, splenic vessels are transected. Splenic artery should be first ligated and transected at the planned pancreatic transection line. Splenic vein is transected separately or together with the pancreas by staplers. There are various applicable kinds of vascular ligation such as vascular staplers, clip, tie, or suturing.

Pancreatic Transection

The distal pancreas is divided by a linear stapler (Fig. 5). Although none of the staplers has proved superior in terms of postoperative pancreatic fistula (POPF), short height staplers are usually used. Tissue compression when stapling relates to risk of bleeding and POPF. Gradually increasing pressure with three or four consecutive stairs should be performed with at least 3 min for each stair to achieve best tissue compression before transection.

Fig. 5
The image from a surgical procedure with a stapler is used to connect the pancreas. The adjacent image has ligation done and now the structures are being secured at their original places. A part of an organ can be seen rest is the intestines and the pancreas.

Pancreatic neck transection using linear stapler

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Alternative methods of transecting the pancreas is to use ultrasonic shears or electrocautery to divide pancreatic parenchyma. Pancreatic duct should be identified and ligated or sutured by a nonabsorbable monofilament suture. The stump is oversewn with a running suture to secure bleeding and pancreatic leakage.

Separating Specimen

In this step, LDP with splenectomy is different from LDP without splenectomy.

Laparoscopic Distal Pancreatectomy with Splenectomy

After splenic vessels and the pancreas are transected, dissection is continued further to left lateral direction. Ensuring en bloc dissection with lymph nodes and fat surrounding pancreas is necessary, especially for pancreatic cancer or high malignant potential lesion. After the body and tail of the pancreas is completely separated from retroperitoneum, splenorenal ligament is exposed and divided to mobilize the spleen. The specimen is extracted in a retrieval plastic bag (Fig. 6). Distal pancreatectomy with splenectomy, showing splenic artery ligation and spleen mobilization.

Fig. 6
The image from the surgery in which the artery is secured with clips and the intestine can be seen surrounding it. The adjacent image has a bulb like organ spleen with clippers and retraction devices.

Distal pancreatectomy with splenectomy. (a) Splenic artery ligation, (b) spleen mobilized

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Laparoscopic Spleen Preserving Distal Pancreatectomy

This technique requires more advanced laparoscopic surgical skills (Fig. 7). Operating time is usually longer than LDP with splenectomy. However, postoperative complication rate is reported lower than LDP with splenectomy. Moreover, spleen plays a role in immunity in human body. Postoperative infection rate of spleen preserving was also reported significantly decreasing [5,6,7,8,9]. There are two methods of preserving spleen. They are splenic vessels saving (Kimura’s technique) and sacrificing (Warshaw’s technique). The former associated lower rate of ischemic spleen. In terms of technical advantages, Warshaw technique is easier to do.

Fig. 7
The image from the surgery that has managed to expose the pancreas and splenic vessel near it in the abdomen of the patient. The region appears fleshy and with coils or loops.

Spleen preserving distal pancreatectomy

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With Warshaw’s technique, splenic vessels are transected two times. First time of transecting is similar to LDP with splenectomy. After that mobilization of distal pancreas and splenic vessels is proceeded to splenic hilum. Then, pancreatic tail is separated from splenic hilum. Splenic artery and vein are exposed above freed pancreatic tail. These vessels are divided second time. The short gastric vessels are preserved.

In splenic vessel preserving technique, dissection is performed along splenic vein and artery. There are direct branches from splenic vessels to the pancreas. These vessels should be dissected meticulously and divided using ultrasonic shears or advanced bipolar energy, if necessary, clips are applied. When uncontrollable bleeding happens, Warshaw’s technique is an alternative option.

Finally, inspection for bleeding and fluid clearance is completed. A drain is positioned close to pancreatic stump. Specimen in placed in retreival bag and exteriorized via expanded incision of umbilical port or Pfannenstiel incision.

Complication and Management

Complications are POPF, postpancreatectomy hemorrhage (PPH), and delayed gastric emptying. These complications are identified and classified according to consensus of International Study Group of Pancreatic Surgery (ISGPS). Among them, POPF and bleeding are most common [10, 11]. Management of POPF and PPH are described in “Laparoscopic pancreaticoduodenectomy.”

Summary

Standard laparoscopic distal pancreatectomy is now indicated for both benign and premalignant lesions located in body or tail of pancreas. It is still controversial to indicate standard LDP for pancreatic adenocarcinoma. Standard LDP can be done with or without splenectomy.