Overview
Definition:
Spleen-preserving distal pancreatectomy is a surgical procedure involving the removal of the distal portion of the pancreas (tail and body) while intentionally preserving the spleen and its blood supply, typically the splenic artery and vein
This technique is favored over standard distal pancreatectomy (with splenectomy) to mitigate the immunological and thrombotic complications associated with splenic removal.
Epidemiology:
Distal pancreatectomy is performed for a variety of benign and malignant neoplasms, as well as for chronic pancreatitis and trauma affecting the pancreatic body and tail
While exact incidence figures for spleen-preserving techniques are not universally tracked, it is increasingly becoming the standard of care for appropriate indications, especially in younger patients or those at higher risk of infection.
Clinical Significance:
This procedure is crucial for treating lesions in the pancreatic body and tail while preserving important immunological function and reducing long-term morbidity
For DNB and NEET SS candidates, understanding the indications, surgical nuances, and potential complications is vital for managing patients with pancreatic diseases and for excelling in surgical examinations.
Indications
Neoplastic Lesions:
Benign tumors (e.g., serous cystadenomas, mucinous cystic neoplasms, neuroendocrine tumors), premalignant lesions (e.g., intraductal papillary mucinous neoplasms - IPMNs), and malignant tumors (e.g., pancreatic ductal adenocarcinoma, neuroendocrine carcinomas, lymphomas) located in the pancreatic body or tail.
Inflammatory Conditions:
Recalcitrant chronic pancreatitis in the distal pancreas causing intractable pain, pseudocyst formation, or ductal obstruction, where conservative management has failed
Traumatic injuries to the pancreatic body and tail.
Other Indications:
Splenic vein thrombosis secondary to pancreatic mass compressing the vein, necessitating pancreatectomy but not splenectomy
Isolated pancreatic duct dilatation in the distal pancreas.
Preoperative Preparation
Patient Assessment:
Thorough evaluation of patient's comorbidities, nutritional status, and coagulation profile
Imaging (CT, MRI, EUS) to delineate tumor extent, relationship to vascular structures (SMV, splenic vein), and resectability.
Risk Stratification:
Assessing risks of splenectomy vs
spleen preservation, considering tumor proximity to splenic hilum, evidence of splenic vein involvement, and patient's immune status.
Imaging And Staging:
Detailed review of cross-sectional imaging for tumor size, location, vascular invasion, and nodal status
Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) may be useful for tissue diagnosis and staging.
Informed Consent:
Discussing surgical options, including the necessity and potential for splenectomy if spleen preservation is not feasible during surgery, potential complications, and expected outcomes
Emphasize the benefits of spleen preservation.
Procedure Steps
Approach:
Laparoscopic or open approach depending on surgeon expertise, tumor complexity, and patient factors
Laparoscopic approach is preferred for smaller, benign lesions.
Mobilization:
Identification and careful dissection of the pancreatic parenchyma from the splenic vein and artery
Extensive mobilization of the splenic flexure of the colon and posterior aspect of the pancreas is often required.
Division And Ligation:
Dividing the pancreas at the planned resection margin, typically after ligation of small pancreatic duct branches
Excision of the distal pancreas is then completed, ensuring clear margins around the splenic artery and vein.
Preservation Of Splenic Vasculature:
Meticulous preservation of the splenic artery and vein
The splenic hilum and its vascular pedicle are dissected free from the pancreatic specimen
The spleen itself remains in situ, attached via its vascular pedicle.
Anastomosis And Drainage:
Reconstruction typically involves a pancreaticojejunostomy (e.g., Roux-en-Y) to divert pancreatic exocrine secretions and a biliary-enteric anastomosis if the common bile duct is involved or reconstructed
Placement of surgical drains is essential.
Postoperative Care
Monitoring:
Close monitoring of vital signs, fluid balance, and pain control
Serial monitoring of amylase, lipase, and liver function tests
Monitoring for signs of pancreatic fistula, bleeding, or infection.
Nutritional Support:
Early initiation of enteral or parenteral nutrition as needed
Gradual advancement of diet once pancreatic exocrine function is established and fistula risk is low.
Pain Management:
Aggressive pain management using multimodal analgesia, including patient-controlled analgesia (PCA) if necessary
Management of post-pancreatectomy pancreatitis.
Mobilization And Discharge:
Early mobilization to prevent deep vein thrombosis and pneumonia
Discharge planning involves patient education on dietary modifications, wound care, and signs of complications.
Complications
Early Complications:
Pancreatic fistula (most common, grades B and C require intervention)
Post-pancreatectomy hemorrhage (from pancreatic stump or splenic artery/vein injury)
Splenic infarction (rare, if splenic artery is compromised)
Wound infection
Intra-abdominal abscess.
Late Complications:
Diabetes mellitus (especially if significant portion of endocrine function is lost)
Exocrine insufficiency leading to malabsorption
Pancreatic pseudocyst formation
Splenic vein thrombosis (if splenic vein is ligated or injured).
Prevention Strategies:
Meticulous surgical technique to ensure adequate pancreatic stump closure and secure ligation of vessels
Appropriate use of drains
Judicious handling of splenic vasculature
Prophylactic antibiotics and postoperative anticoagulation if indicated
Careful oncologic resection for malignancies.
Key Points
Exam Focus:
Indications for spleen preservation vs
splenectomy
Importance of preserving splenic vasculature
Management of pancreatic fistula (grades A, B, C)
Reconstruction techniques (pancreaticojejunostomy).
Clinical Pearls:
Always assess for SMV/splenic vein involvement preoperatively
Identify potential risks to splenic blood supply during mobilization
Consider laparoscopic approach for benign lesions to minimize invasiveness.
Common Mistakes:
Inadvertent injury to the splenic vein or artery during dissection
Inadequate pancreatic stump closure leading to fistula
Failure to recognize and manage pancreatic fistula promptly
Performing splenectomy unnecessarily when spleen can be preserved.