Overview
Definition:
Laparoscopic distal pancreatectomy (DP) is a minimally invasive surgical procedure to remove the tail and/or body of the pancreas, preserving the spleen (organo-sparing DP) or removing it (DP with splenectomy)
It is indicated for benign and malignant lesions located in the distal pancreas.
Epidemiology:
Distal pancreatic lesions account for a significant proportion of pancreatic resections
The incidence of distal pancreatectomy is increasing due to advancements in minimally invasive techniques and improved diagnostic capabilities for early-stage pancreatic tumors.
Clinical Significance:
Laparoscopic DP offers reduced postoperative pain, shorter hospital stays, faster recovery, and potentially better cosmetic outcomes compared to open surgery
It is crucial for treating various pancreatic pathologies, including adenocarcinoma, neuroendocrine tumors, cysts, and chronic pancreatitis, impacting patient survival and quality of life.
Indications
Benign Lesions:
Serous cystadenomas
Mucinous cystic neoplasms (MCNs)
Intraductal papillary mucinous neoplasms (IPMNs) involving the distal pancreas
Benign neuroendocrine tumors
Large or symptomatic pancreatic pseudocysts not amenable to drainage.
Malignant Lesions:
Small, resectable distal pancreatic adenocarcinomas (typically <2 cm, without vascular invasion or distant metastasis)
Well-differentiated neuroendocrine tumors (NETs) of the distal pancreas
Low-grade acinar cell carcinomas
Metastatic lesions to the distal pancreas.
Inflammatory Conditions:
Recurrent or refractory chronic pancreatitis involving the distal pancreas, especially when associated with pain or pseudocyst formation, and unresponsive to conservative management
Side-branch IPMNs causing obstruction or symptoms.
Contraindications:
Extensive local invasion (vascular encasement, involvement of major vessels like SMA/SMV)
Metastatic disease
Significant comorbidities precluding major surgery
Uncontrolled coagulopathy
Previous extensive abdominal surgery with dense adhesions.
Diagnostic Approach
History Taking:
Detailed history of abdominal pain (location, character, radiation, duration)
Presence of jaundice, weight loss, anorexia
History of pancreatitis, diabetes, or pancreatic cysts
Family history of pancreatic cancer
Review of prior imaging studies.
Physical Examination:
Abdominal examination for masses, tenderness, hepatosplenomegaly
Assessment for signs of malabsorption or malnutrition
Examination for stigmata of chronic liver disease or portal hypertension.
Imaging Modalities:
Contrast-enhanced computed tomography (CECT) of the abdomen: Essential for evaluating lesion size, location, vascular involvement, and presence of metastases
Magnetic resonance imaging (MRI) with MRCP: Superior for characterizing cystic lesions and delineating ductal anatomy
Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA): Useful for tissue sampling and detailed local staging
Positron emission tomography (PET-CT): For staging suspected malignant lesions and detecting distant metastases.
Laboratory Tests:
Complete blood count (CBC) with differential
Liver function tests (LFTs) including bilirubin, AST, ALT, alkaline phosphatase, GGT
Amylase and lipase levels
Carbohydrate antigen 19-9 (CA 19-9) and CEA for suspected malignancy monitoring
Tumor markers for neuroendocrine tumors (e.g., chromogranin A, gastrin, insulin)
Coagulation profile.
Surgical Management
Preoperative Preparation:
Optimization of nutritional status
Correction of any coagulopathy or electrolyte imbalance
Antibiotic prophylaxis
Deep vein thrombosis (DVT) prophylaxis
Consultation with anesthesia and intensivists
Patient counseling regarding risks and benefits.
Anesthesia And Positioning:
General anesthesia with endotracheal intubation
Patient positioned in a modified lithotomy or lateral decubitus position to allow optimal port placement and instrument manipulation
Pneumoperitoneum established to 12-15 mmHg.
Port Placement:
Typically 4-5 ports are used: a primary umbilical trocar for the camera, and additional working ports in the left upper quadrant, right upper quadrant, and supra-pubic region depending on the surgeon's preference and anatomy.
Key Surgical Steps:
Mobilization of the spleen and pancreatic tail from the retroperitoneum
Identification and division of the splenic artery and vein
Careful dissection of the pancreatic parenchyma from the splenic hilum and posterior structures
Division of the pancreas using staplers or harmonic scalpel, followed by oversewing or ligation of the pancreatic duct
Preservation of the spleen (organo-sparing DP) is preferred when feasible by dissecting the pancreas away from the splenic vessels
If splenectomy is required, ligation and division of the splenic artery and vein are performed first.
Specimen Retrieval:
The resected specimen is typically placed in an endoscopic retrieval bag and removed through one of the larger port sites, often the umbilical trocar site.
Postoperative Care
Monitoring:
Close monitoring of vital signs, urine output, and fluid balance
Assessment for signs of bleeding, infection, or pancreatitis
Pain management with intravenous analgesics
Nasogastric tube decompression if indicated.
Drainage:
Placement of surgical drains in the pancreatic bed to monitor for pancreatic fistula output and bile leakage
Drains are typically removed when output is minimal and serosanguinous.
Nutrition:
Initiation of clear liquids once bowel function returns, progressing to a regular diet as tolerated
Patients with significant pancreatic resection or malabsorption may require pancreatic enzyme replacement therapy and dietary modifications.
Early Mobilization:
Encouraged as soon as patient is stable to reduce risk of DVT, pneumonia, and ileus.
Complications
Early Complications:
Pancreatic fistula (most common, graded by International Study Group on Pancreatic Fistula criteria)
Postpancreatectomy hemorrhage
Intra-abdominal abscess
Bile leak
Gastric or duodenal leak
Prolonged ileus
Splenic infarction (if spleen preserved).
Late Complications:
Diabetes mellitus (especially if significant portion of islet cells removed)
Exocrine insufficiency leading to malabsorption
Splenic vein thrombosis (if splenectomy performed)
Incisional hernia
Adhesions and bowel obstruction.
Prevention Strategies:
Meticulous surgical technique, including secure pancreatic stump closure and appropriate drain placement
Careful identification and ligation of vessels
Judicious use of intraoperative imaging
Prompt recognition and management of fistulas and leaks
Prophylactic antibiotics and DVT prophylaxis
Postoperative patient education on diet and activity.
Prognosis
Factors Affecting Prognosis:
Histological type of lesion (benign vs
malignant)
Tumor grade and stage for malignant lesions
Completeness of surgical resection (R0 margins)
Presence of lymph node metastasis
Patient's overall health status and comorbidities
Development of postoperative complications like pancreatic fistula or hemorrhage.
Outcomes:
For benign lesions, prognosis is excellent with complete resection
For malignant lesions, survival is highly dependent on stage at diagnosis and completeness of resection, with 5-year survival rates varying significantly
Laparoscopic DP generally offers comparable oncological outcomes to open surgery with improved recovery.
Follow Up:
Regular clinical follow-up with physical examination and laboratory tests
Imaging surveillance (CT or MRI) is recommended, especially for oncologic patients, to monitor for recurrence or metastasis
Monitoring for new-onset or worsening diabetes and exocrine insufficiency.
Key Points
Exam Focus:
Indications for DP (benign vs
malignant)
Differences between organ-sparing DP and DP with splenectomy
Common complications: pancreatic fistula, bleeding
Management of pancreatic fistula (grades A, B, C)
Importance of imaging modalities in diagnosis and staging
Oncologic principles for malignant distal pancreatic lesions.
Clinical Pearls:
Always consider spleen preservation in benign lesions if technically feasible to avoid post-splenectomy risks
Meticulous dissection of the splenic artery and vein is paramount
Intraoperative ultrasound can be useful for tumor localization and vascular assessment
Early recognition and proactive management of pancreatic leaks are critical.
Common Mistakes:
Inadequate preoperative assessment of vascular involvement for malignant lesions
Incomplete mobilization leading to iatrogenic injury of surrounding structures
Underestimation of pancreatic stump leakage risk
Delayed diagnosis and management of postoperative complications
Insufficient follow-up leading to missed recurrences.