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8/21/2019 Surgical resection of lesions of the body and tail of the pancreas.docx
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Surgical resection of lesions of the body and tail of the pancreasAuthors
Timothy R Donahue, MDOscar Joe Hines, MD, FACSSection EditorStanley W Ashley, MD
Deputy EditorKathryn A Collins, MD, PhD, FACSDisclosures: Timothy R Donahue, MD Consultant/Advisory Boards: Celgene [Adjuvant pancreatic cancerclinical trial]. Oscar Joe Hines, MD, FACS Nothing to disclose. Stanley W Ashley, MDNothing todisclose. Kathryn A Collins, MD, PhD, FACS Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these areaddressed by vetting through a multi -level review process, and through requirements for references to beprovided to support the content. Appropriately referenced content is required of all authors and must conform toUpToDate standards of evidence.
Conflict of interest policy
All topics are updated as new evidence becomes available and ourpeer review processiscomplete.Literature review current through:Apr 2014. | This topic last updated:Apr 29, 2014.
INTRODUCTIONA variety of pancreatic pathologies, malignant and benign, may indicate the
need to remove the pancreatic tissue to the left of the superior mesenteric artery and vein (ie,
distal pancreas). Distal pancreatectomy, which removes the body and tail of the pancreas,
accounts for approximately 25 percent of all pancreatic resections. Distal pancreatectomy was
first performed by Billroth in 1884. Less extensive resections can also be performed in the form
of central pancreatectomy, which removes part of the body of the pancreas, or enucleation,
which limits the resection to the lesion and immediately adjacent parenchyma.
The indications, preoperative evaluation and preparation, and techniques for resecting lesions
of the body and the tail of the pancreas will be reviewed here. Resection of the head of the
pancreas requires concomitant resection of the duodenum (ie, pancreaticoduodenectomy) and
is discussed in detail elsewhere. (See"Surgical resection of lesions of the head of the
pancreas".)
PANCREATIC ANATOMYThe pancreas is a compound exocrine and endocrine gland
located in the retroperitoneum at the level of the second lumbar vertebrae. Exocrine pancreatic
secretion is composed of enzymes, water, electrolytes and bicarbonate, which are delivered to
the duodenum via the pancreatic duct of Wirsung and aid with digestion. Endocrine secretions
include insulin, glucagon, and somatostatin from the islets of Langerhans, A cells, and D cells,
respectively. Removal of up to 90 percent of the mass of the pancreas can be performed
without resulting in diabetes.
The pancreas is divided into five parts including the head, uncinate process, neck, body, and tail
(figure 1). The head of the pancreas lies to the right of the superior mesenteric artery. The
uncinate process is a variable posterolateral extension of the head that passes behind the
retropancreatic vessels and anterior to the inferior vena cava and aorta. The neck is defined as
the portion of the gland overlying the superior mesenteric vessels. The body and tail lie to the
left of the mesenteric vessels; there is no meaningful anatomic division between the body and
tail.
Ductal anatomyThe pancreatic duct, located at the posterior (dorsal) aspect of the gland,
joins the common bile duct to drain into the duodenum via the major papilla (ampulla of Vater)(figure 2andpicture 1). The anatomy of these ducts can vary. In 85 percent of individuals, the
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pancreatic duct and the common bile duct enter the duodenum through a common channel. In 5
percent of patients, both ducts enter the duodenum through the same ampulla but via separate
channels. In the remaining 10 percent of patients, each duct enters the duodenum through a
separate ampulla [1]. The entry of the common bile duct into the pancreatic tissue posteriorly
can also vary (figure 3).
Neurovascular supplyThe arterial supply to the duodenum and pancreas is derived from
the celiac artery (figure 4), providing the superior pancreaticoduodenal arteries (anterior and
posterior branches), and the superior mesenteric artery, providing the inferior
pancreaticoduodenal arteries (anterior and posterior branches) (figure 5). The splenic artery
supplies primarily the body and tail of the pancreas. The venous drainage (figure 6)follows the
arteries to provide tributaries to the splenic vein and superior mesenteric vein which drain into
the portal vein.
The pancreas is innervated by sympathetic fibers from the splanchnic nerves (figure 7)and
parasympathetic fibers from the vagus, both of which give rise to intrapancreatic periacinar
nerve plexuses. The parasympathetic fibers stimulate exocrine and endocrine function, whereas
the sympathetic fibers have an inhibitory effect.
INDICATIONS FOR DISTAL PANCREATECTOMYDistal pancreatectomy is performed
primarily for malignant and premalignant diseases of the pancreas, including pancreatic
adenocarcinoma, pancreatic cystic neoplasms, and neuroendocrine tumors. In one series of
232 distal pancreatectomies of which 164 were performed for pancreas-specific disease,
malignant or premalignant disease was resected in 84 percent [2]. Benign indications for distal
pancreatectomy include chronic pancreatitis, pancreatic pseudocysts, and trauma associated
with pancreatic ductal disruption.
AdenocarcinomaPatients with adenocarcinoma in the body and tail of the gland have
historically presented with more advanced disease because lesions in this area can become
quite large before patients develop symptoms, the most common of which is pain. Body and tail
lesions tended to be less resectable and are associated with shorter survival than
adenocarcinoma of the pancreatic head, even though the biology of the tumors is the same
[3,4]. Improved high-resolution pancreatic-protocol computed tomography (CT) and magnetic
resonance (MR) imaging techniques have improved the early recognition of lesions involving
the body and tail of the pancreas. As a result, distal pancreatectomy for pancreatic
adenocarcinoma is becoming more frequently performed. (See"Clinical manifestations,
diagnosis, and staging of exocrine pancreatic cancer", section on 'Diagnostic approach'.)
Neuroendocrine tumorsNeuroendocrine tumors within the body and tail of the pancreas
can be resected or enucleated depending upon the size and relationship of the tumor to the
pancreatic duct [5]. Nonfunctioning tumors that are large or preoperatively confirmed (via
endoscopic ultrasound-guided biopsy) as high grade using the World Health Organization
Classification system, should be resected rather than enucleated, to achieve a margin-negative
resection and appropriate lymph node harvest. Likewise, lesions close to the main pancreatic
duct should also be resected, rather than enucleated, to minimize the potential for a
postoperative pancreatic leak and fistula. (See"Classification, epidemiology, clinical
presentation, localization, and staging of pancreatic neuroendocrine tumors (islet-cell tumors)".)
There is ongoing debate regarding the resection of primary malignant neuroendocrine tumors in
the face of metastatic disease [6,7]. Resection may be appropriate if the primary site of the
tumor is causing symptoms, or when primary tumor and associated liver metastases are each
amenable to potentially curative resection. (See"Metastatic gastroenteropancreatic
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neuroendocrine tumors: Local options to control tumor growth", section on 'Management of the
primary site in patients with metastases'.)
Premalignant and cystic neoplasmsPremalignant and cystic pancreatic neoplasms for
which distal pancreatectomy may be indicated include mucinous cystic neoplasms (MCN),
serous cystadenoma, solid pseudopapillary epithelial neoplasms (SPEN, also called papillarycystic neoplasms), and intraductal papillary mucinous neoplasms (IPMN). MCN and SPENs are
most commonly located in the body and tail of the gland, serous cystadenomas have equal
distribution throughout the gland, and IPMN (both main duct and branch duct types) are
primarily located in the head of the gland. (See"Pathology of exocrine pancreatic
neoplasms"and"Classification of pancreatic cysts"and"Pancreatic cystic neoplasms".)
Until premalignant and benign lesions can reliably be differentiated from malignant cystic
neoplasms, most experts argue that cysts suspicious for malignancy should be resected [8-10].
For IPMN lesions, a management algorithm is given (algorithm 1)[10]. (See"Diagnosis and
treatment of intraductal papillary mucinous neoplasm of the pancreas", section on
'Surgery'and"Pancreatic cystic neoplasms", section on 'Malignant potential and management'.)
PseudocystsPseudocysts are nonepithelialized collections of pancreatic fluid that develop
four to six weeks after the onset of an episode of acute pancreatitis [11]. Indications for
treatment include rapidly enlarging or symptomatic cysts. Treatment options include
percutaneous drainage, endoscopic drainage, internal surgical drainage, or resection, including
distal pancreatectomy. Distal pancreatectomy is usually reserved for cases where disruption of
the main pancreatic duct (with or without a failed attempt at stenting) has occurred, or if there
has been significant involvement of an adjacent structure (eg, splenic artery pseudoaneurysm)
[11]. (See"Management of acute pancreatitis".)
Chronic pancreatitisResults of distal pancreatectomy for chronic pancreatitis are mixed
[12,13]. The entire gland is usually involved and relief of chronic abdominal pain appears the
greatest for resections of the head of the pancreas, rather than the tail [14]. In addition, the
incidence of new-onset diabetes mellitus can be as high as 20 to 30 percent [13,15]. Thus,
distal pancreatectomy is rarely needed in the management of chronic pancreatitis.
(See"Complications of chronic pancreatitis"and"Treatment of chronic pancreatitis".)
TraumaDistal pancreatectomy is indicated in trauma patients when the main pancreatic duct
is disrupted. This injury most commonly occurs after blunt trauma in which the pancreas is
crushed against the spine [16]. (See"Management of duodenal and pancreatic trauma in
adults".)
PREOPERATIVE IMAGINGThe preoperative evaluation, for all indications of distalpancreatic resection, should begin with a high resolution pancreatic protocol computed
tomography (CT) scan that includes a precisely-timed intravenous (IV) contrast infusion to
enhance the pancreatic parenchyma and surrounding vessels. High resolution abdominal
imaging is needed to determine the size, location, and relation of any masses or cysts to
surrounding structures, and for patients with disruption of the pancreatic duct, to assess the
location and amount of peripancreatic fluid, including potential fluid in the lesser sac.
Following the injection of IV contrast, 2 to 3 mm images of the pancreas are obtained during the
"pancreatic arterial phase" and then 5 mm images are later captured during the "venous phase."
During the pancreatic phase, the pancreatic parenchyma, celiac axis, and superior mesenteric
artery are enhanced with contrast, while during the venous phase, the superior mesenteric vein,
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portal vein, and splenic vein are enhanced. If the institution does not have a well-established
pancreas CT protocol, then high-resolution CT with IV contrast may be sufficient.
Some surgeons prefer a magnetic resonance cholangiopancreatogram (MRCP) instead of a
pancreas CT protocol or high-resolution CT scan. MRCP is more precise at imaging the
relationship of a mass or cyst to the main pancreatic duct, but can be more difficult fornonradiologists interpret.
Endoscopic ultrasound (EUS) can also provide detailed information about solid masses and
cyst characteristics [17]. Endoscopic retrograde cholangiopancreatogram (ERCP) can be
performed at the same time as EUS, and can provide detailed information of the main
pancreatic duct and its relation to the mass or cyst, but this information can usually be obtained
from CT or MRCP. (See"Endoscopic ultrasound in the staging of exocrine pancreatic
cancer"and"Endoscopic ultrasound in chronic pancreatitis".)
PREOPERATIVE EVALUATION AND PREPARATIONPatients with indications for
resecting the distal pancreas frequently have significant medical comorbidities. Most pancreatic
resections are performed under elective circumstances for which adequate time is available to
assess risk factors and optimize the patient's medical status. Preoperative medical assessment
is discussed elsewhere. (See"Estimation of cardiac risk prior to noncardiac
surgery"and"Evaluation of preoperative pulmonary risk"and"Preoperative medical evaluation
of the healthy patient".)
For patients taking antiplatelet therapy for primary or secondary prevention of cardiovascular
disease, or other indications, cessation ofaspirinprior to elective pancreatic surgery may not be
necessary. In a retrospective review of 1017 patients undergoing pancreas resection, 28.4
percent were maintained on aspirin therapy throughout the perioperative period [18]. Among
these patients, 322 underwent resection of the tail of the pancreas, 82 in the aspirin group and
240 in the no aspirin group. Overall, there were no significant differences between the aspirin
and no aspirin groups for intraoperative blood loss, rate of blood transfusion, or other major
procedure-related complications. (See"Perioperative medication management", section on
'Aspirin'.)
Once a decision has been made to proceed with surgery, the patients should be informed of the
possibility of splenectomy, and the potential for splenectomy-related complications
(See'Perioperative morbidity and mortality'below.)
Bowel preparationWe place the patients on a clear liquid diet for a 48-hour period but do
not otherwise prepare the bowel prior to pancreatic resection. Although there are no
randomized trials directly evaluating outcomes for bowel preparation versus no bowelpreparation for distal pancreatectomy, indirect evidence comes from systematic reviews of
randomized trials in colorectal surgery that suggest that bowel preparation is not necessary.
However, inadvertent colon injury during resection of the pancreas may not represent the same
situation as controlled colon resection. One review that compared bowel preparation with no
bowel preparation for patients undergoing pancreaticoduodenectomy found no difference
between the groups with respect to complications [19]. (See"Surgical oncologic principles for
the resection of colon cancer", section on 'Mechanical bowel preparation'.)
Bowel preparation continues to be common practice. In a survey of perioperative practices
among centers participating in the DISPACT trial, mechanical bowel preparation (mostly
enemas) was standard at 8 hospitals, but 14 hospitals did not use any kind of bowel preparationbefore distal pancreatectomy [20].
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AntibioticsFor biliary tract surgery, antibiotic prophylaxis is recommended for open
procedures in patients at high risk for infection (defined as age greater than 70 years, acute
cholecystitis, a nonfunctioning gallbladder, obstructive jaundice, common bile duct stones).
Appropriate antibiotics are given in the table (table 1). Few studies have specifically evaluated
antibiotic prophylaxis and wound or other infectious complications following distal
pancreatectomy. In one study, antibiotic prophylaxis (piperacillin/tazobactam) reduced theincidence of wound infection; however, the results of this study need to be validated and
compared with other prophylactic antibiotic regimens [21]. (See"Antimicrobial prophylaxis for
prevention of surgical site infection in adults"and"Control measures to prevent surgical site
infection following gastrointestinal procedures in adults".)
Patients for whom antibiotics have been initiated to manage established infection should be re-
dosed prior to surgery [22,23].
ThromboprophylaxisThromboprophylaxis should be administered according to the
patients risk for thromboembolism (table 2). Patients undergoing major pancreatic resection are
at moderate to high risk for venous thromboembolism due to the nature of the surgery (major
open surgery >45 minutes). The presence of malignancy increases the risk [24]. We also place
intermittent pneumatic compression devices prior to induction and continue their use until the
patient is ambulatory. (See"Prevention of venous thromboembolic disease in surgical patients",
section on 'Moderate risk general and abdominal-pelvic surgery patients'and"Prevention of
venous thromboembolic disease in surgical patients", section on 'High risk general and
abdominal-pelvic surgery patients'.)
ImmunizationFor patients in whom concomitant splenectomy is anticipated, preoperative
immunization direct against encapsulated organisms (Streptococcus pneumoniae, Neisseria
meningitidis, Haemophilus influenzae) should be given preoperatively. The current vaccine
recommendations are discussed in detail elsewhere. If vaccination was not possible prior to
surgery, or unanticipated splenectomy was performed, the patient should be vaccinated
postoperatively. (See"Prevention of sepsis in the asplenic patient", section on 'Timing of
immunizations'.)
GENERAL PRINCIPLES
Resections for malignancy
Staging laparoscopyWhen the indication for resection of the distal pancreas is
adenocarcinoma, a staging laparoscopy should be performed prior to proceeding to pancreatic
resection to minimize the number of cases for which the cancer appears resectable on
preoperative imaging, only to be found unresectable at the time of laparotomy due to occultperitoneal metastases or local invasion [25,26]. Metastases less than 1 cm in diameter on the
surface of the liver and peritoneum are rarely detected by preoperative imaging techniques [27].
Staging laparoscopy has been shown to alter the management approach in up to 44 percent of
patients [28].
To perform a staging laparoscopy, our preferred approach is to use a 5 mm port for the camera
and one or two 5 mm working ports for atraumatic graspers and/or biopsy forceps. The liver
surface and peritoneum should first be inspected for distant disease. Any suspicious nodules
should be biopsied and sent for frozen section analysis. Next, the transverse colon should be
lifted anteriorly to inspect the mesocolon for direct extension. The lesser sac can be explored by
dividing the gastrocolic ligament, but this is rarely needed for diagnostic purposes. Vascularinvolvement can be assessed using a laparoscopic Doppler probe, although this technique is
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probably more useful for periampullary tumors where vascular involvement frequently
determines resectability. (See"Clinical manifestations, diagnosis, and staging of exocrine
pancreatic cancer", section on 'Staging laparoscopy'.)
Extent of resectionThe pancreas should be transected to achieve a disease-free margin on
frozen section analysis, and ultimately on permanent section.
In the case of intraductal papillary mucinous neoplasms (IPMN), a transection margin without
high-grade dysplasia or invasive cancer is often sufficient for those with a dominant lesion in the
body or tail but with less advanced involvement of the remainder of the gland
Splenectomy and lymphadenectomyWhen performing pancreatectomy for a distal lesion
that is biopsy-proven or highly suspicious for cancer, splenectomy should generally be
performed to provide a margin-negative resection, and to ensure sampling of at least 15
regional lymph nodes (figure 8)[29]. The resection specimen should include all of the tissue
around the splenic artery and vein, including the associated lymph nodes.
Splenic preservationPreserving the spleen during distal pancreatic resection was firstintroduced by Mallet-Guy and Vachon in 1943 [30]. An attempt at splenic preservation can be
made when treating small neuroendocrine tumors in the body and tail of the pancreas that are
likely benign, and premalignant cystic lesions without any objective signs of advanced pathology
(eg, large size, mural nodules, or solid component) [31,32]. However, splenic salvage may not
be technically possible for lesions that involve the splenic vessels, for large cysts or tumors, or
lesions associated with significant inflammation that obscure the borders of the distal pancreas.
Whether or not to preserve the spleen should be decided on a case-by-case basis. Distal
pancreatectomy with splenic preservation can be accomplished using an open or laparoscopic
approach. (See'Laparoscopic approach'below.)
Some [2,33,34], but not all series [35-37], have demonstrated benefits to splenic preservation,including lower perioperative infectious complications. A systematic review that included 11
observational studies for a total of 897 patients identified a significantly lower incidence of
intraabdominal abscess for spleen preserving distal pancreatectomy (open, laparoscopic)
compared with distal pancreatectomy with splenectomy (5.1 versus 11.4 percent) [38]. The rate
of splenic infarction with splenic salvage was 2.5 percent. No differences were identified for
operative time, or the incidence of bleeding, pancreatic fistula, wound infection, or thrombosis.
However, splenic preservation can lead to splenic enlargement, hypersplenism, and gastric
varices if the splenic vein is sacrificed at the time of pancreatic resection. Some surgeons
advocate maintaining vascularization to the spleen via the splenic artery and vein, while others
resect these vessels and maintain only the short gastric vessels [31,32]. We preserve at least
half of the short gastric vessels during mobilization of the pancreas in case splenic vein
preservation, which requires meticulous and tedious dissection of enumerable small and fragile
venous tributaries, cannot be achieved.
Pancreatic transection and closureTransection of the pancreas can be performed using a
variety of methods including sharp division and subsequent oversewing of the transection line,
or using stapling devices (with or without staple line reinforcement) that simultaneously divide
and close the cut end. Alternative techniques include a hand-sewn closure, placement of a
seromuscular patch, reinforcement with mesh, ultrasonic dissection, use of bipolar scissors,
sealing the end with fibrin glue, and creating a pancreaticoenteric anastomosis. General issues
related to creating a pancreaticoenteric anastomosis, which is more commonly used for
gastrointestinal reconstruction following pancreaticoduodenectomy, are discussed elsewhere.
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(See"Surgical resection of lesions of the head of the pancreas", section on 'Pancreatic-enteric
anastomosis'.)
The pancreatic transection and closure technique chosen is based upon the character of the
pancreas being transected and the experience and discretion of the surgeon given that there is
no convincing evidence to support one technique over another [39-41]. We generally use astapled technique for distal pancreatectomy, regardless of whether the approach is open or
laparoscopic. A systematic review that included two trials and eight observational studies found
a trend toward a lower pancreatic leak rate with stapled closure [39]. A later metaanalysis that
included 16 observation trials found similar results [41]. A later trial (DISPACT [DIStal
PAnCreaTectomy] trial) randomly assigned 177 patients to stapled closure and 175 patients to
handsewn closure, and found no significant difference in incidence of pancreatic fistula rate
between the two groups [42]. A retrospective review evaluating different methods of pancreatic
stump closure found that pancreatic fistula following transection of a pancreas >12 mm thick
was associated with male sex, body mass index >25 kg/m2, and stapled closure [43].
Seamguard, which is a bioabsorbable staple line mesh product, has been investigated in
several small nonrandomized studies for the prevention of leaks and fistulas after distal
pancreatectomy [44,45]. In a trial that randomly assigned 100 patients to mesh or no mesh, the
incidence of clinically important leaks, defined as ISGPF (International Study Group on
Pancreatic Fistula) grade B and C, was significantly lower in the staple line mesh compared with
the nonmesh group (20 versus 1.9 percent) [46]. However, this technique cannot be used in all
situations, given that a thick or fibrotic pancreas may be very difficult to engage with the stapler.
This method will require more study before it can be recommended [47].
For nonstapled transection (either sharp or with electrocautery), the main pancreatic duct
should be identified and directly sutured closed. Omental flaps and falciform ligament
reinforcements have been used to cover the cut end of the pancreatic duct [48,49].
Alternatively, tissue adhesives have also been applied to the raw cut surface of the pancreas,
but whether or not this has any benefit is uncertain [48,50-52]. One small trial found a trend
toward a reduced rate of postoperative pancreatic fistula using fibrin glue after suture closure of
the main pancreatic duct [51]. However, a later randomized trial did not find any significant
difference in the incidence of pancreatic fistula with the adjunctive use of a falciform patch with
fibrin glue reinforcement following pancreatic transection and duct closure [48]. The use of fibrin
glue by direct injection into the pancreatic duct remnant did not reduce complication rates in
another trial [52].
Drainage of the pancreatic bedOnce hemostasis has been confirmed, we place a large-
bore, closed-suction drain adjacent the cut edge of the pancreas. The rationale for leaving a
drain after distal pancreatectomy is to provide controlled drainage and prevent an undiagnosed
pancreatic leak, which can lead to a large intraabdominal abscess or pancreatic-cutaneous
fistula. (See'Postoperative pancreatic fistula'below.)
Although drain placement after pancreatic resection remains commonplace [20], the role of
routine drainage after distal pancreatectomy remains ill-defined [53-55]. The use of abdominal
drains, in general, is highly controversial and evidence supports the limiting use of prophylactic
intraabdominal drainage for many procedures [56-58]. A randomized trial is currently underway
to specifically address the use of drains following pancreatectomy (NCT01441492).
DISTAL PANCREATECTOMYDistal pancreatectomy removes the body and tail of the
pancreas to the left of the superior mesenteric artery and vein, and can be accomplished using
an open or laparoscopic approach.
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Surgical resection of lesions of the body and tail of the pancreas.docx
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Regardless of the approach, pancreatic resection is performed under general anesthesia. For
open pancreatic resection, epidural analgesia is a useful adjunct to anesthesia that also aids
with postoperative pain management and improves pulmonary function. (See"Management of
postoperative pain", section on 'Postoperative epidural analgesia with local anesthetics and
opioids'.)
Open surgical versus laparoscopic distal pancreatectomyGiven that there are few long-
term data comparing laparoscopic with open resections for cancer, most surgeons, advocate an
open operation when the concern for malignancy is high, reserving laparoscopic resection for
benign or premalignant indications [59,60]. We agree with this approach. However, as surgeons
have become more comfortable with laparoscopic distal pancreatectomy, more cases have
been reported [59,61]. A review of the National Inpatient Sample (NIS) database identified 8957
distal pancreatectomies [62]. Overall, 4.3 percent were performed using a minimally invasive
approach with the rate tripling from 1998 to 2009 from 2.4 to 7.3 percent. A robotic-assisted
laparoscopic approach has also been described, but use of this technique is not widespread
[63-71].
Theoretical advantages to the laparoscopic approach include less perioperative pain, a reduced
length of hospital stay, and a quicker recovery. Disadvantages with laparoscopic distal
pancreatectomy include technical difficulties, inability to manually palpate the gland and to
appreciate the extent of a cyst or mass, potential difficulty securing the pancreatic duct stump,
and the potential for inadequate margins in cancer resections [59,60,72,73]. It may also be
more difficult to preserve the spleen.
There have been many small case series reporting the technical feasibility of the laparoscopic
approach [59,61,73-78], but there have been no randomized trials directly comparing outcomes
for an open versus laparoscopic approach. One early review included four studies with a total of
665 patients [65]. Laparoscopic distal pancreatectomy took about 10 percent longer to perform
but reduced hospital stay by 2.7 days. A later and larger review that included 1814 patients from
18 studies found no differences in operative time, margin positivity, incidence of postoperative
pancreatic fistula, or mortality [66]. Laparoscopic distal pancreatectomy was associated with
less blood loss, shorter length of hospital stay, a significantly lower overall incidence of
complications (34 versus 44 percent), and a lower incidence of surgical site infection (3 versus 8
percent).
Whether oncologic outcomes are equivalent remains to be determined for specific types of
malignancies [61,79]. As examples:
In a retrospective review of 123 patients who underwent laparoscopic distal
pancreatectomy and splenectomy for neoplastic cysts (n = 39), neuroendocrine tumors (n
= 43), and adenocarcinoma (n = 13), the median survival for patients with ductal
adenocarcinoma was similar to reports for the open approach at 14 months [79].
In a multicenter European study involving 25 centers and including 97 distal
pancreatectomies for a variety of pathologies, 23 percent of patients with pancreatic
malignancies had tumor recurrence, which is similar to cited rates using the open
approach. [61].
TechniquesFor distal pancreatectomy, the patient should be positioned supine or in a
partial right lateral decubitus position (ie, left side up 30 to 45 degrees). During laparoscopic
surgery, reverse Trendelenburg may aid in shifting the colon and small bowel inferiorly away
from the field of dissection.
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