Distal pancreatectomy

The following are “knows” from the syllabus

• Distal pancreatectomy

• Role for splenic preservation

• Explore the abdomen for metastatic disease

• Exposure

  • Greater omentum separated from the transverse colon to enter the lesser sac
  • Divide the gastro-splenic ligament and take the short gastrics and left gastro-epiploic arteries
  • Elevate stomach away from pancreas
    • May need to divide posterior gastric adhesions to do so
    • If lap use a Nathanson retractor
  • Consider dividing gastro-epiploic vein as it drains into the gastrocolic trunk as it permits better mobilisation of the antrum and means it wont be inadvertently be torn

• Ligation and transection

  • Mobilise the inferior surface of the pancreas
    • Lateral to middle colic vessels
    • Identify and ligate the IMV
  • Create a tunnel under the pancreas at the planned transection margin
  • Mobilise and ligate the splenic artery superior to the pancreas
  • Transect the pancreas with a stapler taking the splenic vein as well (or take seperatly)

• Mobalisation

  • Mobilise the pancreas towards the splenic hilum
  • Mobilise the spleen
    • Pull the spleen medially
      • Take the splenocolic ligament, splenorenal ligamnet and phrenocolic ligament
      • Role the spleen medially identifying the kidney, adrenal and left renal vein below
  • Complete the mobilisation and remove the specimen

• Leave a drain

• Close the abdomen

Splenic preservation

• Indications for splenic preservation
  • Benign or low-grade malignant lesions (e.g. mucinous cystic neoplasms, neuroendocrine tumours)
  • Inflammatory conditions or trauma where spleen is not involved
  • To preserve splenic immune function, especially in younger or immunocompromised patients
• Benefits
  • Avoids risk of overwhelming post-splenectomy infection (OPSI)
  • Reduces risk of postoperative thrombocytosis and thromboembolic events
  • Preserves immune surveillance and function of spleen
• Two main techniques
  • Kimura technique
    • Dissect splenic artery and vein off the pancreas
    • Preserve both vessels while removing distal pancreas
    • Technically more demanding but retains normal splenic perfusion
    • Lower risk of infarction or secondary splenectomy
  • Warshaw technique
    • Ligate splenic artery and vein at pancreatic transection
    • Preserve short gastric and left gastroepiploic vessels for splenic perfusion
    • Simpler and faster, useful if splenic vessels are involved or hard to preserve
    • Risk of splenic infarction, subcapsular haematoma, or need for later splenectomy