Distal pancreatectomy

Indications

• Chronic inflammation
• Trauma
• Tumour

Principles

• Conventionally includes splenectomy - best option for non-HPB surgeons
• Conservative distal pancreatectomy is spleen-sparing - can be done for low-grade endocrine tumours
• Splenic vaccinations beforehand

Technique for distal pancreatectomy and splenectomy

• Transverse subcostal incision
• Expose pancreas by separating omentum from transverse mesocolon and entering lesser sac
• Fixed retraction
• Identify SMV, first by following middle colic vein down to it from above from within the transverse mesocolon.
• Gently develop the plane between the vein and pancreas using blunt dissection. Get your finger in behind the pancreas, then cut down onto your fingertip from above to complete the separation.
• Divide pancreas
  • Transection with either stapler or diathermy then oversewing show equivalent rates of fistula
  • GIA blue, although can adapt to bulkiness of pancreas
  • Need to underrun the duct with 4/0 PDS if using diathermy
• Ligate splenic artery with suture transfixion x2
• Ligate vein, if possible just distal to IMV entry to preserve it
• Continue medial to lateral dissection posterior to pancreas and anterior to left renal vein, and then dividing splenic ligaments to remove specimen
• Haemostasis, two drains in pancreatic bed

Post-op:

• Leave drains for 5-7 days then start shortening them

Difficulties:

• Bleeding
  • Often from tears in splenic vein - just expose, temporary control, catch up, suture ligate

Complications:

• Pancreatic insufficiency
  • Uncommon if pre-op function was normal
• Haematoma/collection
• Pancreatic fistula
  • Exclude ductal obstruction at head of pancreas
  • Will close spontaneously, usually within a month
  • Octreotide may possibly hasten closure