Completely Laparoscopic Subtotal Pancreatectomy with Splenic Artery Preservation

Laparoscopic distal pancreatectomy has emerged as an attractive minimally invasive alternative for selected patients. Although technically challenging, distal pancreatectomy with splenic artery preservation has consistently been correlated with reduced blood loss and perioperative morbidity in multiple studies. Herein presented is our technique for completely laparoscopic (non-hand-assisted) subtotal pancreatectomy with splenic artery preservation (LSP-SAP). An 87-year-old woman with an incidentally identified 3-cm cystic lesion in the pancreatic body-tail interface underwent EUS, which supported side-branch intraductal papillary mucinous neoplasm. The patient subsequently underwent laparoscopic resection. A completely laparoscopic procedure was performed using a four-trochar technique. The tail and body of the pancreas were dissected off of the retroperitoneum along the embryologic plane and separated from the colonic splenic flexure. Next, the splenic artery was dissected, isolated, and preserved, while the splenic vein was dissected off the ventral pancreas up to the level of the splenic-portal vein confluence. The technique employed a bipolar cutter-sealing device for dissection and hemostasis. Pancreatic parenchymal transection was performed with a standard vascular load endomechanical stapling device. Total procedure time was 210 min, and the estimated blood loss was 200 mL. Postoperatively, the patient was admitted, advanced to regular diet the next day, and discharged home on postoperative day 3. The pathological review of the specimen revealed high-grade dysplasia with a non-invasive malignant component, classified as intraductal carcinoma. Foci of PanIN 1-3 were identified with no high grade dysplasia at the surgical margin. Five lymph nodes were included in the specimen and were negative for malignancy. Completely LSP-SAP can be safely performed in selected patients. This procedure may be an optimal alternative to open surgery.