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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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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