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386
S. Ross et al.
Duodenojejunostomy
• The jejunum distal to the hepaticojejunostomy is brought up in an antecolic fashion to the duodenal staple line.
• Using the scissors, we remove the duodenal staple line to expose the lumen. A
generous incision is made with scissors on the anti-mesenteric aspect of the jejunal limb to expose the lumen.
• The duodenojejunostomy is undertaken in a similar fashion to the hepaticojejunostomy, this time using two running 3-0 non-absorbable V-Loc™ sutures
(Figs.21.21, 21.22, 21.23, and 21.24).
• Arm #4 is used to retract the stomach in the cephalad and ventral direction by
grasping the stapler line.
• We run the dorsal and ventral layers of the anastomosis from the 9-o’clock to
3-o’clock positions, with knots tied on the extra-luminal surface at the 3-o’ clock
position. On the ventral layer, a Gambee technique allows inversion of the serosal surfaces and prevents mucosal perturbance.
Fig. 21.21 Duodenojejunostomy
21 Robotic Pancreatoduodenectomy
Fig. 21.22 Duodenojejunostomy
387
Fig. 21.23 Duodenojejunostomy
388
Fig. 21.24 Duodenojejunostomy, completed
S. Ross et al.
Drainage andClosure
• Using the energized scissors, a falciform ligament ap is developed and placed
over the hepaticojejunostomy and the GDA stump for reinforcement.
• An omental ap is placed over the pancreatojejunostomy and duodenojejunostomy to minimize leaks.
• A closed suction Jackson-Pratt drain is placed next to the hepaticojejunostomy
and pancreatojejunostomy anastomosis.
• The robot is undocked, and the diaphragm is irrigated with bupivacaine to minimize postoperative pain.
• The fascia for all working ports is closed using an absorbable monolament
suture. The skin is closed with 4-0 Vicryl
Brunswick, NJ, USA).
®
sutures (Johnson & Johnson, New
References
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21 Robotic Pancreatoduodenectomy
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Part VI
Surgical Technique—Distal
Pancreatectomy
Chapter 22
Open Distal Pancreatectomy
AndrewJ.Sinnamon andPamelaJ.Hodul
Introduction
First reported attempts at open distal pancreatectomy date back to the 1880s, with
Trendelenburg’s resection of a pancreatic tail sarcoma in 1882, and Billroth performing resections of both the pancreatic head and tail in 1884 [1]. Sadly,
Trendelenburg’s initial foray into a distal pancreatic resection did not end well, as
the patient reportedly died on postoperative day 1. Distal pancreatic resection was
subsequently accomplished by the likes of Finney and Mayo at the turn of the century, but in general, signicant gains in pancreatic resection were limited due to the
three observations made by Mickulicz: (1) the pancreas being “exceedingly difcult
to reach,” (2) the notoriously difcult diagnosis of pancreatic disease, and (3) the
“overwhelming physiological pitfalls” of surgery itself [1–3]. However, with the
discovery of tumors of the endocrine pancreas in the late 1920s, enthusiasm for
attempts at pancreatic resection returned, with a burst of activity by pancreatic surgeons including Mayo, Roscoe, and Whipple, during which time the technique for
the distal pancreatectomy was rened [1, 4].
Following the establishment of pancreatic resection by these founders of surgery,
modern surgical methodology generally favored a retrograde approach to distal pancreatectomy. This has classically been described and taught utilizing a lateral-tomedial operative ow. In this way, the spleen is mobilized rst and retracted medially
to gain exposure to the distal pancreas and lift it from the retroperitoneum. The
popularity of this method is perhaps related to the ease of controlling the pancreas
once the spleen is mobilized and manipulated with the left hand of the operating
surgeon. However, this maneuver poses obvious risk of bleeding and may not place
due focus on lymphadenectomy or resection margins in cases of malignancy.
A. J. Sinnamon (*) · P. J. Hodul
Moftt Cancer Center, Tampa, FL, USA
e-mail: Andrew.Sinnamon@moftt.org; Pamela.Hodul@moftt.org
Switzerland AG 2025
E. P. Ceppa et al. (eds.), The SAGES Manual of Evolving Techniques in
Pancreatic Surgery, https://doi.org/10.1007/978-3-031-78409-5_22
393© The Author(s), under exclusive license to Springer Nature
394
A. J. Sinnamon and P. J. Hodul
As emphasis on oncologic principles over trauma principles grew for elective
resections, a transition to an antegrade approach gradually took hold in the surgical
school of thought. The most referenced technique for an antegrade operative
approach was described by Strasberg, Drebin, and Linehan in 2003 and termed the
radical antegrade modular pancreatosplenectomy (RAMPS) [5]. The rationale for
the RAMPS approach was to utilize a medial-to-lateral dissection to provide early
vascular control and optimize lymphadenectomy (the “antegrade” aspect of
RAMPS) and to achieve negative tangential margins by tailoring dissection to the
appropriate retroperitoneal fascial plane by adjusting as needed (“modular”). By
“modulating” the dissection, one may perform an anterior RAMPS by removing the
anterior renal fascia while preserving the left adrenal gland or, alternatively, perform a posterior RAMPS by removing the adrenal en bloc with the retroperitoneal
dissection. Modern high-quality cross-sectional imaging allows for careful preoperative planning to plan between the two. Initial experience with RAMPS showed
good lymph node retrieval rate with median of 15 nodes removed as well as over
90% negative tangential margins in cases of adenocarcinoma, which was conrmed
in a subsequent follow-up study [6, 7]. While prospective comparison of RAMPS to
standard retrograde distal pancreatectomy is limited, growing retrospective data
suggests a higher lymph node retrieval rate and more frequent R0 resection for
oncologic resections [8–11]. Differences in intraoperative blood loss and operative
time remain unclear [8, 11].
Since lymphadenectomy and clear retroperitoneal margins were the intended
goals of the RAMPS technique, it is most appropriate for oncologic resections.
However, because of the advantages of early vascular control with an antegrade
approach, the technique has been applied to other indications for distal pancreatic
resection as well. As a result, RAMPS has steadily become a preferred approach
among many surgeons for open distal pancreatectomy and splenectomy and has
subsequently been adapted for minimally invasive approaches, not to be discussed
in this chapter.
With the rise of laparoscopy and robotic platforms, minimally invasive approaches
have become preferable for many distal pancreatic resections using either antegrade
or retrograde approach. However, open distal pancreatectomy remains the safest
option in many cases. This is particularly so for patients with signicant past surgical history, pancreatitis, and locally invasive malignancy. Borderline resectable pancreatic adenocarcinoma is often best approached in an open manner for vascular
involvement or need for en bloc resection of adjacent organs. When approaching
these cases, the surgeon should be comfortable with both retrograde and antegrade
approach so they may adapt to the case at hand. As such, both will be described in
this chapter.
22 Open Distal Pancreatectomy
395
Preoperative Planning
Appropriate preoperative imaging to guide operative planning is critical. Pancreatic
protocol CT scan is the preferred imaging modality in most cases, including thin
section cuts at least <3mm in thickness and preferably 0.5–1mm [12]. Intravenous
contrast should be used with imaging acquisition to include pancreatic parenchymal
and arterial phase as well as delayed portal venous phase. If a specic pancreatic
protocol is not available, a CT of the abdomen and pelvis with as thin as cuts as
possible with arterial and venous phase may be an acceptable alternative. MRI with
MRCP may be additionally helpful in cases with pancreatic cystic neoplasms where
the relationship between cyst and pancreatic duct is of importance.
Open distal pancreatectomy is often performed for the specic reason that vascular involvement by a pathologic process makes a minimally invasive approach
unsafe. For this reason, preoperative planning must include careful review of
pancreas- dedicated imaging with attention to vascular anatomy. A potential site to
divide the splenic artery must be identied that is free of disease pathology. This
includes the absence of tumor encasement or abutment, but also in vasculopathic
patients, this site must also be free of signicant calcications to be compliant for
safe ligation. If there is no site for margin-negative division of the splenic artery due
to tumor involvement up to and including the celiac trunk, en bloc resection of the
celiac trunk (Appleby procedure) may be required. En bloc celiac resection with
distal pancreatectomy will be thoroughly discussed in a subsequent chapter. In addition to identifying a suitable site for division, the course of the splenic artery should
also be noted preoperatively to minimize any possibility of disastrously mistaking
the common hepatic artery for the splenic during the operation.
An understanding of the portal venous anatomy is also mandatory for preoperative planning. It should be known if the inferior mesenteric vein (IMV) drains into
the splenic vein as this would be necessarily divided during the resection. Similarly,
the drainage of the left gastric vein should be noted as it may be preferable to leave
this intact for improved gastric venous outow. Identication of a proper site for
ligation and division of the splenic vein is critical. For pancreatic cancer cases,
thrombosis of the splenic vein is relatively common and may propagate to the level
of the junction with the superior mesenteric vein (SMV). Occlusion of the splenic
vein due to thrombosis or tumor encasement may result in left-sided portal hypertension. The presence of large varices, collaterals, or splenomegaly should be noted
to prepare for safe resection while avoiding hemorrhage.
Based on preoperative imaging review, a general operative strategy may be
planned. Depending on the site of disease, one may decide whether to divide the
pancreas at the surgical neck (i.e., a subtotal pancreatectomy) versus transection at
a point more distally. A more distal resection spares exocrine and endocrine function but also typically involves dividing a thicker pancreas. Transection of the body
appears to result in a higher rate of postoperative pancreatic stula but no difference
in clinically signicant stulae [13–15]. Operative planning must also consider the
possibility of resection of adjacent structures, most commonly the splenic exure of
396
A. J. Sinnamon and P. J. Hodul
colon, posterior stomach, or left adrenal gland. The possibility of splenic preservation will be discussed in detail in a subsequent chapter. If partial colectomy is
planned, appropriate bowel preparation is warranted if not routinely performed for
pancreatectomy. Surgical planning should consider whether an antegrade or retrograde approach is most suitable given the anatomy. Lastly, the retroperitoneal margin should be examined for an oncologic resection; if the posterior margin appears
threatened with a standard resection plane, an anterior or posterior RAMPS (en bloc
adrenalectomy) should be considered depending on the depth of invasion.
Other preoperative planning to consider for open distal pancreatectomy includes
splenic immunization, thromboprophylaxis, consideration of bowel preparation,
preoperative antibiotics, and relevant medications for an Enhanced Recovery After
Surgery (ERAS) protocol. For planned splenectomy, vaccination against S. pneu-
moniae, N. meningitidis, and H. inuenzae should ideally be started 10–12weeks
preoperatively, if possible, for completion of all vaccines 2weeks prior to surgery.
If not possible, vaccine series may be safely resumed 14days postoperatively [16,
17]. Thromboprophylaxis should be considered according to a patient’s calculated
risk for venous thromboembolism. Bowel preparation should be performed if considering partial colectomy as noted above. However, the use of routine preparation
for distal pancreatectomy is not standard; among 23 surveyed European centers
performing distal pancreatectomy, routine bowel preparation was standard in only 8
[18]. Antibiotic prophylaxis should be administered within 1 h of incision and
redosed accordingly during surgery. The use of ERAS protocols for pancreatectomy, potentially utilizing epidural anesthesia, will be discussed in a subsequent
chapter, but may be an important piece of preoperative planning for open distal
pancreatectomy.
Operative Setup andSteps
After induction of general anesthesia and placement of appropriate monitoring lines
and urinary catheter, the patient is placed in the supine position with arms out. The
abdomen is shaved, and sterile skin prep is applied. Open distal pancreatectomy
may be performed using a variety of incisions, most commonly either a midline or
transverse subcostal incision, and is per the operating surgeon’s preference.
Appropriate incision may be tailored according to patient body habitus and intraabdominal anatomy based on imaging review. A transverse incision is more benecial
than midline for distal pancreatectomy according to one survey of pancreatic surgeons [18]. Furthermore, a Cochrane review pooling data from different operations
to compare midline versus transverse incision concluded that there is no difference
in infection rate for elective operations and a lower rate of incisional hernia for
transverse incision, and possibly less pain [19]. A left subcostal incision approximately two ngerbreadths inferior to and in a parallel orientation with the costal
margin is most appropriate and may be extended across the midline as needed. It is
our preference in many cases to use a bilateral subcostal incision for optimal
22 Open Distal Pancreatectomy
exposure, providing ample visualization of both the medial aspect of vascular dissection and the lateral peri-splenic dissection, both sites of potential unwanted nuisance bleeding. We prefer to use the Thompson retractor system for open distal
pancreatectomy.
397
Diagnostic Laparoscopy
Regardless of the preferred open incision, diagnostic laparoscopy is valuable prior
to entering the abdomen as it may spare a considerable proportion of patients a
nontherapeutic laparotomy. This is particularly the case when operating for pancreatic adenocarcinoma. Older data suggests that diagnostic laparoscopy at the outset
of a planned pancreatic resection for adenocarcinoma may change management in
up to 44% of cases [20]. More contemporary data from the Dutch PREOPANC trial
found that staging laparoscopy identied occult peritoneal metastatic disease in
11–12% of cases [21]. Laparoscopy may be rapidly performed using a single camera port, with placement of additional ports as needed for visualization and/or
biopsy of suspicious lesions. Ports may be placed that will be incorporated into the
open incision, but this is not mandatory; a supraumbilical camera port is typically
most appropriate for staging purposes and will obviously not lie in a subcostal incision. When operating for malignancy, laparoscopy should include thorough examination of the liver surface, omentum, peritoneal surface, and pelvis. Any suspicious
lesions are biopsied and sent for frozen pathologic examination.
Open Exposure ofthePancreas
Once the decision is made to proceed with laparotomy, the abdomen is entered via
the preferred incision. Care should be taken during this step to spare the falciform
ligament so that it may be used later for ap coverage of the transected pancreas.
Exposure of the pancreas may be rst obtained by dividing the gastrocolic ligament
to enter the lesser sac. Dissection is continued up the greater curvature of the stomach dividing the gastrocolic and gastrosplenic ligaments containing the short gastric
vessels all the way to the left crura. Bipolar energy devices are useful for efcient
hemostasis at this step. The gastroepiploic pedicle should be spared for gastric perfusion. Once the superior-most short gastric vessels are divided, it can be helpful to
turn laterally to dissect just superior to the spleen in order to simplify completion of
the dissection at a later point. Division of the gastrocolic ligament is then continued
medially toward the pylorus. Dissection in this direction can proceed as far toward
the patient’s right as necessary to provide adequate exposure. In cases with a history
of pancreatitis, the gastrocolic ligament may be found to be fused to the transverse
mesocolon, or the posterior stomach may be densely adhered to the anterior pancreatic body. Careful dissection at this time should be undertaken to avoid entering the