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24 Robotic-Assisted Approach toMinimally Invasive Distal Pancreatectomy
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References
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with vascular resection for locally advanced pancreatic tumors. Pancreas. 2011;40(8):1264–70.
2. Suman P, Rutledge J, Yiengpruksawan A. Robotic distal pancreatectomy.
JSLS. 2013;17(4):627–35.
3. Zureikat AH, Moser AJ, Boone BA, Bartlett DL, Zenati M, Zeh HJ 3rd. 250 robotic pancreatic
resections: safety and feasibility. Ann Surg. 2013;258(4):554–9; discussion 559–62.
4. Hwang HK, Kang CM, Chung YE, Kim KA, Choi SH, Lee WJ. Robot-assisted spleenpreserving distal pancreatectomy: a single surgeon’s experiences and proposal of clinical
application. Surg Endosc. 2013;27(3):774–81.
5. Zhan Q, Deng XX, Han B, Liu Q, Shen BY, Peng CH, etal. Robotic-assisted pancreatic resection: a report of 47 cases. Int J Med Robot Comput Assist Surg. 2013;9(1):44–51.
6. Shakir M, Boone BA, Polanco PM, Zenati MS, Hogg ME, Tsung A, etal. The learning curve
for robotic distal pancreatectomy: an analysis of outcomes of the rst 100 consecutive cases at
a high-volume pancreatic centre. HPB. 2015;17(7):580–6.
7. Napoli N, Kauffmann EF, Perrone VG, Miccoli M, Brozzetti S, Boggi U.The learning curve
in robotic distal pancreatectomy. Updat Surg. 2015;67(3):257–64.
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a single institution’s experience in open, laparoscopic, and robotic approaches. J Am Coll
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9. Guerrini GP, Lauretta A, Belluco C, Olivieri M, Forlin M, Basso S, et al. Robotic versus
laparoscopic distal pancreatectomy: an up-to-date meta-analysis. BMC Surg. 2017;17(1):105.
10. Liu R, Liu Q, Zhao ZM, Tan XL, Gao YX, Zhao GD.Robotic versus laparoscopic distal pancreatectomy: a propensity score-matched study. J Surg Oncol. 2017;116(4):461–9.
11. Waters JA, Canal DF, Wiebke EA, Dumas RP, Beane JD, Aguilar-Saavedra JR, etal. Robotic
distal pancreatectomy: cost effective? Surgery. 2010;148(4):814–23.
12. Magge DR, Zenati MS, Hamad A, Rieser C, Zureikat AH, Zeh HJ, et al. Comprehensive
comparative analysis of cost-effectiveness and perioperative outcomes between open, laparoscopic, and robotic distal pancreatectomy. HPB. 2018;20(12):1172–80.
13. Korrel M, Jones LR, van Hilst J, etal. Minimally invasive versus open distal pancreatectomy
for resectable pancreatic cancer (DIPLOMA): an international randomised non-inferiority
trial. Lancet Reg Health Eur. 2023;31:100673.
Chapter 25
Spleen-Preserving Distal Pancreatectomy
JaneWang, CamillaGomes, ZaimChaudhary, andAdnanAlseidi
Introduction
Multiple surgical approaches exist for distal pancreas pathology and include options
such as radical antegrade modular pancreatosplenectomy (RAMPS), distal
pancreatectomy- splenectomy (DPS), vessel-resecting, spleen-preserving distal pancreatectomy (VR-SPDP) or Warshaw technique, and vessel-preserving, spleenpreserving distal pancreatectomy (VP-SPDP) or Kimura technique. These
procedures can be accomplished in a minimally invasive fashion [1], and surgeons
should choose the procedure based on experience, patient factors, and specic
pathology.
Proper oncologic resections are essential for malignant neoplasms to ensure the
best outcomes. For such an indication, the RAMPS procedure remains the best
option [1]. However, distal pancreatectomy alone is acceptable for benign disease,
premalignant lesions such as cystic neoplasms, and early neuroendocrine tumors. In
these instances, a less aggressive approach should be considered, including splenic
preservation. This is important, as resecting the spleen can lead to complications
such as overwhelming post-splenectomy infections (OPSI), portal vein thrombosis,
and even increased cancer risk [2].
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 78409- 5_25.
J. Wang (*) · C. Gomes · A. Alseidi
Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
e-mail: jaeyunjane.wang@ucsf.edu; camilla.gomes@ucsf.edu; adnan.alseidi@ucsf.edu
Z. Chaudhary
University of California, Berkeley, Berkeley, CA, USA
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_25
431© The Author(s), under exclusive license to Springer Nature
432
Existing literature supports the superiority of SPDP, which has been associated
with improved short- and long-term outcomes and decreased cost when compared
to DPS. A meta-analysis conducted by Nakata et al. analyzed 404 patients with
regard to SPDP vs DPS [3]. They found that the former had fewer infectious complications, clinically signicant pancreatic stulas, and abdominal abscesses [3].
They also found that SPDP was associated with signicantly shorter operative times
and less intraoperative blood loss [3]. Similar ndings were reported in another
meta-analysis by Shi etal. which analyzed 448 patients from 16 studies, although
they reported no difference in operative time or hospital length of stay [4]. Finally,
a study conducted by Lopez et al. demonstrated that SPDP was associated with
lower cost compared to DPS at $52,951 vs $45,123, respectively [5].
Thus, we believe that splenic resection should be reserved only for cases with
clear indications, such as for malignancies, and when technically necessary, like in
the setting of splenic vein thrombosis. Within the realm of splenic preservation, one
can pursue either VR-SPDP or VP-SPDP, both with their own risks and benets.
The remainder of this chapter will focus on key pre- and intraoperative steps for
both procedures, as well as our recommendations and preferences.
J. Wang et al.
Preoperative Preparation
A contrast-enhanced CT scan is an important tool to not only assess the pancreatic
pathology in question, but also to evaluate the key vasculature and anatomy.
Appropriate workup, such as endoscopic ultrasound with or without ne needle
aspiration, should be pursued based on the suspected pathology. Patients who ultimately undergo a DPS should receive vaccinations 14days after surgery [6].
Key Shared Operative Steps
SPDP can be performed in either a vessel-preserving or vessel-resecting manner.
Both approaches share the same patient set-up and key fundamental steps, which
will be described in this section. We place the patient in the supine position with
both arms out. A urinary catheter and nasogastric tube should be placed.
Trocar Placement
After the abdomen is entered and pneumoperitoneum achieved via either Veress
needle or open Hasson technique, the authors place four trocars. The goal is to triangulate around the body and tail of the pancreas while maintaining an adequate
working distance for sufcient range of motion. We use a 12 mm trocar for the
25 Spleen-Preserving Distal Pancreatectomy
433
camera port and place it approximately 15–20cm away from the target anatomy
(typically supraumbilical or to the left of midline for non-obese patients). We then
place a second 12mm trocar at the left mid-clavicular line, approximately 10–12cm
from the target anatomy and more cephalad than the camera port. This port is often
used for the stapler as well as ultrasound. We typically place an assistant 5mm trocar at the left anterior axillary line at about the same height as the second 12mm
trocar; this port site can eventually be used for a drain if needed. Finally, the last
5mm trocar is placed approximately 5cm below the xiphoid either in the midline
or to the right of the midline (depending on the location of the pathology). An
optional, additional 5mm trocar can be placed in the right anterior axillary line (a
mirror image of the port on the left) to assist with liver/stomach retraction.
Figure25.1 illustrates the nal trocar placement.
Pearls andPitfalls
In general, we avoid placing the camera port at a xed location relative to the umbilicus as patient habitus can alter optimal placement. Instead, we think about trocar
placement relative to the target anatomy. For example, if the tumor is in the pancreas
neck and very close to midline, the trocar should be placed to the right of midline to
allow for optimal angles for dissection.
Fig. 25.1 This diagram
illustrates port placement,
with the larger circles
representing 12mm trocars
and the smaller circles
representing 5mm trocars
434
J. Wang et al.
Entry into theLesser Sac
The next step is to enter the lesser sac. If the liver obscures the surgical eld, a liver
retractor can be placed to retract the left lobe. The stomach should be retracted in
the cephalad direction toward the diaphragm, and the transverse colon identied.
The lesser sac is entered through the gastrocolic ligament approximately 1cm inferior to the gastroepiploic vessels. Video 25.1 illustrates this step.
Pearls andPitfalls
Care must be taken to avoid entering and otherwise injuring the transverse mesocolon. This can be avoided by elevating the stomach sufciently, staying in a plane
parallel to the posterior surface of the stomach, and keeping the tip of the energy
device pointed toward the diaphragm. In addition, this step may be particularly
challenging in patients with a history of chronic pancreatitis, as the planes may be
fused. If the surgeon is not able to enter the lesser sac from a specic area, we recommend moving to another location.
Division oftheShort Gastric Vessels
The aforementioned dissection is carried along the greater curvature of the stomach,
and an energy device is used to divide the short gastric vessels to release the stomach from the spleen. The surgeon should maintain a distance of 1cm inferior to the
gastroepiploic artery. This dissection should be continued even after the gastric fundus is released from the left crus until the left gastric artery and vein are reached,
staying inferior to these vessels. The peritoneal fold between the anterior pancreas
and posterior stomach should also be divided. Finally, the dissection should be carried medially enough to visualize the pancreatic neck. Video 25.1 illustrates this step.
Pearls andPitfalls
The surgeon should avoid veering too far from the inferior border of the stomach, as
one may inadvertently take down the omentum or even injure a high splenic exure.
One should also avoid pulling too hard as this may avulse the vessels.
25 Spleen-Preserving Distal Pancreatectomy
435
Splenic Flexure Mobilization
Although there are multiple ways to approach splenic exure mobilization, we recommend starting with a lateral approach. The surgeon should start by developing a
plane between the mesocolon and Gerota’s fascia and continuing the dissection
superiorly until the inferior pole of the spleen is visualized. We then recommend
starting the medial dissection by rst incising the peritoneum at the inferior border
of the pancreatic body and then continuing this dissection laterally while gently
retracting the pancreas up. Finally, the medial dissection should be connected to the
previous lateral dissection plane and the splenocolic ligament transected. This
approach to splenic exure mobilization is particularly helpful in obese patients.
Video 25.2 illustrates this step.
Pearls andPitfalls
During the lateral dissection, the surgeon should be wary of carrying the dissection
too deep and ending up retrorenal. In addition, especially in patients with thick
omentum, one must be cautious not to injure the pancreas or colon as these structures are in close proximity and can easily get mistaken for or pulled up into omental tissue.
Pancreas Mobilization
The inferior border of the pancreas should already be mobilized after completion of
the previous step. The surgeon should then proceed with retropancreatic dissection.
Specically, the pancreas should be gently lifted up and the retropancreatic tissue
distal to the anticipated transection plane pushed down. Once this is complete, the
superior border of the pancreas should be mobilized as well. This results in complete mobilization of the pancreas. Video 25.3 illustrates this step.
Pearls andPitfalls
Elevation of the pancreas should be done gently as to not avulse the vessels. To help
differentiate between the splenic artery and the left gastric artery, both of which can
be encountered with pancreas mobilization, one can gently move the pancreas back
and forth; the splenic artery will move in unison with the pancreas, whereas the left
gastric artery will not.
436
J. Wang et al.
Identify Pancreatic Pathology
This step can be done at any point after adequate exposure of the pancreas is
achieved. If the pathology of interest is not clearly visualized, one can consider
using intraoperative ultrasound as an adjunct. This allows for identication of an
appropriate transection plane.
The next key steps involve the splenic vessels. These will be discussed in the
context of VP and VR-SPDP, as outlined in the sections “Steps Unique to VesselPreserving, Spleen-Preserving Distal Pancreatectomy” and “Steps Unique to
Vessel- Resecting, Spleen-Preserving Distal Pancreatectomy.” The remaining shared
steps are detailed below.
Pancreatic Transection
Pancreatic transection should be performed with a linear stapler. The exact load
depends on the thickness of the tissue, although the authors typically use a black
load. Buttressing technology has not proven helpful and the authors no longer use it
in their practice. The decision to place a drain depends on the appearance of the
transection line; if it appears uncrushed and intact, we do not leave a drain.
Pearls andPitfalls
The key to successful, non-traumatic transection is gentle and slow compression of
the tissue and careful ring of the stapler. In fact, the authors slowly compress the
pancreas over a 3–5min period and then pause for 1–2min prior to transection. In
addition, the authors are careful to minimize any rotational movement during this
process. One must also take care to visualize the tip of the stapler prior to ring to
avoid injury to other structures. On occasion, the pancreas is too thick for the stapler, in which case the surgeon has a few options. First, the surgeon can transect the
pancreas at a more proximal location (i.e., at the neck) where the tissue is thinner.
Another option is to use advanced bipolar energy to thin the pancreas anteriorly
before stapling. Finally, one can also transect the pancreas with a bipolar energy
device and then place buttressing U-stitch sutures on the remnant pancreas.
Specimen Removal andClosure
The specimen is removed via a large retrieval bag through the 12mm camera port
site. The incision should be extended as needed to allow for specimen extraction.
This is a notable advantage to the spleen-preserving approach, as resecting the
25 Spleen-Preserving Distal Pancreatectomy
spleen often requires specimen extraction through a larger incision such as a separate Pfannenstiel incision. The surgical eld is then examined for hemostasis, pneumoperitoneum released, all trocars removed under direct visualization, and the
fascia and incisions closed. This concludes the operation.
437
Steps Unique toVessel-Preserving, Spleen-Preserving
Distal Pancreatectomy
VP-SPDP is thought to be more technically challenging but is also accompanied by
fewer splenectomy-related complications [7]. The key to success is adequate dissection and extensive mobilization of the splenic exure and pancreas. This approach
involves dissecting the vessels off the pancreas.
Splenic Vein Dissection
The splenic vein is situated fairly deep in the pancreatic parenchyma and is typically
visualized during the retropancreatic dissection as described above. The vein should
be carefully dissected from the pancreas using a hook electrocautery from a medial
to lateral approach; this step must be approached with caution given the thin vessel
wall as well as the numerous branches. These smaller vessels should be carefully
isolated and divided with an energy device.
Splenic Artery Dissection
The splenic artery can typically be found in an anterior and cephalad location and
can be identied either via a posterior retropancreatic approach or anterior-superior
approach, though the latter approach has a higher risk of misidentication of the
hepatic artery. Upon successful dissection of the splenic artery, the pancreas body
and tail should be fully mobilized. This step is followed by stapled pancreatic transection, which is detailed above in “Key Shared Operative Steps.” Of note, one can
also choose to transect the pancreas parenchyma as the rst step (after carefully
developing a plane at the proposed transection line between the splenic vessels and
pancreas), and then free the pancreas from the splenic vein and artery starting at the
point of parenchymal transection and progressing laterally toward the spleen. The
surgeon can use umbilical tape as a handle assist with this step. Video 25.4 illustrates this step.
438
Pearls andPitfalls
Bleeding is a feared complication of the vessel-preserving approach. If one encounters bleeding from arterial branches, we recommend placing a clip on the bleeding
branch and then using an energy device (i.e., advanced bipolar) to divide the vessel
on the specimen side. If the bleeding is more profuse, one can consider placing a
Bulldog clamp on the splenic artery to allow for visualization of the injury and vessel repair. For suspected venous bleeding, small pancreatic vein branches are easily
coagulated, and clips are rarely necessary for veins with a luminal diameter≤5mm.
Signicant uncontrolled bleeding from the splenic vein, however, may require conversion to a vessel-resecting, spleen-preserving distal pancreatectomy. Finally, one
should be gentle while dissecting the splenic vein to prevent vessel thrombosis.
J. Wang et al.
Steps Unique toVessel-Resecting, Spleen-Preserving
Distal Pancreatectomy
VR-SPDP was rst described by Warshaw in 1988 and relies on collateral circulation from the short gastric vessels [8].
Dissection andDivision ofSplenic Vessels
After mobilization of the pancreas, a tunnel is created at the tip of the pancreatic tail,
after which the splenic vessels are divided (typically with a linear stapling device).
The next step is division of the pancreas parenchyma and splenic vessels proximally
at the proposed transection line. Although some will divide the parenchyma and
vessels together, we recommend dividing the splenic vein, artery, and parenchyma
with three separate stapler loads. If unable to take them individually, we recommend
taking the artery rst and then the vein and parenchyma together. Finally, the spleen
should be inspected prior to and after vessel division to assess for color and viability.
Recommendations andPreferences
There is currently no consensus on whether VR or VP-SPDP is superior. In general,
those in favor of the former quote signicantly shorter operative times, less intraoperative blood loss, and overall shorter hospital length of stay [3]. This may also be
the preferred technique in cases when the splenic artery and vein are signicantly
inamed, thrombosed, brosed, or otherwise involved in the pancreas pathology.
25 Spleen-Preserving Distal Pancreatectomy
439
The vessel-preserving method is signicantly more technically demanding as it
requires meticulous dissection of the splenic vessels. However, it is associated with
fewer spleen-related complications such as splenic infarction, secondary splenectomy, and overall morbidity [3]. Thus, we ultimately recommend pursuing VP-SPDP,
with VR-SPDP serving as a contingency if the surgeon encounters signicant bleeding or if tumor involvement or degree of inammation poses a high risk of morbidity and mortality.
Conclusion
In summary, we have described the benets of splenic preservation when indicated
and have also reviewed the two main methods of SPDP.While there is no formal
consensus on the superiority of one method versus another, there is literature
describing increased morbidity with vessel-resection, and we thus recommend vessel-preservation as the rst-line approach, followed by vessel-resection as a bail- out
maneuver.
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Yamaue H, Morikawa T, et al. Minimally invasive preservation versus splenectomy during
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