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VIDEO 21
Partial splenectomy
Video duration 8 minutes 40 seconds
In this video, we will demonstrate a partial splenectomy.
OUTLINE
The video is divided into the following parts:
• Port positioning
• Division of the short gastric vessels and superior pole
vessels
• Ultrasound
• Parenchymal transection
• Important points.
Figure v21.1 demonstrates the port positioning. It is
important to place the ports high enough in the left upper
quadrant and far enough to the left of the patient. To
exemplify how high up in the upper quadrant and how
far over to the left we place the ports, we show you here
positioning of one of the 12 mm ports and two of the
5 mm ports.
The first step in devascularizing the superior pole of the
spleen is division of the short gastric vessels. In order to
expose the short gastric vessels, we need to lyze some
adhesions between the left lateral section of the liver and
the superior pole of the spleen. In order to fully mobilize
the superior pole of the spleen, we need to mobilize the
left lateral section of the liver. This is not a routine step for
our partial splenectomy, but necessary here because of
the abnormal size of the spleen. We can see here the left
lateral section of the liver mobilized towards the right side
of the patient. An Endoloop placed at the very tip of the
Figure v21.1 It is important to place the ports high enough in the left upper quadrant and far enough to the left of the patient.
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
449
450 Video 21
left triangular ligament facilitates this step. Beginning the
division of the phrenicolienal ligament at this step facilitates the mobilization process. The gastrolienal ligament is
now nicely exposed. With this exposure, we can now
begin to divide the short gastric vessels.
This section demonstrates the division of the superior
pole vessels. We continue our dissection inferiorly to
expose the superior pole vessels. The superior pole artery
is clipped and divided. The next step is to expose the
superior pole vein. In the background, you can see the
superior pole vein and we are switching to scissors for
the dissection. In order to facilitate clip application, we are
preshrinking the vein with bipolar forceps. Here you can
see the application of the locking clips. Bleeding from a
capsular tear can be stopped with a hemostatic agent
made of oxidized regenerated cellulose.
Before we begin the parenchymal transection, we use
ultrasound to confirm that the devascularization of the
superiorpole is complete.Using intraoperativeultrasound,
we can see that the devascularization of the superior pole is
not complete. We therefore expose the hilar vessels in the
retroperitoneum to control additional branches to the
superior pole. Clamping the vessels and confirming flow
to the superior pole via ultrasound allows us to confirm
complete isolation of the superior pole of the spleen.
The last step of the operation is parenchymal transection. A similar parenchymal transection technique as for
the liver can be used here. Thanks to the vascular isolation, parenchymal back bleeding is minimal. The superior
pole is now completely detached from the rest of the
spleen. Minor bleeding can be stopped with the bipolar
forceps.
IMPORTANT POINTS
• For total or partial splenectomies, place the ports high
enough in the left quadrant.
• Avoid minor tears in the splenic parenchyma.
• Use ultrasound to define the zone of ischemia.
• Use gentle retraction during the splenic mobilization.
• Be mentally prepared to convert to a total splenectomy or
an open procedure.
Laparoscopic pancreas resection
VIDEO 22
Pancreatic enucleation
Video duration 8 minutes 44 seconds
In this video, we will show you a pancreatic enucleation.
OUTLINE
The video is divided into the following parts:
• Port positioning
• Pancreatic exposure
• Ultrasound
• Enucleation
• Important points.
For port positioning, the pancreatic exposure, enucleation, and use of ultrasound need to be considered
(Figure v22.1).
The first step is exposing the pancreas and locating the
lesion, which in this case is located in the pancreatic body.
We are exposing the pancreas by entering the lesser sac.
Next, we will take the omentum off the transverse colon.
Here the splenic flexure is taken down. Now the inferior
border of the pancreas is mobilized.With superior traction
on the pancreas,the retroperitonealattachmentsare taken
down. Be careful not to injure the splenic vein which
Figure v22.1 For port positioning, the pancreatic exposure, enucleation, and use of ultrasound need to be considered.
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
451
452 Video 22
Figure v22.2 Ultrasound can be helpful in determining the
relationship between the pancreatic duct and the lesion.
vein inferior. Here the cystic lesion to be enucleated
comes into view. Ultrasound can also be helpful in
determining the relationship between the pancreatic
duct and the lesion (Figure v22.2).
The next step is the enucleation. Here the cystic lesion
at the inferior border of the body of the pancreas comes
into view. For retraction of the lesion, we are holding onto
the fibrous tissue attached to the lesion rather than the
lesion itself. At this step of the operation, we should be
careful not to injure the pancreatic duct which we know
from the intraoperative ultrasound is close to this location. A small duct of the main pancreatic duct is clipped
and divided. Now the lesion is completely detached and
we place it in an endoscopic retrieval bag for later
removal. We now proceed to approximate the walls of
the cavity in order to minimize a pancreatic fistula.
Finally, a drain is placed in one of the port sites.
comes into view here. We continue our dissection along
the inferior border of the pancreas towards the spleen.
Once the pancreatic body has been completely mobilized, we proceed with intraoperative ultrasound. It is
important to identify the splenic artery and splenic vein
in relationship to the lesion. Doppler mode can be
helpful in identifying the artery and vein. On this
Doppler flow image, the artery is superior and the
IMPORTANT POINTS
• Determine preoperatively that the pancreatic duct is not
involved when you are planning an enucleation.
• Optimize port positioning for both exposure and
enucleation.
• Use ultrasound to locate smaller lesions and parenchyma
approximation that might potentially reduce the fistula rate.
VIDEO 23
Cystgastrostomy
Video duration 8 minutes 4 seconds
This video demonstrates a cystgastrostomy.
OUTLINE
The video is divided into the following parts:
• Port positioning
• Exposure of cyst in the lesser sac
• Cystotomy
• Posterior wall anastomosis
• Gastrotomy
• Anterior wall anastomosis
• Important points.
Figure v23.1 demonstrates the port positioning.
First, we will show you exposure of the cyst in the lesser
sac. First, we separate the greater omentum from the
transverse colon and transverse mesocolon; this step can
be difficult in patients with recurrent episodes of pancreatitis or infections. One might consider an endogastric
laparoscopic approach in such cases. Separating the
greater omentum from the transverse colon and transverse mesocolon at a length of about 10–15 cm is enough
for exposure. Here the posterior wall of the stomach
comes into view. Grabbing the stomach at the lesser
curvature and using superior traction aids exposure of
the pancreas. As we are dividing the adhesions between
the stomach and the pancreas, the cyst comes into view
(Figure v23.2). We carefully uncover the cyst from the
capsular and overlying pancreatic parenchyma. Once the
inferior part of the cyst has been completely mobilized, we
focus our dissection on the superior part.
The first step in creating a cystgastrostomy is the cys-
totomy. The ideal location for the cystotomy is best
Figure v23.1 The scheme demonstrates the port positioning for a cystgastrostomy.
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
453
454 Video 23
Figure v23.2 We are dividing adhesions between the stomach and the pancreas, and the cyst comes into view.
chosen with ultrasound. Factors that affect the choice of
an ideal location for the cystotomy are safety but also ease
of creating the anastomosis. Here, you see the amylaserich pancreatic fluid leaking from the cyst. The next step is
enlarging the cystotomy. Bleeding can be easily stopped
with the bipolar forceps. The next step is the posterior wall
anastomosis. We have shown here one technique of
anchoring the suture with a large knot at the end of
the suture. It is important to take large bites in order to
incorporate the entire wall of the stomach as well as the
entire wall of the cyst. The further we progress with the
anastomosis, the easier it becomes.
Once the posterior wall has been completed, we perform
a gastrotomy. Performing the gastrotomy at this step helps
in choosing an ideal location. It is important not to make a
false lumen but rather make a full-thickness gastrotomy.
The last step is anterior wall anastomosis. Here we show
anchoring the suture with a slip knot; achieving good
exposure while suturing the anastomosis can be difficult.
In order to avoid leaks, we reconstruct the anterior walls
from both corners. As mentioned, full-thickness bites that
also incorporate the mucosa are important. This will
prevent the mucosa from obstructing the anastomosis.
By including the entire wall of the cyst, we prevent
postoperative bleeding. We perform the anastomosis of
the anterior wall from both corners as we achieve better
visualization that way.
IMPORTANT POINTS
• Optimal port positioning depends on the cyst location.
• Consider a laparoscopic endogastric approach for large
cysts and the presence of adhesions.
• Use ultrasound to determine an optimal location for the
cystotomy.
• Use generous bites when suturing.
• Tack down the gastric mucosa to avoid obstruction of the
anastomosis.
VIDEO 24
Distal pancreaticosplenectomy
Video duration 11 minutes 12 seconds
In this video, we demonstrate a distal pancreaticosplenectomy.
OUTLINE
The video is divided into the following parts:
• Port positioning
• Pancreatic exposure
• Dissection of the splenic vessels
• Division of the short gastric vessels
• Pancreatic transection
• Splenic mobilization
• Important points.
It is important to place the ports high enough in the left
upper quadrant (Figure v24.1). The camera port should
not only be high enough in the left upper quadrant but
also far enough over to the left for good visualization. The
working ports and the ports for retraction are placed to the
left of the midline.
We are now beginning with the pancreatic exposure.
One of the first steps is to deflect the colon downwards in
order to avoid injury during the pancreatic exposure. All
adhesions to the spleen are divided because traction can
lead to capsular tears. The splenic flexure is deflected
downwards for safe mobilization of the spleen. Here we
are dividing the gastrosplenic ligament in order to expose
the tail of the pancreas. Now that we have exposed the
distal pancreas, we are placing an additional 12 mm port
for later stapling. The ideal angle to the distal pancreas can
be chosen once it has been exposed.
Figure v24.1 It is important to place the ports high enough in the left upper quadrant.
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
455
456 Video 24
Figure v24.2 On this image the clipped splenic artery and the
splenic vein are exposed.
We are now dissecting out the splenic artery; the splenic
artery is located at the superior border of the pancreas and
in order to expose it, we are opening the capsule of the
pancreas. Here the splenic artery comes into view. The
splenic artery is clipped and divided. We are now continuing our dissectiondistally along thegastrosplenicligament.
Next we are dividing additional short gastric vessels. Take
time for hemostasis at this step in order to achieve good
working conditions. Here we can see the adhesions
between the stomach and the tumor. In order to avoid
a positive margin, we would perform a sleeve gastrectomy
to keep the adhesions with the specimen. This step is
obviously specific to this case and not routinely performed
during a distal pancreaticosplenectomy.
Next is the pancreatic transection. For safe staple division of the pancreas, the tissue should not be too thick.
Therefore we are dissecting out the pancreas some more.
Here we are dissecting out the pancreas off the retroperitoneum. Be careful to avoid a splenic vein injury. Now
the clipped splenic artery and the splenic vein are exposed
(Figure v24.2). We are continuing to thin out the pancreas in order to avoid having too much tissue to staple
through. Now that the pancreas is thinned out enough,
we are ready to staple. As we are also stapling across the
splenic vein, we have a vascular clamp ready in case of
stapler misfiring. Now the splenic artery can be easily
divided.
The last step of the operation is splenic mobilization.
Additional retroperitoneal attachments to the pancreas
are divided. Adhesions to the lateral abdominal wall
and the p hrenicosplenic ligament are divided. Be careful to avoid a colonic injury at this step. With ventral
traction on the spleen, the inferior portion of the
phrenicosplenic ligament is divided. At this step , the
specimen is completely mobile and can be removed
from the abdomen.
IMPORTANT POINTS
• Ensure you place the ports high enough and far enough
to the left.
• Take time for hemostasis in order to achieve excellent
working conditions.
• Avoid bleeding from the splenic vasculature and use
only gentle retraction on the spleen to avoid capsular
tears.
VIDEO 25
Spleen-preserving pancreatectomy
of the body and tail
Video duration 12 minutes 56 seconds
In this video, we will show you a spleen-preserving
pancreatectomy of the body and tail.
OUTLINE
The video is divided into the following parts:
• Port positioning
• Pancreatic exposure
• Pancreatic mobilization
• Controlling the hilar vessels
• Splenic artery division
• Division of the pancreas
• Splenic vein division
• Important points.
Figure v25.1 demonstrates the port positioning; the
two 12 mm ports accommodate the camera and ultrasound. The port positioning might have to be modified
depending on the location of the lesion in the pancreas.
In this first step, we expose the body and tail of the pancreas. In order to do this, we open up the lesser sac below the
gastroepiploic arcade. Ventral traction on the stomach
facilitates this process. As we continue our dissection distally, we should be careful not to injure the splenic flexure.
The next step will be pancreatic mobilization. We begin
our dissection at the inferior border of the pancreas. At
this step, we are careful not to go through the colonic
mesentery. We continue our dissection very close to the
inferior border of the pancreas. During this dissection,
Figure v25.1 The figure demonstrates the port positioning. The two 12 mm ports accommodate the camera and ultrasound. The port
positioning might have to be modified depending on the location of the lesion in the pancreas.
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
457
458 Video 25
Figure v25.2 In this image, the splenic artery stump, splenic vein stump, adrenal vein, renal vein, IMV, and SMV can be seen.
the splenic vein comes into view. Be careful not to cause
injury to the duodenum at this step. We follow the splenic
vein towards the tail of the pancreas. As we follow the
Gerota’s fascia, the anterior kidney comes into view. Here
we complete the division of the lienocolic ligament. At
this step of the operation, the inferior and distal part of the
pancreas is completely mobile.
We now continue our dissection more proximally
towards the body of the pancreas. Here you can see the
portal venous confluence coming into view. Using ultrasound, we confirm the location of the lesion within the
pancreas and its location relative to the splenic vein and
artery. On this ultrasound image, you can see the lesion
and the splenic vein at 5 o’clock in relationship to the
lesion. We will now continue our dissection of the retroperitoneum, staying ventral to the renal vessels. Here you
can see the left renal vein and left kidney coming into
view. At this step, we need to be careful not to injure the
left adrenal gland or its vessels. Here you can see the left
adrenal vein draining into the left renal vein. In contrast
to the original description of radical anterior modular
pancreatosplenectomy, we do not resect the left adrenal
gland with the retroperitoneum. At this step, the aorta
comes into view. We proceed to sampling the left celiac
plexus. The celiac trunk is just a little bit more superior
and injury should be avoided. Here, all the retroperitoneal
tissue lateral to the adrenal gland is resected.
We now focus our attention on mobilizing the superior
and the distal part of the pancreas. For this, we continue to
open up the gastrosplenic ligament and divide one or two
short gastric vessels. As we are planning on dividing
splenic vessels later, more short gastrics should not be
taken. This avoids left-sided portal venous hypertension.
As we are dissecting the superior aspect of the pancreatic
tail, we need to be careful not to injure the splenic vessels.
Here the splenic artery and splenic vein can be seen. With
superior traction on the specimen, the inferior aspect of
the pancreatic tail is dissected out. Here we are dividing
the inferior aspect of the splenorenal ligament. We are
now ready to divide the hilar vessels. We are planning on
preserving the spleen with the Warhsaw technique. This
means the spleen will be perfused via the short gastrics,
while the splenic vessels are taken. Here the splenic artery
is dissected out and divided. We will now dissect out, clip,
and divide the splenic artery proximal to the lesion. For
this, we need to completely expose the dorsal side of the
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