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Chapter 7 / Technical Aspects of Pancreatic Surgery 81
further resection until clear margins are achieved. Specimens should be
oriented for the pathologist. e SMA margin must be identied and inked
for the pathologist, as it cannot be accurately assessed in a retrospective
fashion.
Pancreatic, Biliary, and Gastrointestinal Reconstruction
Reconstruction after pancreaticoduodenectomy begins with the pancreatic
anastomosis.
1. e pancreatic remnant is mobilized from the retroperitoneum and
distal splenic vein for a distance of 2 to 2.5cm to allow accurate suture
placement for the pancreaticojejunal anastomosis. e transected jeju-
num is brought retrocolic through a generous incision in the transverse
mesocolon to the left (rather than the right) of the middle colic vessels.
is minimizes tension on the anastomosis and provides a more direct
route for the small bowel mesentery to approximate the pancreatic rem-
nant than is aorded using a right-sided mesenteric window. A two-layer,
end-to-side, duct-to-mucosa pancreaticojejunostomy is performed.
FIGURE 7.3 Illustration demonstrating sharp dissection of the SMA margin, the most criti-
cal component of step 6. Medial retraction of the SMV–PV conuence facilitates dissection
of the soft tissues adjacent to the lateral wall of the proximal SMA. The IPDA (or arteries)
is identied at its origin from the SMA, ligated, and divided.
Section I / Pancreas82
Occasionally, we use a one-layer anastomosis if the pancreas is small, is
rm, and contains a dilated duct. Additionally, a small silastic stent may
be used if the pancreatic duct is small. If the duct is too small to allow
passage of the stent, an invaginating technique dunking the pancreatic
remnant into the jejunal limb may rarely be required. e anastomosis
between the pancreatic duct and the small bowel mucosa is completed
with 5-0 monolament absorbable sutures. Each stitch incorporates
a generous bite of the pancreatic duct and a full-thickness bite of the
jejunum. e posterior knots are tied on the inside and the lateral and
anterior knots on the outside. When a stent is used, this is placed into
the pancreatic duct and small bowel for a distance of approximately 2 to
3cm prior to tying the anterior sutures.
2. A single-layer biliary anastomosis is performed using interrupted 4-0 or
5-0 absorbable monolament sutures at a distance from the pancreati-
cojejunal anastomosis chosen to eliminate any tension. An interrupted
technique is utilized to avoid purse stringing of the anastomosis. A stent
is rarely ever used, even when the bile duct is of normal caliber.
3. An antecolic, end-to-side gastrojejunostomy is constructed in two layers.
A posterior row of 3-0 silk sutures is followed by a full-thickness inner
layer of running absorbable monolament sutures; an anterior row of silk
sutures completes the anastomosis. e distance between the biliary and
gastric anastomoses should be at least 45 to 50cm, allowing the jejunum
to assume its antecolic position for the gastrojejunostomy without ten-
sion and also minimizing the risk of reux cholangitis. A 10-Fr feeding
jejunostomy tube may be placed approximately 30cm distal to the gas-
trojejunostomy and used for feeding in the postoperative period.
Prior to closure, the abdomen is carefully irrigated with water, and the
small bowel is run to ensure proper alignment. e use of drains remains
controversial although many surgeons still drain both the hepaticojejunos-
tomy and the pancreaticojejunostomy. In patients undergoing neoadjuvant
therapy that includes radiation, the authors prefer to only drain the right
upper quadrant with a single silastic drain to capture lymphatic uid in the
rst 2 to 3 days after surgery. e falciform ligament, which was mobilized
at the start of the laparotomy, is now placed between the hepatic artery and
the aerent jejunal limb to cover the GDA stump. is maneuver minimizes
the risk of pseudoaneurysm formation at this site in the event of a pancreatic
anastomotic leak. A tongue of omentum may be used for the same purpose.
Pylorus Preservation
Pylorus preservation may be considered in patients with small periampullary
neoplasms but should not be performed in patients with large pancreatic
head tumors or in the setting of grossly positive pyloric or peripyloric lymph
nodes. e essential dierences in technique (compared to standard pancre-
aticoduodenectomy) involve steps 3 and 4 described above. e duodenum is
divided approximately 2 to 3cm beyond the pylorus with a linear GIA stapler
and the gastroepiploic arcade divided at that level. e staple line is removed
prior to creation of the duodenojejunostomy leaving approximately 2cm of
the duodenum distal to the pylorus; we usually send the duodenal margin for
frozen section evaluation to exclude an unsuspected positive margin from
appearing as a surprise on the nal pathology report. e pylorus is gently
dilated with a Kelly clamp or index nger (or both). e anastomosis is then
performed in an end-to-side fashion using a single- (author’s preference) or
double-layer technique with monolam ent absorbable sutures. Placement of
a feeding jejunostomy in the setting of pylorus preservation may be consid-
ered due to the potentially increased incidence of delayed gastric emptying.
Chapter 7 / Technical Aspects of Pancreatic Surgery 83
Venous Resection
Venous resection should only be performed in carefully selected patients
with tumor adherence to the SMV or SMV–PV conuence without evidence
of tumor encasement (>180 degrees) of the SMA or celiac axis. Steps 1
through 5 are completed as described above. Tumor adherence to the lateral
wall of the SMV–PV conuence prevents dissection of the SMV and PV o the
pancreatic head and uncinate process, thereby inhibiting medial retraction
of the SMV–PV conuence (and lateral retraction of the specimen). Division
of the splenic vein is performed when tumor abutment (on the lateral wall
opposite the splenic vein) or encasement is at the level of the splenic vein
junction. Division of the splenic vein allows complete exposure of the SMA
medial to the SMV and allows the retroperitoneal dissection to be completed
by sharp division of the soft tissues anterior to the aorta and to the right
of the exposed SMA. e specimen is then attached only by the SMV–PV
conuence. Vascular clamps are placed 2 to 3cm proximal and distal to
the involved venous segment, and the vein is transected, allowing tumor
removal (Fig. 7.4). A 2- to 3-cm segment of SMV–PV conuence can safely be
resected without the need for interposition grafting as increased SMV and
PV length is provided when the splenic vein is divided. Venous resection is
always performed with inow occlusion of the SMA and systemic heparin-
ization. It is important to mark the anterior surface of the SMV and PV prior
to venous resection to prevent an inadvertent anastomotic twist.
Upper gastrointestinal hemorrhage due to sinistral portal hyperten-
sion following splenic vein ligation can occur if the IMV enters the SMV
rather than the splenic vein—in which case there is inadequate venous out-
ow from the stomach and spleen due to splenic vein ligation. In contrast,
when the IMV enters the splenic vein, the IMV provides a route for collat-
eral venous ow from the ligated splenic vein in a retrograde fashion to the
systemic venous circulation. When the splenic vein must be divided and the
IMV enters the SMV, we create a distal splenorenal shunt to allow decom-
pression of the stomach and spleen into the systemic venous circulation.
Ideally, the splenic vein–PV junction should be preserved. However,
this is only possible when tumor invasion of the SMV or PV does not involve
the splenic venous conuence. Splenic vein preservation signicantly limits
mobilization of the PV and prevents primary anastomosis after segmental
SMV resection unless the resection is limited to less than 2cm. erefore,
most patients who need SMV resection with splenic vein preservation require
an interposition graft. Our preferred conduit is the internal jugular vein
(IJV). Venous resection and reconstruction can be performed either before
the specimen has been separated from the right lateral wall of the SMA or
after complete mesenteric dissection. We rst described the latter “artery-
rst” approach in the manuscript by Leach et al., and this is our preferred
approach. Postoperatively, patients with vascular resection/ reconstruction
are prescribed aspirin and subcutaneous heparin starting in the recovery
room assuming coagulation parameters are acceptable (INR < 1.5).
DISTAL PANCREATECTOMY
is operation can be performed laparoscopically, open, or with a hybrid
technique. A distal pancreatectomy can be completed from medial to lat-
eral (transect pancreas at PV–SMV–splenic vein conuence and dissection
completed from the patient’s right to left) or from lateral to medial (mobi-
lizing the distal pancreas and spleen o of the retroperitoneal attachments
and vasculature rst, with pancreatic transection and dissection of the root
of small bowel mesentery as the nal step). Regardless of which technique
is used, we always ligate the splenic artery before dividing the splenic vein.
Section I / Pancreas84
Frequently, when dealing with a large tumor in the proximal body of the
pancreas, we may divide the pancreas before dividing the splenic artery—
and sometimes even before ligating the splenic artery. By dividing the
pancreas, exposure to the celiac artery and proximal splenic artery is sig-
nicantly improved.
Lateral to Medial Approach
e greater omentum is separated from the transverse colon, and the splenic
exure is mobilized caudally. e peritoneum lateral to the spleen is then
incised in a cephalad direction up to the gastroesophageal junction (GEJ)
and the spleen and distal pancreas mobilized out of the left upper quad-
rant, as the spleen and pancreas are dissected free of their
retroperitoneal
FIGURE 7.4 Illustration demonstrating resection of the SMV–PV conuence with splenic
vein preservation. Vascular clamps have been placed on the SMV below and the PV above
the involved venous segment, and a baby bulldog is utilized to occlude the splenic vein.
ARummel tourniquet is placed on the SMA in preparation for excision of the SMV en bloc
with the specimen. The intact splenic vein tethers the PV, making a primary anastomosis
impossible in most cases. As such, the reconstruction will require a segmental vein graft
(we prefer a conduit of IJV that we prepare prior to the application of vascular clamps). In
order to reduce the possibility of performing the anastomosis with a twist in the conduit,
the IJV is marked while still in situ to ensure correct orientation.
Chapter 7 / Technical Aspects of Pancreatic Surgery 85
attachments to the kidney and adrenal gland. e short gastric vessels are
ligated and divided, allowing medial and cephalad retraction of the stom-
ach. Before division of the splenic vein, the splenic artery should be ligated,
even if it is not divided. e IMV may be divided if it enters the splenic vein,
or alternatively, the splenic vein can be divided just proximal (to the left) of
the IMV–splenic vein junction. e mesenteric root is divided from the left
lateral border of the SMV to the left lateral border of the aorta, staying ante-
rior to the SMA. Exposure of the SMA inferior to the neck of the pancreas
allows the dissection to proceed directly anterior to this vessel under direct
vision. If the splenic artery was not ligated earlier in the operation (author’s
preference), this is now completed. Again, the artery is divided before
ligation and division of the splenic vein. e pancreas is then transected
(before ligation of the splenic artery if increased exposure is needed), a step
that can be performed in a variety of manners. e most common tech-
niques include stapler transection or division with electrocautery followed
by suture ligation/closure. Regardless of technique, the most important
step is identication and suture ligation of the pancreatic duct (we prefer
5-0 monolament suture). e staple line may also be reinforced with 5-0
monolament sutures on pledgets. When the pancreas is divided further
medially than the level of the pancreatic neck, the point of pancreatic tran-
section is virtually always too thick for a stapling device.
After delivery of the specimen, we routinely bring the mobilized falci-
form ligament through the lesser omentum to cover the stump of the splenic
artery and the pancreatic transection site—analogous to the use of the fal-
ciform ligament following pancreaticoduodenectomy discussed previously.
Medial to Lateral Approach
After entering the lesser sac through the gastrocolic ligament, the inferior
border of the pancreas is identied, and the peritoneum is incised. e dis-
section is carried medially until the SMV is identied as it passes beneath
the pancreas. A tunnel along the anterior surface of the SMV–PV conuence
can then be created, and the superior border of the pancreas is freed from
the hepatic artery and PV. During laparoscopy, passing a sling underneath
the pancreas and elevating the gland can aid in the further exposure of the
pancreatic body and tail as the dissection proceeds laterally. Once sucient
space has been created for the passage of a stapling device, the pancreas is
transected. It is then reected to the left, facilitating its complete dissection
from its retroperitoneal attachments.
Splenic Preservation
Distal pancreatectomy may also be performed with preservation of the
spleen. Two techniques are available in this context, namely, preservation
of the spleen via retrograde ow through the short gastric vessels (Warshaw
technique) or by preserving the entire length of the splenic artery and vein.
e Warshaw technique involves entering the lesser sac through the gas-
trocolic omentum but halting the dissection prior to encountering the left
gastroepiploic and short gastric vessels. e avascular plane behind the
pancreas is then mobilized starting at the inferior border of the gland near
its tail, anterior to the splenic vessels. Dissection continues until the supe-
rior border is freed from the retroperitoneum. e tail of the pancreas can
then be gently reected to the patient’s right, away from the splenic hilum,
exposing the vessels for stapler xation. After division, the dissection of the
pancreas (and splenic vessels) proceeds to the right as far as is required
to clear the indicated pathology. e pancreatic substance is then divided
with a stapler (including the splenic vessels en masse), allowing delivery of
the specimen.
Section I / Pancreas86
Preservation of the splenic vessels is only applicable for certain tumor
histologies (i.e., mucinous cystic neoplasms that lack malignant character-
istics or symptomatic serous cystadenomas), as dissection in this plane vio-
lates oncologic principles of en bloc resection of regional lymphatic tissue.
is procedure involves meticulous dissection of the multiple small vessels
away from the pancreatic parenchyma that arise from the splenic artery or
drain to the splenic vein. is is usually performed from medial to lateral to
avoid the labyrinth of tiny vessels often present at the splenic hilum.
Laparoscopic Approach
Any of the approaches described above for distal pancreatectomy may be
performed laparoscopically. A Hasson cannula placed supraumbilically
allows visualization with a 30-degree laparoscope. A 5-mm working port
is placed in the right upper quadrant approximately in the mid-clavicular
line, and a second port of 12mm (to allow passage of an Endo GIA stapler)
is placed to the left of the midline at approximately the same level. Another
5-mm port for retraction is often placed further laterally on the left side
for the surgical assistant. An umbilical tape or vessel loop passed under-
neath the pancreas aides in retraction and dissection of the specimen. e
resection is then completed as described above with pancreatic transection
completed using a stapler with seam guard (Gore).
Hybrid Approach
A laparoscopic-assisted hybrid technique combines the benets of mini-
mally invasive surgery with the security of precise and direct ligation of the
pancreatic duct and splenic artery. e patient is positioned in the right lat-
eral decubitus position (left side up). A Hasson cannula is placed at the umbi-
licus, pneumoperitoneum is achieved , and a standard four-port laparoscopy
is undertaken. e splenic exure of the colon is mobilized and the greater
omentum dissected from the distal transverse colon. e peritoneum lateral
to the spleen is incised proceeding cephalad until reaching the GEJ from the
patient’s left side. e dissection then continues lateral to medial mobiliz-
ing the spleen and tail of the pancreas toward the midline. e left crus of
the diaphragm marks the medial most extent of the laparoscopic dissec-
tion. e short gastric arteries are divided. e patient is then returned to
the supine position and a limited upper midline incision created, and the
operation proceeds as for the medial to lateral approach. e splenic artery
is identied at the superior border of the pancreas and ligated (either before
or after pancreatic transection). e splenic vein–SMV junction is identi-
ed at the inferior border of the pancreatic body and, after dissection for a
short distance, divided with an Endo GIA stapling device either ush with
the SMV–PV conuence or just proximal to the IMV–splenic vein junction.
Mobilization of the inferior aspect of the pancreas is now completed and the
specimen freed from the retroperitoneum. After selection of an appropriate
point of transection, the pancreas is divided as described above.
TOTAL PANCREATECTOMY
Total pancreatectomy is accomplished by following steps 1 and 3 of our six-
step pancreaticoduodenectomy. After identication of the infrapancreatic
SMV and completion of the portal dissection, the proximal splenic artery
is exposed and ligated. Resection as described for distal pancreatectomy is
then completed. While dissection of the SMA occurs from both the patient’s
left and right side, it is important, when possible, to leave some of the auto-
nomic nerves on the adventitia of the SMA to preserve small bowel inner-
vation and prevent rapid gastrointestinal transit. Division of the splenic
Chapter 7 / Technical Aspects of Pancreatic Surgery 87
vein is often delayed until the completion of steps 4 (gastric or duodenal
transection) and 5 (ligament of Treitz, proximal jejunum, and duodenum).
en, in preparation for completion of the retroperitoneal dissection, the
spleen and distal pancreas are again reected medially, exposing the ori-
gin of the splenic vein–SMV junction; the splenic vein is then ligated and
divided. Step 6 of pancreaticoduodenectomy is then completed in the stan-
dard manner and the specimen delivered intact. With the entire pancreas
removed, reconstruction is a simpler procedure, involving only biliary and
gastric anastomoses.
CENTRAL PANCREATECTOMY
In rare patients with relatively small tumors of the pancreatic neck of favor-
able histology (i.e., benign-appearing mucinous cystic neoplasms, branch
duct IPMNs, solid pseudopapillary neoplasms), segmental resection of the
pancreatic neck and proximal body with preservation of the splenic artery
and vein may be utilized to preserve islet cell function. e proximal pan-
creas and pancreatic duct are oversewn as described above for distal pan-
createctomy. Reconstruction includes Roux-en-Y pancreaticojejunostomy
to the remaining segment of the distal pancreas. e small bowel is divided
35 to 45 cm distal to the ligament of Treitz. e distal limb is brought
through the transverse colon mesentery (retrocolic) and sewn to the dis-
tal pancreas as a two-layer, end-to-side, duct-to-mucosa pancreaticoje-
junostomy as described for pancreaticoduodenectomy. Additionally, the
oversewn distal end of the pancreatic head is reinforced by buttressing the
serosa of Roux limb, distal to the pancreaticojejunostomy, to the pancreatic
transection site. e proximal pancreaticobiliary limb is connected down-
stream to restore intestinal continuity as a side-to-side jejunojejunostomy.
SUMMARY
A preoperative evaluation that includes detailed patient assessment for
comorbid conditions, functional status, and tumor marker trends and
assessment of resectability by objective CT criteria minimizes rates of non-
therapeutic laparotomy in patients with pancreatic cancer. e operative
techniques detailed in this chapter are utilized to minimize intraopera-
tive and perioperative complications. Pancreaticoduodenectomy and total
pancreatectomy alone or in combination with vascular resection are tech-
nically demanding and should not be undertaken without thorough under-
standing of the nuances of upper abdominal anatomy. Best outcomes are
obtained in high-volume centers by multidisciplinary teams that include
experienced pancreatic surgeons, anesthesiologists, and nurses attuned
to the intricacies of operative technique. Utilization of postoperative care
pathways promotes early recognition of complications. As improved sys-
temic therapies increase survival duration for patients with localized pan-
creatic cancer, the management of local-regional disease with surgery will
become even more complex and the role for extended resection to include
vascular resection and reconstruction considered with increased frequency.
Patient selection and detailed preoperative planning are simply invaluable
to insure the desired results.
Suggested Readings
Balachandran A, Darden DL, et al. Arterial variants in pancreatic adenocarcinoma.
Abdom Imaging 2008;33(2):214–221.
Christians KK, Lal A, et al. Portal vein resection. Surg Clin North Am 2010;90(2):309–322.
Christians KK, Tsai S, Tolat PP, et al. Critical steps for pancreaticoduodenectomy in
the setting of pancreatic adenocarcinoma. J Surg Oncol 2013;107(1):33–38.
Section I / Pancreas88
Evans DB, Farnell MB, et al. Surgical treatment of resectable and borderline
resectable pancreas cancer: expert consensus statement. Ann Surg Oncol
2009;16(7):1736–1744.
Katz MH, Hwang R, et al. Tumor-node-metastasis staging of pancreatic adenocarci-
noma. CA Cancer J Clin 2008;58(2):111–125.
Katz MH, Fleming JB, et al. Anatomy of the superior mesenteric vein with special ref-
erence to the surgical management of rst-order branch involvement at pancre-
aticoduodenectomy. Ann Surg 2008;248(6):1098–1102.
Katz MH, Pisters PW, et al. Borderline resectable pancreatic cancer: the importance
of this emerging stage of disease. J Am Coll Surg 2008;206(5):833–846; discussion
846–838.
Katz MH, Varadhachary GR, et al. Serum CA 19-9 as a marker of resectability and
survival in patients with potentially resectable pancreatic cancer treated with
neoadjuvant chemoradiation. Ann Surg Oncol 2010;17(7):1794–1801.
Leach SD, Davidson BS, Ames FC, et al. Alternative method for exposure of the ret-
roperitoneal mesenteric vasculature during total pancreatectomy. J Surg Oncol
1996;61(2):163–165.
89
INTRODUCTION
Minimally invasive pancreatectomy is rapidly gaining favor in centers
s
pecializing in pancreatic surgery. A growing body of evidence suggests sev-
eral outcome advantages over open approaches; these ndings continue to
engender enthusiasm for laparoscopy. Laparoscopic distal pancreatectomy
(LDP) is the most widely adopted procedure, as it requires basic laparo-
scopic skills of dissection and no reconstruction. Procedures with more
complex resection or reconstruction have seen more gradual acceptance.
e predominant challenge preventing the wide application of minimally
invasive surgery (MIS) approaches in pancreatic surgery continues to be
the lack of adequate surgeon training. Few centers have sucient experi-
ence with more advanced procedures such as pancreaticoduodenectomy
and total pancreatectomy; thus, large comparative trials of laparoscopy
versus open approach are lacking for these procedures. However, the
increasing evidence in support of MIS approaches for all pancreatic opera-
tions continues to emerge as larger series are reported, and more centers
develop minimally invasive programs.
INDICATIONS AND CONTRAINDICATIONS
e indications for MIS pancreatectomy mirror those for open approaches
and include all benign and malignant conditions requiring pancreatic
resection. Expanding the indications for pancreatic resection solely
based on the ability to perform it with minimally invasive approaches is
not recommended. Absolute contraindications for MIS pancreatectomy
are also similar to open approaches and include patients with prohibitive
comorbidities or poor functional status. e majority of reported contra-
indications are therefore relative, and experience of the surgeon is the key
determinate (Table 8.1).
TECHNIQUE
Laparoscopic Distal Pancreatectomy
Setup, Access, and Initial Exposure
e patient is positioned supine with 15 degrees of reverse Trendelenburg.
Whereas some advocate a right lateral decubitus position or place a bump
under the left ank, we prefer a supine position that facilitates a right-to-
left dissection. A total of four trocars are placed as depicted in Figure 8.1.
A periumbilical incision is made, the trocar placed under direct vision, and
a pneumoperitoneum established. e remaining three trocars are placed
under laparoscopic visualization. e gastrocolic ligament is divided
peripheral to the epiploic vessels using the harmonic scalpel, and the lesser
sac is entered. e short gastric vessels are preserved, and the splenic ex-
ure of the colon is mobilized inferiorly. Visual inspection of the
a
nterior
Minimally Invasive
Pancreatic Surgery
Michael L. Kendrick
8
Section I / Pancreas90
aspect of the pancreas is performed, and the lesion is identied either
through palpation or through the use of laparoscopic ultrasonography. e
stomach is sutured anteriorly to the retrocostal peritoneum to facilitate
exposure.
Pancreatic Mobilization
e transverse mesocolon is dissected o the inferior border of the pan-
creas, and the pancreas is dissected out of the retroperitoneum in the antic-
ipated area of transection. Early focus of dissection at the site of anticipated
transection and splenic vessels allows excellent access and exposure for a
safe dissection. In the event of bleeding during splenic vessel preservation,
the vessels can be quickly ligated, reducing blood loss. e splenic vein is
dissected o the posterior aspect of the pancreas. e splenic artery is iden-
tied and dissected either through an anterior approach at the superior
border of the pancreas or via a posterior-inferior approach after elevating
12 mm
12 mm
5 mm5 mm
5 mm
FIGURE 8.1 Trocar positioning for LDP.
Absolute Relative
Prohibitive medical comorbidities Locally advanced malignancy
Poor functional status Proximity to major vasculature
Severe obesity
Prior major abdominal operations
Contraindications for Laparoscopic Pancreatic Resection
TABLE
8.1