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The patient is now placed in 10degrees of head down tilt. The omentum and transverse colon are retracted or pushed toward the left upper quadrant. This allows examination of the ligament of Treitz.

A-1

A-2

The patient is now placed supine. The left lateral lobe of the liver is elevated with a 5-mm retractor placed through the left upper port. The gastrohepatic omentum is grasped, elevated and incised. Care must be taken to identify and preserve an aberrant left hepatic artery if present (A-1).

With the lesser sac opened, suspicious nodes along the left gastric or hepatic arteries can be biopsied if indicated. The neck and body of the pancreas can be examined (A-2).

A-1

The laparoscopic ultrasound probe is inserted through the right lateral port. The examination starts with scanning the left lateral lobe of the liver, examining segments I, II, and

IIIin turn. Examination of the right lobe follows (A-1).

The hepatoduodenal ligament is examined with identification of the common hepatic

duct, common bile duct, portal vein, and hepatic arteries (A-2). Visualization of these structures is aided through the use of color flow Doppler. The pancreas is then examined by slowly rotating the head of the transducer. The relationship of the tumor to the pancreatic duct and surrounding peri-pancreatic vessels (portal vein, superior mesenteric vein, superior mesenteric artery) can be determined.

A-1

Postoperative Tests

■This should be an outpatient procedure.

■Laboratory investigation may be unnecessary.

Local Postoperative Considerations

■Monitor for usual problems after laparoscopy – shoulder pain, and infection/hernia at trocar site(s).

■Severe pain or fever should not occur and if present requires an aggressive evaluation for inadvertent injury to an abdominal viscus during the laparoscopic procedure.

Tricks of the Senior Surgeon

■Be patient and move slowly. Metastases are often small and may be missed with a cursory examination.

■Maintain hemostasis; blood absorbs light and obscures the anatomy.

■A single port examination is inadequate. Multiple ports are required for the appropriate exposure to be obtained.

■Mobilization of the duodenum is not required.

■Place the 10-mm port as lateral as possible in the right upper quadrant. This will allow the ultrasound probe to be placed directly at right angles over the hepatoduodenal ligament, making identification of the bile duct/vessels easier.

Distal Pancreatectomy

Richard H. Bell Jr, Erwin W. Denham (Distal Open Pancreatectomy with Splenectomy),

Ronald A. Hinder (Laparoscopic Distal Pancreatectomy)

Introduction

Although distal pancreatectomies for diffuse chronic pancreatitis have gone out of favor, there are still selected situations when a localized, anatomic distal pancreatectomy is indicated. The following two procedures describe open and laparoscopic techniques – each of which may have selected indications/contraindications.

Indications and Contraindications

of the narcotic).

– DVT prophylaxis with sequential compression devices and/or subcutaneous heparin (check with anesthesia regarding policy on heparin in patients with postoperative epidural analgesia).

– Prophylactic intravenous antibiotics are given 30min prior to incision.

of the pancreas

The middle colic vein is followed downward to localize the superior mesenteric vein. The superior mesenteric vein should be freed below the edge of the pancreas and followed beneath the neck of the pancreas; this maneuver ensures easy division of the

neck of the gland later.

The peritoneum along the inferior border of the pancreas is incised; the body/tail of the pancreas is elevated by gentle sharp dissection behind the gland.

The spleen and distal pancreas are mobilized to the patient’s right side; it is important to stay between the kidney and tail of pancreas, leaving Gerota’s fascia undisturbed posteriorly.

After initial mobilization, the hand enters the retropancreatic space created in Step3. Retroperitoneal attachments along the upper border of the pancreas are ligated and

divided until the origin of the splenic artery is reached; location of this artery is ascertained by palpation.

The spleen and pancreas are held upward and to the patient’s right, so the surgeon can visualize the posterior aspect of the gland and identify the splenic vein as it courses along the back of the gland.