Supine position is often preferred for tumors closer to the portal-superior mesenteric vein access.
A thorough diagnostic laparoscopy may be performed to exclude extrapancreatic disease or factors that may influence surgical approach, when indicated. The operation then proceeds either with minimally invasive techniques or via open midline or left subcostal laparotomy incision, depending on the comfort of the operating surgeon.
The lesser sac is entered through division of the gastrocolic ligament, ensuring adequate control of the short gastric vessels with clips, electrocautery, or ultrasonic scalpel. If the spleen is to be removed with the distal pancreas specimen, the short gastric vessels are similarly divided to allow splenic mobilization. The stomach is retracted anterosuperiorly toward the abdominal wall. The splenocolic ligament is similarly divided to allow caudal retraction of the transverse colon and splenic flexure.
The distal pancreatic body should be entirely visualized at this time. The distal aspect of the gland is then mobilized from the posterior retropancreatic fat using a combination of blunt dissection and bipolar electrocautery or ultrasonic scalpel, either from lateral to medial or medial to lateral.
The splenic vein is directly posterior to the pancreas and comes into view before the artery as the gland is dissected posteriorly. Early preparation of the transection plain is critical if urgent vessel ligation is required in the event of hemorrhage during dissection.
The splenic artery, vein, and pancreas may be ligated/transected in any order as dictated by the flow of the operation and anatomy. The splenic vessels should be ligated with vascular stapler or combination of clips and ties, and the vessel stumps should be kept as short as possible; long vascular stumps increase the risk of thrombosis or rupture. The pancreatic gland itself is transected using a stapler, or energy device, with or without oversewing or use of an omental pedicle flap over the stump.
The distal pancreas (with or without spleen) specimen is then removed. For laparoscopic procedures, this is typically performed via an endoscopic retrieval bag and enlargement of a laparoscopic port site or Pfannensteil-Kerr incision.
The surgical bed is then inspected for adequacy of hemostasis, and the choice of operative drain placement is at the discretion of the operating surgeon.
Educational aid only. Verify every dose, indication, and guideline against current institutional protocol. This is not a substitute for clinical judgment.
