Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Distal and central pancreatectomy
Open central (segmental) pancreatectomy is also described in detail and remains an alternative for benign, indolent, or premalignant lesions in the pancreatic neck, when an enucleation is not feasible and a lymphadenectomy not required. This technique preserves normal pancreatic tissue and function and does not include a splenectomy but requires two planes of transection in the pancreas, leading to potential for increased morbidity. We advocate stapled or sutured closure of the proximal pancreatic stump and reconstruction of the distal pancreas with a dunking, invaginating pancreaticogastrostomy. In selected patients, open central pancreatectomy remains a viable option to preserve pancreatic and splenic function and also avoid an extended pancreatectomy.
Overview
Technical refinements have facilitated a more individualized, disease-directed approach for patients undergoing pancreatectomy. This chapter focuses on some of these surgical techniques, as well as pertinent perioperative considerations for patients subjected to open distal and central pancreatectomy. Specifically, this section details approach, exposure, and technical nuances that facilitate safe and effective surgical resection of lesions located with the neck, body, and tail of the pancreas.
Previous chapters (see Chapter 54, Chapter 55, Chapter 56, Chapter 57, Chapter 58, Chapter 59, Chapter 60, Chapter 61, Chapter 62, Chapter 63 , 65 ) have outlined the definition, classifications, pathogenesis, clinical aspects, diagnostic assessment, and management of acute pancreatitis, chronic pancreatitis, and periampullary and pancreatic tumors, including pancreatic cancer and cystic and endocrine tumors, and will not be discussed here. Preoperative workup and perioperative management (including anticoagulation, antibiotics, preoperative biliary drainage, octreotide analogues, and enhanced recovery pathways) are detailed in Chapters 12 , 13 , 25 , 27 , and 62 . Management of short-term and long-term complications and subsequent surveillance after resection are described in preceding chapters (see Chapters 28 and 62 ).
Resectional techniques
Open distal pancreatectomy
The surgical procedure of choice for a tumor arising in the body or tail of the pancreas is a distal pancreatectomy. This operation entails the removal of that portion of the pancreas extending to the left of the superior mesenteric vein and does not include the duodenum and distal bile duct (see Chapter 2 ). The pancreas is usually divided anterior or to the left of the superior mesenteric vein (SMV)-portal vein (PV) trunk, the exact line of transection depending on the location of the tumor. When feasible and without compromising a margin negative resection, attempts should be made to preserve pancreatic parenchyma and function. Because of advances with minimally invasive surgical techniques, laparoscopic and robotic resections are now commonly performed, even for pancreatic adenocarcinoma (see Chapter 127 ). However, there remains a role for open distal pancreatectomy in certain clinical situations. At our institution, laparotomy for distal pancreatectomy remains the ideal approach for bulky pancreatic adenocarcinomas, those with potential for vascular involvement or multivisceral resection, tumors that are proximal and directly overlying the SMV-PV trunk, or significant varices. A thorough review of cross-sectional imaging provides a preoperative assessment regarding vascular involvement (see Chapters 13 and 17 ); however, intraoperative ultrasound can be used to confirm this suspicion and guide safe resection (see Chapter 24 ). Intraoperative ultrasound allows for identification of landmark anatomy and the direct location and extent of the tumor, and surgeons must be skilled in the application of this technology. It is imperative that surgeons do not compromise the oncologic outcomes and thus require proficiency in both laparoscopic and open left-sided pancreatic resections.
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here