Laparoscopic Distal Pancreatectomy with Splenic Preservation

Abstract

Minimally invasive techniques are now being vastly applied in the pediatric population. Laparoscopic pancreatic resections were initially performed in the 1990s in the adult population. Since then, laparoscopic pancreatic procedures were applied to pancreatic trauma and tumors of the distal pancreas. Increasing success reported to be ~80% for laparoscopic distal pancreatectomy with splenic preservation in the adult population has helped to pave its application in the pediatric population. As such, laparoscopic pancreatic procedures performed in children included resection of tumors as well as in blunt pancreatic injuries. Here we demonstrate in a 5-minute video a laparoscopic distal pancreatectomy with splenic preservation in a child with cysts in the tail of the pancreas found incidentally after a traumatic fall. Our patient is an 11-year-old boy who was evaluated in the emergency department after a 10-foot fall onto a rubber mat while indoor rock climbing. He complained of nonspecific abdominal and low-back pain. The results of physical examination were unremarkable. Computed tomography (CT) of the abdomen and pelvis was performed based on the mechanism. CT findings demonstrated only a focal cluster of nontraumatic cysts in the tail of the pancreas. Two dominant cysts were 6 mm in diameter. The overall area encompassed by cysts was ~1.9×1.1×1.0 cm. He was discharged home with follow-up magnetic resonance imaging of the abdomen at 4 months to reduce radiation exposure. Results at that time showed no change in the size of the cysts. Follow-up ultrasonography of the abdomen performed at 4 and 8 months demonstrated an increase in the size of the cysts. The patient remained asymptomatic. Due to increase in size of the cyst and concerns of the family, laparoscopic distal pancreatic resection with splenic preservation was elected to be performed. The patient was positioned in a modified right lateral decubitus position with a bean bag and kidney rest. A 10-mm versa step port was placed at the umbilicus. Three 5-mm working ports were placed. The gastrocolic ligament was opened with the LigaSure, and the stomach was retracted superiorly. The pancreas was identified. The left renal vein was identified at the inferior border of the pancreas, and the splenic artery and vein at the superior border. The splenic vessels were dissected, mobilizing the tail of the pancreas. The superior mesenteric artery and vein were identified posteriorly. A window was created to the left of these vessels, and a penrose drain was placed around the tail of the pancreas, used for traction. Using the assistance of radiologic imaging with identification of the superior mesenteric vessels, an area was marked with the cautery to the left of the vessels. An endoscopic gastrointestinal anastomosis 2.5-mm stapler was used to divide across the tail of the pancreas. A Jackson Pratt drain was left in the left upper quadrant. A clear liquid diet was initiated on postoperative day 3 (POD3). Regular diet was introduced on POD4, and the drain was removed. He was discharged on POD5. No competing financial interests exist. Runtime of video: 5 mins