Laparoscopic distal pancreatosplenectomy for a large MCN with left portal hypertension

Abstract

Aims: To demonstrate an operative video of a radical laparoscopic distal pancreatosplenectomy for a huge MCN with left portal hypertension in a young woman. Methods: A 35-year old woman presented with non specific upper abdominal pain, predominantly on the left. All relevant blood investigations were normal. An ultrasound scan detected a large upper left abdominal cyst over 15 cm in diameter. She then had a CT scan which suggested a large distal pancreatic cyst, extending to the spleen measuring 20 × 20 cm with no internal septations. The spleen was enlarged at 17 cm and the splenic vein was compressed. In preparation for surgery, she underwent an EUS to confirm the nature and content of the cyst. The fluid was confirmed to be mucinous and the aspirate was acellular. A laparoscopic distal pancreatosplenectomy was planned. Results: Surgery was undertaken in a supine partial lithotomy position with the surgeon standing between the legs. Four ports (12, 12, 5 and 5 mm) were used. An antegrade radical distal pancreatosplenectomy was performed. Intraoperatively, as expected, the patient was found to have significant left-sided portal hypertension due to compression of the splenic vein by the cyst. The procedure was completed laparoscopically in 95 minutes. The intraoperative blood loss was 350 ml. The patient developed a grade-A pancreatic fistula (as defined by ISGPF) for one day. She was discharged after drain removal on the fifth postoperative day with no other significant postoperative complications. Conclusions: It is feasable and safe to perform a laparoscopic distal pancreatosplenectomy for very large pancreatic cysts in presence of significant portal hypertension with minimal comorbidity and short postoperative stay.