Laparoscopic spleen-preserving distal pancreatectomy with splenic vessels preservation for pNET in a young patient

Abstract

Introduction: The frequency of incidentally discovered nonfunctioning pancreatic neuroendocrine tumors (pNET) is increasing due of the modern imaging techniques. Mostly discovered in patients with a small size, surgical treatment by a minimally invasive (MI) approach is worldwide accepted reducing perioperative morbidity. Spleen preserving distal pancreatectomy (SPDP) with splenic preservation, according to Kimura procedure decreases the risk of post-splenectomy sepsis, perigastric varices and splenic infarctions. Method: A 28 year old man (ASA I) referred because a highly suspect non functioning pNET (Ø 3.6 cm). This video highlights the key steps required for performing a SPDP. The video also focused how the pre-operative planning by CT scan, magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) is mandatory. It shows clearly patient and trocar positioning, as well as operative tactics. The dissection strategy along the splenic vessels using novel energy devises to control direct splenic venous branches into the pancreas as well as the transection of the pancreatic tissue by a stapler is showed. Results: Estimated intraoperative blood loss was 100 ml. Operative time: 210 minutes. No major morbidity (Clavien-Dindo ≥III) occured. Discharged on 6th postoperative day. Final pathology: cystic pNET pT1N0, G1, mitotic count/50 HPF < 2, Ki67< 3%. Conclusion: Improvements in imaging and MI approach have enabled surgeons to preserve the major splenic vessels reducing the risk of splenic infarcts, abscesses and re-operations, and minimize the risk of left-sided portal hypertension.