Spleen-Preserving Laparoscopic Distal Pancreatectomy for Insulinoma in a Child

Abstract

Introduction: Insulinomas are rare insulin-secreting neoplasms. Ten percent occur in the setting of multiple endocrine neoplasia-type 1 (MEN-1). This video presents the technical details of a spleen-preserving laparoscopic distal pancreatectomy in a child. Nowadays, the adoption of this approach is limited. Our aim is to bring this procedure closer to routine clinical practice. Operative Technique: A 13-year-old girl with neuroglycopenic symptoms for 6 months was referred to our institution for evaluation and management. The work-up demonstrated hyperinsulinemic hypoglycemia, a 3 cm lesion of the tail of the pancreas, a prolactinoma, and adenomas of two parathyroid glands (MEN-1). A four-trocar laparoscopic distal pancreatectomy was performed with the surgeon between the legs. We started with the division of the gastrocolic ligament using a 5 mm tissue-sealing device to enter the lesser sac. The stomach was retracted cephalad, allowing for a better exposure of the pancreatic tail. The peritoneum on the lower pancreatic margin was incised to get access to the retroperitoneal area. Retropancreatic attachments were dissected. With dissection advanced, the pancreas could be lifted up. The insulinoma became visible on the posterior margin and was well delimited with intraoperative palpation. The next step was dissection of the splenic vein on the superior border, embodied by the tail of the pancreas. Approaching small pancreatic vessels originating in the splenic vein is better performed with a hook monopolar electrocautery. We continued freeing toward the body of the pancreas. The peritoneum around the proximal splenic artery was also incised with the hook. If bleeding from the splenic vein is encountered, compression and application of fibrin sealant could provide hemostasis. A bleeding short vessel could be isolated, ligaclipped, oversewn, or coagulated. If bleeding is impossible to control, it is still possible to spare the spleen according to Warshaw's method (the splenic vessels are ligated and spleen becomes dependent on the short gastric vessels). Once the splenic vessels were retracted and the dissection completed, the umbilical 5-mm port was converted to a 12-mm port. The EndoGIA™ linear stapler was introduced and transection of the pancreas was performed using two 30 mm cartridges. The end of the proximal pancreas was over sewn to prevent pancreatic leak. The specimen was extracted in a retrieval bag through the umbilical port. A drain was left in situ. Results: The postoperative course was uneventful. No postoperative diabetes was observed and no treatment for hypoglycemia was necessary. Early oral feeding on postoperative day 2 was well tolerated. The drain was removed and the patient was discharged home in a good condition at postoperative day 5. Histology analysis confirmed the full resection of the intrapancreatic insulinoma but also revealed a second tumor more distally on the pancreatic tail. The patient remains asymptomatic 20 months after surgery. Conclusions: Spleen-preserving laparoscopic distal pancreatectomy is a feasible, effective, and safe procedure. Distal pancreatectomy is preferred to tumorectomy to avoid incomplete resection in cases of multifocal disease. Laparoscopy gives an excellent view of small vessels and has all the advantages of the mini-invasive surgery. Spleen preservation avoids the overwhelming postsplenectomy infection. No competing financial interests exist. Runtime of video: 5 mins 9 secs