Spleen-Preserving Retrograde Distal Pancreatectomy for Malignant Insulinoma

Abstract

Introduction: Distal pancreatectomy is performed primarily for malignant and premalignant diseases of the pancreas. Neuroendocrine tumors within the body and tail of the pancreas can be resected or enucleated depending upon the size and relationship of the tumor with the pancreatic duct.1,2 This video presents the technical details of a spleen-preserving laparoscopic distal pancreatectomy using a retrograde dissection (Kimura technique) for malignant pancreatic neuroendocrine tumor treatment. Operative Technique: A 47-year-old woman with medical history of hypertension and hypothyroidism comes to endocrinology presenting 3 months history of lumbar pain and 6 months history of neuroglycopenic symptoms. The work-up demonstrated hyperinsulinemic hypoglycemia produced by a 2.7 cm insulin-producing tumor of the body of the pancreas. A 1 cm cyst of the tail of the pancreas, a 5 mm sellar mass, and an adenoma of one parathyroid gland with elevated parathyroid hormone and calcium are seen as well, indicatory of a multiple endocrine neoplasia type 1.3–5 A five-trocar laparoscopic distal pancreatectomy was performed with one surgeon between the legs and two more surgeons on each side of the patient. The liver was retracted for better visibility and started with the section of splenocolic ligament to release the splenic angle of the colon and move it to the midline. Short gastric vessels of the gastrosplenic ligament are sectioned to address the posterior face of the stomach, through the lesser sac. The stomach was retracted cephalad, allowing for a better exposure of the pancreas. The insulinoma became visible on the anteroinferior margin and was well delimited with intraoperative manipulation. Pancreas is accessed through the retroperitoneum. Splenic vessels are dissected. The splenic artery and vein are identified and referred to be able to dissect along the upper edge of the pancreas, in a retrograde approach to preserve vascular structures. Ligaclips are placed on the branches of the splenic vessels. Transection is performed at the level of the junction of the head and neck of the pancreas, leaving enough space between the mass using a linear stapler capable of 60 mm long cuts and with 3.5 mm open staple height. The integrity of the piece is verified and is extracted with a laparoscopic specimen retrieval bag. In the case of this patient with previous surgery, an existing Pfannenstiel-type scar is used to avoid extension of the laparoscopic scars. Blake-type drain is placed in situ. Results: The postoperative course was uneventful. No postoperative diabetes was observed and no treatment for hypoglycemia was necessary. Early oral feeding postoperatively was well tolerated. The patient was discharged home 3 days after surgery with a placed drain. Histology analysis confirmed the full resection of the intrapancreatic neuroendocrine tumor. No competing financial interests exist. Runtime of video: 9 mins 24 secs