Tailored laparoscopic approach for pancreatic tail resection for cancer

Abstract

Laparoscopic resection is becoming the gold standard for distally located lesions of the pancreas. Changing the standard technique from the medial-to-lateral to lateral-to-medial approach can simplify the procedure in case of previous surgery, a known risk factor for conversion. We report the case of laparoscopic pancreatic tail resection with spleen preservation in a 79 y.o. woman affected by an 18 mm hypervascular lesion (Fig.1); the patient underwent to a left nephrectomy, trough a median laparotomy, thirty-three years before, for a clear cell renal carcinoma. The SUV at Ga68-DOTATOC-PET-CT was 14.9 and at F18-FDG-PET-CT was null. Operative technique: four trocar were positioned in L shape manner in the upper left quadrant of the abdomen, with patient in 30° right lateral position. We started lowering the colonic splenic flexure, exposing the tail of the pancreas and the tumor. The lesser sac was opened below the left gastroepiploic vessels. The body-tail were freed from retroperitoneal tissue, in a lateral-to-medial way. Finally, small arterial and venous branches of the splenic vessels were cut between clips. For parenchymal transection we used a 60 mm linear stapler, vascular cartridge; a suture of the stump was required to complete the hemostasis. The specimen was extracted by an endobag through the supraumbilical incision, and a drain was left close to the stump. After an uneventful postoperative course, the patient was discharged in the fourth postoperative day. The pathological report described a metastasis from clear cell renal carcinoma.