Objectives: This video describes our technique of a spleen preserving distal pancreatectomy with cholecystectomy for a solid pseudopapillary neoplasm and gallstones.
Methods: A 53-year-old woman who presented with chronic diarrhea and was found to have a pancreatic tail mass. Preoperative workup included triple phase CT scan and EUS showing 6.53 cm hypodense mass in the tail of the pancreas and 9.5 mm gallstone in the gallbladder.
Results: The operation began by taking down gastrocolic omentum in a stellate fashion and carried the dissection toward the spleen. The short gastric vessels were taken down and the stomach retracted. An intraoperative ultrasound was utilized to identify the location of the tumor mass and the pancreas was dissected along its inferior edge. We took down the splenic flexure of the colon and then began the dissection from the body to the tail along the dorsal attachments from the retroperitoneum. Next the splenic artery and vein were identified and dissected off the pancreatic body and tail. Intraoperative ultrasound was once again utilized to identify the exact location of transection. The pancreas was divided with hook cautery carefully to avoid injuring the splenic artery and vein. Branches off the splenic vein were then divided with very minimal blood loss. The specimen was placed into a laparoscopic catch bag and sent to pathology. At this point, we injected fibrin sealant over the pancreatic stump. The stump was sutured with V-Loc suture in a running fashion back and forth and then both the falciform ligament and omentum flaps were created to buttress this area and was sutured in place. Finally, a 10-French flat JP drain was also placed along the stump.
Conclusion: Operative duration was 4 hours with 50 ml of estimated blood loss. Final pathology confirmed solid pseudopapillary neoplasm which was negative for vascular invasion, high mitotic index, and malignancy. Patient had an uneventful postoperative stay and was discharged on postoperative day 2. This video shows that the robotic approach is safe and efficacious for spleen preserving distal pancreatectomy with cholecystectomy.
