Anthimidis, George

Efthimiadis, Christopher

Fachantidis, Epaminondas

Grigoriou, Marios

Kosmidis, Christopher

Levva, Sofia

Prousalidis, Ioannis

Toulis, Evangelos

English

PubMed

Christopher Kosmidis

Christopher Efthimiadis

George Anthimidis

Marios Grigoriou

Evangelos Toulis

Sofia Levva

Ioannis Prousalidis

Epaminondas Fachantidis

Springer - Publisher Connector

Case report
Open Access
Total laparoscopic distal pancreatectomy for a benign appearing
tumor: a case report
Christopher Kosmidis1*, Christopher Efthimiadis1, George Anthimidis1,
Marios Grigoriou1, Evangelos Toulis3, Sofia Levva1, Ioannis Prousalidis2
and Epaminondas Fachantidis2
Addresses: 1Department of Surgery, Interbalkan European Medical Center, Asklipiou 10, 57 001 Pylaia, Thessaloniki, Greece
2Propedeutic Surgical Department, AHEPA University Hospital, Aristotle’s University of Thessaloniki, St. Kiriakidi 1, 546 36 Thessaloniki, Greece
3Department of Internal Medicine, Interbalkan European Medical Center, Asklipiou 10, 570 01 Pylaia, Thessaloniki, Greece
Email: CK* - dr.ckosmidis@gmail.com; CE - info@efthimiadis.gr; GA - aggs@the.forthnet.gr; MG - drgregoriou@gmail.com;
ET - vanolst@the.forthnet.gr; SL - dr.slevva@gmail.com; IP - sofialevva@yahoo.gr; EF - s_levva@hotmail.com
*Corresponding author
Received: 1 July 2009 Accepted: 17 July 2009 Published: 22 July 2009
Cases Journal 2009, 2:8468 doi: 10.4076/1757-1626-2-8468
This article is available from: http://casesjournal.com/casesjournal/article/view/8468
© 2009 Kosmidis et al.; licensee Cases Network Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Introduction: Therapeutic laparoscopy of the pancreas is still described as experimental surgery by
many surgeons. Many issues remain to be clarified in determining the future of this new method.
Case presentation: The objective of the present study was to present a case of a patient who
underwent totally laparoscopic distal pancreatectomy for a benign appearing tumor in the tail of the
pancreas and to critically discuss the treatment of the pancreatic remnant and the need to perform
splenectomy with or without ligation of the splenic vessels.
Conclusion: Laparoscopic distal pancreatectomy is usually performed en-bloc along with resection
of the spleen, for technical reasons, making the operation short and easy. However, it should only be
performed in centers with expertise in both pancreatic surgery and advanced laparoscopy.
Furthermore, the use of linear stapler to cut the pancreas (4.5-mm staples) seems to prevent fistula
formation and ischemia of the pancreatic stump.
Introduction
Laparoscopic pancreatic surgery is rapidly developing in
relation to technological improvements and increasing
experience among advanced laparoscopic surgeons. As
experience is gained, laparoscopic pancreatic resections
may prove to be associated with real advantages during the
postoperative period. In recent years, laparoscopic distal
pancreatectomy has become an increasingly used techni-
que in the surgical treatment of several pancreatic diseases,
including non-malignant tumors [1-3]. However, case
selection is crucial and should be based on pathology,
clinical features and past medical history. We present
herein a case of a patient who underwent total laparo-
scopic distal pancreatectomy for a benign appearing tumor
in the tail of the pancreas.
Case presentation
A 72-year-old Greek male patient, which had undergone
transurethral resection of prostate 14 years ago, was
followed upwith contrast enhanced computed tomography
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(CECT), which revealed a 4.5 × 4 cm macrocystic lesion in
the tail of the pancreas. The patient complained for vague
postprandial abdominal pain. Physical examinationwasnot
contributory. Ultrasonography (US) revealed a 4.5 × 4 cm
hypoechoic lesion in the tail of the pancreas as well as
cholelithiasis. Magnetic resonance imaging (MRI) also
revealed a 4.5 × 4 cm macrocystic lesion in the tail of the
pancreas. In addition, computed tomography-angiography
(CTA) showed that the tumor distorted and compressed the
splenic vessels (Figure 1). The level of serum CEA and
CA19-9 were within the normal range. Preoperative evalua-
tion led to the possible diagnosis of mucinous cystic
neoplasm of the pancreas. The patient was subjected to
laparoscopy. Intraoperatively a cysticmass of approximately
4.5 cm in diameter was found in the tail of the pancreas in
addition to atrophy of the adjacent parenchyma. Laparo-
scopic cholecystectomy and distal splenopancreatectomy
was performed. Postoperative recovery of the patient was
uneventful, while the drainage was removed and the patient
stepped out on the second and fourth postoperative day
respectively.
Despite the preoperative diagnosis of mucinous cystade-
noma the histology was consistent with a pancreatic
pseudocyst, which was subsequenced to moderately differ-
entiated ductal adenocarcinoma. Resection margins were
negative, as well as perineural invasion was not present and
no metastasis was found in eight peripancreatic resected
lymph nodes.
Patient underwent adjuvant chemotherapy, with gemcita-
bine 1000 mg/m2 weekly for 3 weeks followed by a rest
week, and for 6 cycles. He tolerated treatment well without
side effects. The patient was followed up with US,
abdominal CECT and chest X-ray after 6 months. The
level of CA19-9 was determined one month after surgery
and then every 3 months and it was within the normal
range. The patient remains asymptomatic 6 months after
the operation.
Technique
The patient was placed in supine position with his legs
apart. A gastric tube and a bladder catheter were inserted.
The monitors were placed over the left and right shoulders
of the patient. A Veress needle was inserted under the
umbilicus to induce pneumoperitoneum. The intra-
abdominal pressure was monitored and maintained at
around 12 mmHg. A 10 mm camera port was inserted in
the umbilical position. A 10 mm port was placed in the
subxiphoid area. Another two 5 mm trocars were placed,
one near the midclavicular line (in the right subcostal
area), and another on the anterior axillar line. The
operating table allowed changing the patient's position
easily: a slight (35°) anti-Trendelenburg tilt was obtained.
We used a 10 mm 30-degree telescope for visualization.
Laparoscopic cholecystectomy was initially performed.
Subsequently the operating table was rotated about 30° to
the right. The surgeon stood between the legs of the
patient, while the first and second assistants, respectively,
stood on the left and right of the operating surgeon. The
scrub nurse was on the right side of the operating surgeon.
A 12 mm port, through which the stapler could be
introduced, was inserted in the left upper quadrant. The
operating surgeon used the instruments placed in the right
subcostal area and in the left side. The pancreas was
explored through the infragastric access. Using an atrau-
matic grasper introduced through the subxiphoid trocar,
the assistant grasped the stomach at the great curvature
and raised it. The operating surgeon used an ultrasound
dissector to mobilize the splenic flexure. All suspensory
ligaments of the spleen were divided, including the short
gastric vessels. The gastrocolic omentum was divided,
preserving the gastroepiploic artery. Thus, a window was
opened in the gastrocolic ligament, below the gastro-
epiploic arch. The lesser sac was entered and the window
was then enlarged to expose the pancreas. The peritoneum
overlying the inferior border of the pancreas was incised,
and via this largely avascular plane of dissection the
lower border of the pancreas was elevated, allowing for
retroperitoneal pancreatic access. A linear cutter stap-
ling device [ENDOPATH®, ETS Flex 45 Endoscopic
Articulating Linear 45 mm staple line, 2.5 mm Staple Leg
Length (Vascular/Thin) 45 mm Vascular/Thin, Johnson &
Johnson, USA] was then placed across the pancreas at the
selected resection line (the middle of body). The splenic
vein and artery were deeply embedded within the
parenchyma of the pancreas. The splenic vessels were
dissected en bloc together with the parenchyma, using 2
mechanical stapler fires (Figure 2). Additionally, an
endoscopic clip was applied to the splenic artery at the
level of transection of the pancreas. Once the pancreatic
remnant was dissected, the spleen was mobilized by
Figure 1. Computed tomography-angiography showing that
the tumor distorted and compressed the splenic vessels.
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Cases Journal 2009, 2:8468 http://casesjournal.com/casesjournal/article/view/8468
sectioning any remaining attachments. The specimen was
removed using a gel-port through an incision in the left
upper quadrant (Figure 3). A Jackson-Pratt drain was
placed in the bed of the pancreatic dissection and drawn
out through the 5-mm port site on the anterior axillar line.
It was removed on the second day postoperatively, once it
was determined that there was no pancreatic fluid leak.
Discussion
Although more than a few laparoscopic pancreatic proce-
dures have been described, debate goes on over which
procedures can be safely and effectively performed and
which clearly benefit the patient when performed lapar-
oscopically. Laparoscopic distal pancreatic resection has
increasingly been described as a feasible and safe procedure.
The most common histotypes of resectable distal pancrea-
tic tumors are currently cystic and endocrine neoplasms,
which are frequently benign and usually diagnosed
incidentally during ultrasound examinations [3]. In
general, the indications for laparoscopic distal pancrea-
tectomy are neuroendocrine tumors and benign appearing
tumours [4]. However, Melotti et al reported that laparo-
scopic resection of ductal carcinomas was safe and
oncologically correct [3]. In our case, the preoperative
diagnosis was a benign appearing tumor (mucinous cystic
neoplasm). However, the histology revealed a pancreatic
pseudocyst and a separate area of moderately differen-
tiated ductal adenocarcinoma. The resection margins and
the eight removed lymph nodes were disease-free.
Laparoscopic distal pancreatectomy offers patient benefits
in terms of postoperative recovery and length of stay,
together with acceptable perioperative morbidity and
complication rates [5,6]. However, laparoscopic distal
pancreatectomy raises two problems: sparing the spleen
with or without ligation of the splenic vessels, and treating
the pancreatic remnant. Distal pancreatectomy with
en-bloc splenectomy has been considered the standard
technique for treatment of benign and malignant pan-
creatic disorders [7-10]. However, splenic preservation has
lately been advocated [2,5,7-14]. In patients with malig-
nant tumors in the body-tail of the pancreas, splenectomy
has a negative influence on long-term survival after
resection. The incidence of diabetes after spleen-preserving
distal pancreatectomy for chronic pancreatitis is less
than after en-bloc splenectomy. Spleen salvage eliminates
the risk of overwhelming infections [4]. The question
is whether it should be performed with or without splenic
vessel preservation. Kimura et al have described the
technique of preserving both the splenic artery and vein
[15]. Warshaw has described a technique of distal
pancreatectomy in which splenic vessels are ligated both
at the level of transection of the pancreas and again at the
splenic hilum, leaving the spleen to survive on blood flow
through the short gastric vessels [16]. To achieve laparo-
scopic access and sufficient exposure of the distal pancreas,
a number of the short gastric vessels must be divided
which, together with a divided splenic pedicle, would
Figure 2. The linear cutter stapling device (Endoscopic
Vascular Stapler 45 mm) dissecting the pancreas at the
selected resection line at the middle of body.
Figure 3. The specimen of the distal pancreas together with
the spleen.
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Cases Journal 2009, 2:8468 http://casesjournal.com/casesjournal/article/view/8468
likely render the spleen nonviable. Splenomegaly is a
contraindication for Warshaw’s method because the
increased mass is not sufficiently nourished by the short
gastric vessels. There is no doubt that by preserving the
splenic artery and vein, the blood supply to the spleen is
well maintained and the risk of splenic necrosis and
abscess formation is reduced. On the other hand, distal
pancreatectomy with conservation of the splenic artery
and vein is both time and labour consuming. Dissecting
the splenic vessels from the pancreas may be difficult in
the presence of tumours distorting and compressing the
course of the vessels [4,15,17].
However, in general, distal pancreatectomy is performed
en-bloc along with resection of the spleen. The en-bloc
pancreatic-spleen resection is usually performed for tech-
nical reasons; it makes the operation short and easy [4].
In our case, the spleen was resected en bloc with the distal
pancreas because the splenic vein and artery were deeply
embedded within the parenchyma of the pancreas.
As in open resections, the major challenge is still the
management of the pancreatic stump. The formation of
fistulae is a result of the soft tissue typical of the residual
pancreas of patients suffering from cystic or endocrine
benign tumors [3]. Once the stapler is fired, the surgeon
may choose to oversew the staple line as an additional
measure to ensure pancreatic ductal closure. Park et al do
so routinely [5]. A bipolar vessel sealing device used to
divide the pancreas has been described by Matsumoto
[18]. According to Melotti et al the best technique to cut
the pancreas is using the linear stapler. During their initial
experience they used 3.5-mm staples before changing to
4.5-mm staples to prevent ischemia of the pancreatic
stump and reduce fistula formation [3]. In our case, we
used 4.5-mm staples, in line with the most current results
of Melotti et al [3].
Despite extensive preoperative and even intraoperative
investigation (including intraoperative ultrasound), there
is no minimally invasive substitute for manual palpation
and exploration of the pancreas. Recent advances in hand-
assisted laparoscopic surgery may address this limitation
of totally laparoscopic surgery. The disadvantage of hand-
assisted laparoscopic surgery is that often a larger than
expected incision for the surgeon’s hand is required; this
carries with it the risk of wound infection and incisional
hernia, in addition to the obvious functional and cosmetic
impairment [5].
Conclusions
In conclusion, laparoscopic pancreatic surgery is becoming
gradually more popular among surgeons. In general, distal
pancreatectomy is performed en-bloc along with resection
of the spleen for technical reasons, making the operation
short and easy. The use of linear stapler to cut the pancreas
(4.5-mm staples) seems to prevent fistula formation and
ischemia of the pancreatic stump. Our case confirmed
the safety and feasibility of laparoscopic distal pancrea-
tectomy in the treatment of pancreatic tumors. It is not
possible, however, to draw from this case report any
definitive conclusions. Laparoscopic distal pancreatect-
omy should only be performed in centers with expertise
in both pancreatic surgery and advanced laparoscopy.
Laparoscopic technology is in a rapid state of development
and further improvements might play an important role
for the future diffusion of laparoscopic pancreatectomy.
Abbreviations
CECT, contrast enhanced computed tomography; US,
Ultrasonography; MRI, Magnetic resonance imaging;
CTA, computed tomography-angiography.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
KC and EC and FE performed the operation and together
with AG and GM contributed to the conception and design
of the manuscript. PJ, TE and LS analyzed and interpreted
the patient data regarding the disease. AG and LS were
major contributors in writing the manuscript. All authors
read and approved the final manuscript.
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Total laparoscopic distal pancreatectomy for a benign appearing tumor: a case report

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