Surgical technique
Laparoscopic spleen-preserving distal pancreatectomy with splenic vessels resection (laparoscopic Warshaw procedure)

https://doi.org/10.1016/j.jviscsurg.2022.03.002Get rights and content

Introduction

The laparoscopic approach has become the standard for left pancreatectomy, and two randomized studies have shown its advantage over the open approach [1], [2]. Preservation of the spleen should be preferred for benign lesions or lesions with low malignant potential. For malignant lesions, on the other hand, splenic conservation for reasons of immunological interest [3], [4] or splenic resection for oncological reasons is still debated. Retrospective studies have shown that if the pancreatic adenocarcinoma is distant (> 5 cm) from the splenic hilum [5], [6], the risk of lymph node involvement is very low. Laparoscopic left pancreatectomy without splenectomy can be performed with preservation of the splenic vessels (Kimura intervention) [7] or with splenic vessels resection (Warshaw) [8]. In the latter case, the vascular supply to the spleen will be provided via the short gastric vessels and the left gastro-epiploic pedicle. The main complication is splenic necrosis, either partial, or less frequently, total [9]. We present the laparoscopic left pancreatectomy technique according to Warshaw.

Section snippets

Installation, equipment and positioning of the trocars

The patient is positioned supine with the legs spread apart. The right arm is placed alongside the body and the left arm is extended 90 degrees in relation to the trunk. The surgeon stands to the patient's right with the assistant between the legs, and the scrub nurse to the surgeon's right. The laparoscopy tower is located to the patient's left, with two screens positioned facing the operator and the assistant. Laparoscopy with 3-D vision is more frequently used. Five or 6 trocars (T1-6) are

Division of the gastro-colic ligament and gastric suspension

The anterior face of the pancreas in the lesser sac is exposed by dividing the gastro-colic ligament using thermofusion forceps while respecting the transverse colon and the vascular arcade of the greater gastric curvature. This opening must extend sufficiently high on the left to allow good exposure of the pancreatic tail and the splenic hilum, while carefully preserving the short gastric vessels and the left gastro-epiploic pedicle, which are needed to ensure splenic blood supply after

Exposure of the mesenterico-portal axis and pancreatic section

The posterior peritoneum is incised along the lower border of the pancreas in order to release the distal pancreas widely to the left. The anterior surface of the superior mesenteric vein is exposed after control of pancreatic venous collaterals and the dissection is pursued as high as possible along its retro-pancreatic course to expose its junction with the splenic vein. At the upper border of the pancreas, the lymph nodes around the falx of the hepatic artery and the left gastric pedicle are

Transection of the splenic vein termination and the splenic artery at its origin

Once the pancreatic isthmus has been severed, the end of the splenic vein is easily accessible in the operating field, unlike the origin of the splenic artery, which is generally not yet visible. The exposure of the splenic vessels is facilitated by retraction of the distal pancreas upwards with the help of a grasping forceps. Due to the laparoscopic approach, which requires a bottom upward approach, it is easier to control the splenic vein first, ligating or stapling it with a vascular stapler

Mobilization of the left pancreas

The release of the posterior surface of the pancreas is performed gradually from right to left. The lower edge is released with traction on the specimen to one side and on the transverse mesocolon to the other side (a). Depending on the operative findings, a resection of a portion of the mesocolon, the inferior mesenteric vein or the duodeno-jejunal angle may be necessary. The upper edge of the distal pancreas is released after tracting the specimen caudad with upward traction on the stomach.

Anatomy of the splenic hilum

After sacrifice of the splenic vessels, the blood supply of the spleen is provided by the short gastric vessels and the left gastro-epiploic pedicle. The splenic artery runs along the superior border of the pancreas and gives off pancreatic and gastric collaterals. At the level of the splenic hilum, it divides into superior and inferior pole terminal branches, which anastomose with the short-gastric vessels and the left gastroepiploic vessels respectively. The venous vascularization parallels

Distal transection of the splenic artery

Unlike the proximal dissection where the splenic vein is transected before the artery, the splenic artery is divided before the splenic vein at the splenic hilum because it is more easily accessible due to its extra-pancreatic course at this level. It is essential to divide the splenic vessels before their bifurcation in order to preserve the collateral circulation at the level of the splenic hilum and therefore to reduce the risk of splenic necrosis. Even before completely freeing the tail

Proximal transection of the splenic vein

It is not always easy to divide the splenic vein at its origin because of its intra-parenchymal development, anatomical abnormalities and inflammatory phenomena related to the underlying pathology. Control will depend on the length of the pancreatic tail and its relationship to the splenic vessels. If the pancreatic tail is short (a), this dissection is simple and the vein is easily controllable after dividing the artery because it is not surrounded by the pancreatic parenchyma. On the other

Drainage and extraction of the specimen

The intervention ends with verification of hemostasis at the level of the pancreatic transection line, the vascular stumps, the spleen and the greater gastric curvature after releasing the gastric suspension. The spleen is most often partially discolored but this does not always require a splenectomy. A suction drain is left at the pancreatic transection line. The specimen is removed in a bag after enlarging the T1 trocar orifice (Fig. 1) to 2–3 cm or through another old abdominal scar.

Conclusion

In principle, the splenic vessels can be resected (for reasons of tumorous invasion or inflammatory adhesions) or if necessitated by an intra-operative wound; this does not systematically require splenectomy or conversion [10]). The Warshaw technique is frequently associated with partial splenic ischemia (more than 50%) and with segmental portal hypertension that is evident on imaging but is most often asymptomatic. This procedure can be easily performed via laparoscopy [11]. No randomized

Disclosure of interest

The authors declare that they have no competing interest.

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