♦ A contrast-enhanced computed tomography (CT) scan utilizing a pancreatic protocol is obtained for preoperative assessment of pancreatic disease. This study provides images of the pancreas during arterial and venous phases to allow for a full evaluation of smaller lesions and to help delineate the relationship of the splenic vessels to the lesion.

♦ Patients with radiographic abnormalities of the body and tail of the pancreas usually undergo endoscopic ultrasound with or without FNA (fine needle aspiration) and cystic fluid sampling if indicated.

♦ In patients with a dilated pancreatic duct, an Endoscopic Retrograde Cholangiopancreatography (ERCP) may be useful for evaluating the papilla and ductal anatomy and its relationship to the lesion. Alternatively, Magnetic Resonance Cholangiopancreatography (MRCP) is also useful as a noninvasive means for elucidating pancreatic pathology and anatomy.

♦ In our institution, a pancreas protocol CT and EUS (Endoscopic Ultrasound) fully assess the majority of patients and obviate the need for additional studies.

♦ If splenectomy is anticipated, then preoperative vaccination against encapsulated bacteria (H. Influenza, Streptococcus, Meningococcus) should be given 7 to 10 days before surgery.

♦ Patients with functional pancreatic neuroendocrine tumors may require preoperative hospitalization to optimize physiologic status.

♦ Similar to other major abdominal surgeries, preoperative antibiotics and DVT (deep venous thrombosis) prophylaxis are provided per Surgical Care Improvement Project (SCIP) guidelines.

♦ For a laparoscopic approach, a 30-degree and 45-degree laparoscope, ultrasonic dissector, 5-mm and 10-mm clip applier, blunt-tipped atraumatic bowel graspers, fine-tipped needle driver, articulating endoscopic stapler, fibrin glue with laparoscopic delivery device, and hand port should be available.

♦ In addition, a laparoscopic ultrasound should be available to help locate and characterize lesions intraoperatively. The ultrasound is often particularly useful for clarifying the spatial relationship of neuroendocrine tumors to the main pancreatic duct. In addition, intraoperative ultrasound may help explain other occult pathology, which may change intraoperative decision-making.

♦ General anesthesia with endotracheal intubation and complete neuromuscular blockade is generally required for this operation.

♦ After intubation, a nasogastric (NG) tube should be placed to decompress the stomach during the operation and for patient care during the immediate postoperative period.

♦ A Foley catheter should be placed and standard preoperative antibiotics given per surgeon.

♦ The patient is positioned in a 30-degree right lateral decubitus position using a beanbag or large gel rolls. This allows for rotation of the patient during mobilization of the pancreas and allows the use of gravity as a retractor during the case. The 30-degree lateral decubitus also provides for rotation into a horizontal position if conversion to an open procedure is required.

The left arm will often need to be placed in a padded cradle “airplane” position and gently fixed out of the operative field. The upper and lower extremities are well padded, and the patient is carefully secured to the table.

This procedure can also be done with the patient in supine position. The surgeon stands between the patient’s legs and the assistant stands to the left of the patient. This position is best for medial-to-lateral dissection.

♦ Pneumoperitoneum is achieved by either the Veress needle technique, with the needle placed through the umbilicus, or the open Hassan technique at the site of the operating laparoscope. The laparoscopic distal pancreatic resection is performed via four trocars.

♦ A critical component of any laparoscopic approach is port placement.

♦ The locations of these trocars may vary slightly depending on the body habitus of the patient. In general, the trocars should be triangulated around the body and tail of the pancreas with a working distance that allows sufficient range of motion.

♦ We have obtained the greatest flexibility by utilizing three 12-mm trocars and one 5-mm trocar.

♦ Figure 11-1 outlines the position of the trocars. In general, a 12-mm trocar is placed in the supraumbilical position to the left of the midline, and exploratory laparoscopy is performed. A 12-mm trocar is placed just 5 cm lateral to the left midclavicular line. This trocar will allow passage of the flexible laparoscopic ultrasound probe and the articulated endoscopic staple device. The assistant’s port is a 5-mm trocar placed in the left midclavicular line approximately 10 cm above the camera port. If necessary this position can be converted into a hand port during the operation. Finally, a fourth 12-mm trocar is placed in the right midclavicular line approximately 5 cm above the camera port. An additional 5-mm subxiphoid trocar can be added, retracting the left lobe of the liver if necessary.

♦ In general, the principles of laparoscopic resection are similar to an open distal pancreatectomy.