Keywords

Preference Card

  • 5 mm 30° scope

  • 10 mm 30° scope

  • Camera

  • Light cord

  • Light source

  • CO2 source

  • Fog reduction and elimination device (FRED ™)

  • Laparoscopic ultrasound probe

  • Laparoscopic electrocautery device and grounding pad

  • Laparoscopic 5 mm LigaSure (Maryland tip)

  • Laparoscopic suction and irrigation

  • Laparoscopic clip applier

  • Laparoscopic grasper

  • Laparoscopic shears

  • Laparoscopic PDS Endoloop ™

  • 45 mm Endo GIA stapler

  • 45 mm Endo GI purple load (one cartridge)

  • Endoscopic retrieval bag

  • Mini vessel loop pack

  • Umbilical tape ¼ inch

  • Pediatric feeding tube 5–8 Fr

  • Trocars:

    • 12 mm Hasson

    • Three 5 mm trocars

  • Sutures:

    • 0 Vicryl UR-6 × 2

    • 4-0 Vicryl PS-2 × 2

    • 3-0 silk SH × 6

    • 5-0 PDS RB1 × 2

    • 2-0 silk FSL for drain

  • 19-French round Jackson-Pratt/Blake drain

  • Have available: Major general and vascular trays in event of conversion to open procedure

Patient Positioning/Operating Room Setup

  • Patient positioning and operating room setup (Fig. 48.1)

  • Trocar placement:

    • Start with 12 mm Hasson cannula supraumbilical port placement.

    • Place camera in supraumbilical port.

    • Add 5 mm right upper quadrant trocar × 2.

    • Add 5 mm left upper quadrant trocar.

Fig. 48.1
figure 1

Patient positioning and operating room setup. ANS anesthesiologist, M monitor, S surgeon, A1 first assistant, A2 second assistant, N nurse

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Nodal Points

Diagnostic Laparoscopy

  • If no lesions, proceed with surgery. Otherwise, this is a stage IV disease and there is no benefit from surgery.

Enter Lesser Sac (Fig. 48.2)

  • Using a DeBakey grasper, retract the stomach medially, while assistant retracts ligament.

  • With the ultrasonic shears, divide the gastrocolic ligament from the distal antrum to the fundus, preserving the gastroepiploic vessels along the greater curvature.

  • Dissect all the way along the greater curvature, making sure to divide the short gastric vessels up to the gastroesophageal junction.

Fig. 48.2
figure 2

Entering the lesser sac

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Mobilizing the Pancreas and Creation of the Retropancreatic Space (Fig. 48.3a, b)

  • The stomach is retracted anteriorly and superiorly.

  • Retract the transverse colon downward.

  • Using the LigaSure device, divide the anterior layer of the transverse mesocolon in order to mobilize the posterior surface of the pancreas.

  • Identification of lesion via laparoscopic ultrasound.

  • Continue the dissection till the loose areolar tissue behind the pancreas is free.

  • Start mobilization through the inferior border of the pancreas.

  • The body and tail of the pancreas can be elevated by carefully dissecting the retropancreatic space.

Fig. 48.3
figure 3

(a) Mobilizing the pancreas and (b) creation of the retropancreatic space

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Exposure of Vasculature

  • Dissect along the inferior border of the pancreas until the portal vein, superior mesenteric vein, and inferior mesenteric vein are identified.

  • Using blunt dissection, dissect through the fascial planes until the junction of the splenic vein and the superior mesenteric vein is identified.

  • At this point, skeletonize and isolate the splenic artery at the upper border of the pancreas.

  • Using an endoscopic linear with a vascular cartridge, divide the splenic artery.

  • Reload stapler with vascular cartridge and divide the splenic vein.

Division of the Pancreas (Fig. 48.4a, b)

  • Distal to the identified tumor, divide the body of the pancreas using an endoscopic linear stapler loaded with a medium-sized cartridge.

Fig. 48.4
figure 4

(a, b) Division of the pancreas

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Distal Pancreatic and Spleen Mobilization

  • Dissect the pancreatic tail free of the surrounding tissue all the way to the hilum of the spleen.

  • While performing the medial to lateral dissection, resection of Gerota’s fascia and adequate lymph node dissection should be performed.

  • Perform lymph node dissection along the celiac trunk.

  • Dissect the spleen free of its retroperitoneal attachments.

  • Once completely free, remove the specimen in an endoscopic retrieval bag.

Hemostasis

  • Secure the splenic artery stump with a PDS Endoloop™.

  • Apply Floseal™ to the resection bed.

Drain Placement

  • Place a 19-Fr round Jackson-Pratt drain adjacent to the cut edge of the pancreas and brought out of the left lateral trocar site where it is secured to the skin.

Specimen Retrieval

  • Place specimen in an Endocatch bag.

  • Retrieve bag through the supraumbilical incision.

  • If specimen is larger than fascial opening, extend the opening enough to allow retrieval.

Closure

  • Close the supraumbilical port fascia with a running #1 PDS suture.

  • Remove remaining trocars and close the 5 mm skin incisions with 4-0 Vicryl.

  • Cover incisions with Steri-Strips.

Pearls and Pitfalls

  • Care should be taken when performing splenectomy as splenic injury can lead to a significant amount of blood loss. Any injury to the splenic capsule should be promptly repaired with non-absorbable suture before returning to the step of the operation that was being performed.