Distal pancreatectomy

1.Position the patient supine.
2.Make a subcostal or midline incision.
3.Conduct a laparotomy.
4.Dissect the greater omentum off the transverse colon and mobilize the splenic flexure of colon.
5.Incise the peritoneum over the inferior border of the tail of the pancreas. Identify the inferior mesenteric vein and dissect in a plane deep to this. Insert your right index finger behind the tail of pancreas (deep to the splenic vessels) and use your finger tip to raise the peritoneum over the superior border of the tail mindful of the splenic artery and vein lying deep to the pancreas and incise this layer.
6.Now examine the body and tail of pancreas, possibly using IOUS to confirm resectability.
7.Palpate the splenic artery at the upper border of the neck of pancreas, open the peritoneum here, encircle and doubly ligate in continuity.
8.Retract the spleen to the patient’s right and incise the lienorenal ligament. Extend this incision superiorly to free the spleen from the diaphragm and inferiorly to free any remaining attachments to the splenic flexure of colon.
9.Divide the gastrosplenic ligament and the short gastric, left gastro-epiploic vessels.
10.Dissect along the deep surface of the pancreas in order to free it from Gerota’s fascia. Identify the inferior mesenteric vein at the inferior border and ligate it.
11.With continued posterior dissection identify the junction of the splenic and portal veins. Encircle and doubly ligate the splenic vein 2cm proximally.
12.Ligate the splenic artery again and then divide distal to the two ties that are to stay.
13.Apply a TA60 (3.5mm staples) across the neck of the pancreas and staple. Deliver the specimen. You may also sometimes oversew the pancreatic duct using 4/0 PDS along with any other vessels (superior pancreatic artery).
14.Lavage, large bore suction drain to pancreatic remnant and close.

A pancreatic fistula should usually heal in 4-6/52 but will require ongoing drainage.