Laparoscopic distal pancreatectomy and splenectomy for malignant tumors

Laparoscopic distal pancreatectomy has become the gold standard for benign tumors. As more surgeons have expertise in open and laparoscopic pancreatic surgery, increasing numbers of benign-appearing tumors are being removed via minimally invasive techniques and found to have malignancy on final pathology. Because of our growing experience in laparoscopic distal pancreatectomy, we have begun removing preoperatively suspected malignancies in the distal pancreas with minimally invasive techniques.

All cases were collected prospectively in a database and analyzed retrospectively. All cases begun laparoscopically with the intention of performing the resection with minimally invasive techniques were considered even if the operation was ultimately converted to an open procedure.

A total of 12 cases have been attempted of which four required hand assistance and one required conversion to an open approach due to delayed bleeding from a calcified splenic artery that had been transected with laparoscopic GIA stapler device. In total, eight (67%) patients had malignant disease and four (33%) were found to have benign tumors. The median lymph node retrieval is 8 (range 3-16) with no positive margins. The morbidity rate is 17% with one reoperation (8%) and one mortality (8%) at 30 and 90 days.

The laparoscopic approach to malignant pancreatic tumors is feasible with similar morbidity and mortality rates to benign series. When tumors are next to the confluence of the splenic portal vein, a hand-assisted approach may be adviseable. Calcified splenic arteries should be sought on preoperative imaging and either transected in non-calcified segments or controlled via open techniques via the hand port.