Vein-Guided Approach for Safe Control of Splenic Vein Tributaries in Robot-Assisted Splenic Vessel-Preserving Distal...

Splenic vessel-preserving distal pancreatectomy (SVPDP) preserves splenic function while maintaining physiological perfusion and drainage, but remains technically demanding. Standardization has so far centered on the splenic artery, with prior strategies describing whether it is approached from the ventral or dorsal aspect of the pancreas. The venous side has received little systematic attention: small tributaries draining the pancreas into the splenic vein, most consistently the centro-inferior pancreatic vein (CIPV), are a frequent unpredictable source of bleeding during posterior dissection. A vein-guided approach is described that uses the splenic vein and its tributaries as the anatomical roadmap for posterior dissection, maintaining continuous "vein-on-sight" visualization to safely control these venous branches as a group rather than relying on any single landmark. Because the splenic artery runs immediately cephalad to the vein on the dorsal pancreatic surface, the venous plane developed by this approach also facilitates subsequent arterial control. Among 24 patients undergoing SVPDP (13 laparoscopic and 11 robot-assisted), the robotic approach showed favorable nonsignificant trends toward lower blood loss, fewer clinically relevant pancreatic fistulas, and higher splenic vein patency. This vein-guided approach complements existing artery-based strategies, extending technical standardization of SVPDP to the venous side.