A Novel Method for Hemorrhage Control During Laparoscopic Distal Pancreatectomy with Splenic Vessel Preservation: Triple Occlusion.

Introduction: Laparoscopic distal pancreatectomy (LDP) has the advantages of reduced blood loss, shorter hospital stays, and a better postoperative quality of life compared with open distal pancreatectomy (ODP).¹ Meanwhile, spleen-preserving laparoscopic distal pancreatectomy is the preferred technique for low-grade malignant and benign tumors located in pancreatic body and tail, since it preserves the immune function of the spleen. The splenic-vessel-preserving (SVP) Kimura technique and splenic vessel resection Warshaw technique are the two primary procedures. Although the Kimura procedure and the Warshaw procedure were comparable in most postoperative outcomes, the former was superior to the latter in reducing the risk of gastric varices and splenic infarction.^2,3 However, in cases of large tumors in the distal pancreas or those with tight adhesions of the tumor to the splenic vessels, laparoscopic Kimura procedure is technically challenging because of the higher risk of intraoperative hemorrhage.⁴ Herein, we present an effective surgical approach to laparoscopic SVP that minimizes the chances of vascular injury and maximizes the chances of a successful splenic preservation-triple occlusion strategy.

Methods: A 46-year-old woman was admitted to our department owing to vague pain in the upper abdomen lasting for 6 months. Enhanced computed tomography (CT) scan revealed a 3.9 ✕ 4.3 cm cystic tumor in the distal pancreas, which has a smooth cystic wall without wall nodules; despite poor demarcation of the tumor from the splenic vein, tumor markers were all within normal limits (CA19-9, 5.78 U/ml; CEA, 1.14 ng/ml), so a benign tumor was considered. We present the triple-occlusion strategy during laparoscopic Kimura operation. This approach, as demonstrated in the video, includes triple occlusion of the proximal splenic artery, proximal splenic vein, and splenic pedicle; In addition, we use cold scissors to carefully dissect the tumor from the splenic vein, which minimizes the possibility of splenic vein injury and tumor rupture caused by thermal damage of ultrasonic scalpel, thus improving the safety of the surgery and the chances of spleen preservation.

Results: The operation lasted for 136 min with 10 ml of estimated blood loss. Multiple sites of the cystic wall were sampled (including the margins of the splenic vein), and intraoperative freezing was conducted to consider mucinous tumors, with no cancer cells detected. The amylase in the drainage fluid on postoperative day (POD) 3 was 1410 U/l, and the drainage tube was removed on POD 4. The patient showed an uneventful recovery and was discharged on POD 5. Finally, mucinous cystadenoma with mild atypical hyperplasia was diagnosed by pathological examination.

Conclusion: The laparoscopic triple-occlusion strategy may be helpful for selected patients with tumors located at the distal pancreas, especially for those with large tumor or tumors with tight adhesion to splenic vessels.