Distal Pancreatectomy with Splenic Preservation

■ Preserving the spleen during removal of the body/tail of the pancreas in patients with chronic pancreatitis is difficult; scarring around the splenic vein may make dissection and preservation of the vein difficult and even dangerous.

■ If a neoplasm is suspected, the spleen and splenic vessels should not be preserved.

■ If the distal pancreatectomy is for pain, there is no suspicion of malignancy, and the splenic vein is patent, an attempt to preserve the spleen is justified.

■ The course of the operation is quite different when splenic preservation is the goal.

■ After entering the lesser sac, the operation commences with division of the pancreatic neck over the isolated superior mesenteric-portal vein.

■ The spleen is not mobilized; the body/tail of the pancreas is dissected from the point of division of the gland toward the spleen by dividing the multiple small branches entering the splenic vein from the pancreatic parenchyma.

■ Branches of the splenic artery entering the pancreas are divided individually as dissection progresses to the patient's left.

■ Before proceeding with dissection of the body/tail of the gland from the splenic vessels, it is wise to gain control of both the proximal splenic vein near its entrance to the SMV and the splenic artery near its origin; expeditious vascular control can be obtained if bleeding becomes excessive during subsequent dissection.

■ Splenic venous branches are controlled best with fine vascular staples or fine ties of 4-0 or 5-0 silk; these vessels are small, delicate, and easily torn.

■ The surgeon decides how much blood loss is acceptable when trying to preserve the spleen and should be willing to abandon this approach if necessary.

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