Single incision laparoscopic distal pancreatectomy with splenectomy for neuroendocrine tumor of the tail of pancreas.

Laparoscopic resection is becoming the standard of care for tumors located in the body and tail of pancreas. We herein report a patient with neuroendocrine tumor in the tail of pancreas who underwent single incision laparoscopic distal pancreatectomy with splenectomy without the use of a commercial port device.

INTRODUCTION

Laparoscopic resection is becoming the standard of care for tumors located in the body and tail of pancreas.[1] We herein report a patient with neuroendocrine tumor in the tail of pancreas who underwent single incision laparoscopic distal pancreatectomy with splenectomy without the use of a commercial port device.

CASE REPORT

A 46-year-old male patient presented with history of decreased appetite and diarrhea of 3 months duration. He gave a history of acute pancreatitis one year before at which time multi-detector computerized tomography (MDCT) imaging showed evidence of acute pancreatitis with no necrosis and a bulky tail of pancreas. A MDCT of the abdomen done now showed a well-circumscribed lesion in the tail of pancreas with infiltration into the splenic hilum [Figure 1]. The maximum diameter of the tumor was 3.5 cm. His Serum Chromogranin A level was 970ng/L. His rest of the lab parameters were within normal limits. He received pneumococcal and meningococcal vaccine two weeks before the planned surgery. A single incision laparoscopic distal pancreatectomy with splenectomy was performed.

Figure 1

MDCT abdomen – Arrow showing the tumor in the tail of pancreas

Operative procedure details:

Patient was placed in the supine position with a 45 degree left up position. A 3 cm vertical incision was chosen at the umbilicus and subcutaneous tissue was dissected off from the sheath. CO2 pneumoperitoneum of 15 mm Hg was achieved using a veress needle. One 12 mm and two 5mm ports were inserted as previously described by us [Figure 2]. A 10 mm, 45 degree scope was used for camera vision. Hook cautery, Harmonic shears (Ethicon – Endo-surgery, Johnson and Johnson) and Enseal device (Ethicon – Endo-surgery, Johnson and Johnson) were used for avascular dissection. At first the splenic flexure of colon was mobilized completely. The lesser sac was entered and widely opened by dividing the gastro-colic omentum. A gastric traction suture was placed to retract the posterior wall of stomach to the right, thereby exposing the lesser sac widely by a suture technique previously described by us to facilitate SIL splenectomy.[2] The short gastric vessels were divided with Enseal device. The inferior border of pancreas was defined. Next, the superior border of pancreas was defined in the proximal and mid-body region of the pancreas. The dissection was next carried out from inferior border onto the posterior surface of pancreas in an avascular plane. The body of pancreas in the midbody region including the splenic vein was looped with a ribbon tape and a surgeons knot loosely tied the same anteriorly. A 2-0 prolene suture was passed into the abdomen from the subcostal region in the left anterior axillary line, through the ribbon tape loop and then exited from an area close to its previous entry point. The ends of the prolene loop were held with a hemostat. Traction on the hemostat facilitated anterior displacement of the body of pancreas facilitating further dissection. The distal body and tail were mobilized from the retroperitoneum in a plane anterior to the kidney in view of intense desmoplasia encountered adjacent to the tumor. The lienorenal ligament was divided using Harmonic shears. At this stage the distal body of pancreas and spleen were completely freed of all attachments. The pancreatic transection plane was chosen 2 cm proximal to the tumor. A 5 mm laparoscope was used during this step with an Endo GIA linear cutter 60 mm, white cartridge (Autosuture), passed through the 12 mm port for stapled transection at the chosen site [Figure 3]. The splenic artery was separately clipped with hemlock clips and divided. The pancreatic stump was overseen with running 2-0 prolene sutures. Fibrin sealant (Tisseal, Baxter) was applied at the pancreatic transection site. A 20F drain tube was placed adjacent to the transected end and the same was exited subcostally at the posterior axillary line. Hemostasis was checked. Keeping anterior leaf of the bag open using two interrupted prolene sutures hitching it to the anterior abdominal wall facilitated bagging of specimen. The specimen was placed in an endobag and was retrieved through the umbilical incision by joining the three port sites [Figure 4a]. Sheath was closed with no 1 PDS suture and skin was approximated with staples [Figure 4b]. On opening pancreas along long axis, solid cystic tumor was noted in the tail region of pancreas with distance of 2 cm from transected pancreas margin [Figures 4c and d]. The nasogastric tube was removed on postoperative day 1. Patient was started on oral liquids on day 2 and gradually increased to a solid diet. The surgical drain was removed on day 4 patient was discharged on day five after surgery. Wound healed and skin clips were removed on 9th postoperative day. Two weeks following surgery, patient presented with fever and leukocytosis and was readmitted. MDCT showed evidence of 20 cc collection in relation to the pancreatic stump, which was drained by percutaneous catheter. He was treated with culture sensitive antibiotics and discharged after removal of percutaneous catheter after seven days. Histopathology of the resected specimen showed a very well differentiated neuroendocrine carcinoma with negative resected margin of pancreas and no lymphnode metastasis. At a postoperative follow-up of 30 months he remains asymptomatic, has chromogranin A levels within normal limits, with hardly discernable scar [Figure 5] and has no recurrence on MDCT imaging.

Figure 2

Single incision at umbilicus with one 12mm and two 5mm ports

Figure 3

Endo GIA stapler transection of distal pancreas

Figure 4

Specimen extraction through the umbilical incision (a), Wound after closure (b), Distal pancreas and spleen specimen (c), Pancreas cut open along long axis showing tumor (d)

Figure 5

At two year followup, SIL scar at umbilicus (B) and appendectomy scar of previous surgery fifteen years before (A)

DISCUSSION

Laparoscopic resection is becoming the preferred approach to resect tumors in the body and tail of pancreas. There are several reports on laparoscopic distal pancreatic resection for neuroendocrine tumors located in the body and tail of pancreas. We have previously reported our experience with SIL procedures, viz.; cholecystectomy, splenectomy and donor nephrectomy.[234]

Spleen preservation is an important issue in patients undergoing distal pancreatectomy. However, MDCT in our patient showed a tumor located in the pancreatic tail with suggestion of splenic hilar infiltration, thus excluding the possibility of splenic preservation. Resection therefore entailed control of splenic vessels, releasing avascular attachments of distal body, tail of pancreas and spleen and transection of pancreas at an appropriate site. SIL distal pancreatectomy with splenic preservation can be a significant technical challenge. Since our patient required a distal pancreatectomy with splenectomy, we envisaged in our patient the possibility of SILDPS.

Innovations are keys to performing advanced SIL procedures. The limitation in number of ports available during SIL procedures needs to be overcome by such innovations. The gastric traction suture is a simple technique described by us previously for providing wide exposure of lesser sac. Also, this helps in division of short gastric vessels and provides the exposure for dissection and looping of the body of pancreas. Looping of the body of pancreas with a ribbon tape and using a prolene loop passed through this ribbon tape provides a simple, yet useful way of firm anterior traction on the body of pancreas facilitating dissection of posterior attachments of spleen and distal pancreas. In addition, this is key to provide traction required during staple transection of pancreas.

Intense desmoplasia is known to occur adjacent to neuroendocrine tumors. We encountered this problem during release of posterior attachments of distal pancreas. In the regular patient this is an avascular plane, but this plane was obliterated by desmoplastic reaction requiring dissection en-block in a plane anterior to the left kidney.

Pancreatic fistula is reported in 8-30% of patients undergoing distal pancreatic resection.[567] None of the described techniques of performing the pancreatic transection and managing the stump has shown to consistently decrease this dreaded complication. Our patient had a postoperative delayed presentation with an abscess; however, this complication is presumably related to the nature of procedure and unrelated to the SIL approach to perform it. Drain placement through the SIL entry site has been reported previously following SIL colorectal surgery, however, we elected to place and exit the drain in a dependent position exiting in posterior axillary line. This decision was taken at the end of the procedure. Although, one may argue that a port placed at this location might help in certain steps of the procedure, we feel a port placed in such a posterior location will be of little help during distal pancreatic resection.[8]

In conclusion, SILDPS is feasible and safe. Simple innovations facilitated the procedure. Complication seen in our patient was managed appropriately and was related to the nature of procedure rather than the approach, namely SILS.