DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Intraductal papillary mucinous neoplasm of the distal pancreas.
POSTOPERATIVE DIAGNOSIS: Intraductal papillary mucinous neoplasm of the distal pancreas.
OPERATION PERFORMED: Laparoscopic distal pancreatectomy and splenectomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Minimal.
PATHOLOGY: Distal pancreas and spleen.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: This is a patient who developed nonspecific left upper quadrant pain radiating to his back. Workup, including CT scan and ERCP, demonstrated what appeared to be side-branch IPMN of the distal pancreas. He was therefore referred for surgical consultation. The patient was explained the operation of laparoscopic distal pancreatectomy and possible complications associated with it. The patient agreed and consented to the procedure.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and identified. After general endotracheal anesthesia, the patient was placed supine on the operating table. He was placed on a bean bag with his left side up in approximately 30 degree position. He was also placed on a kidney rest, and the bed was broken to elevate his left upper quadrant to the surgical field. After adequate induction of general endotracheal anesthesia, the patient’s abdomen was prepped and draped.
Initially, access to the abdomen was gained through a supraumbilical incision. A 10 mm Hasson trocar was placed using a Veress needle technique. A laparoscope was inserted, and the abdomen was inspected, including the area of the trocar placement. No other pathology or injury was apparent. Subsequently, a second 10 mm trocar was placed in the right upper quadrant and two subsequent 5 mm trocars were placed in the left lateral abdomen. Inspection of the abdomen revealed a very bulky omentum. The case was initially started by accessing the lesser sac. In this manner, the greater omentum was separated from the transverse colon with the use of Harmonic scalpel. Once the lesser sac was entered, the short gastric vessels were taken down, and the greater curve of the stomach was completely mobilized to the GE junction.
The splenic flexure was also mobilized bluntly as well as sharply with the use of Harmonic scalpel. This was retracted inferiorly. Once the lesser sac was entered, the pancreas was identified. The inferior border of the pancreas was then dissected with a combination of electrocautery and Harmonic scalpel, and this was taken to the level of the spleen. The lateral attachment of spleen was taken down, and the spleen was mobilized medially. The splenic hilum was identified, and the splenic artery and vein were seen. The spleen and the distal pancreas were elevated from retroperitoneum and with use of the Harmonic scalpel. The pancreas was mobilized out of the retroperitoneum to the level of the SMV.
The SMV was identified with the use of intraoperative ultrasound. The pancreas was also ultrasounded and what appeared to be a cystic mass in the distal pancreas was identified. In this manner, both the cephalad and the inferior aspect of the pancreas was mobilized. The celiac axis was also identified with the use of the intraoperative ultrasound. The pancreas was then transected with a vascular load GIA stapler just to the left of the superior mesenteric vessels.
Once this was completed, the spleen was separated from the distal pancreas again with the use of a vascular stapling device. A laparoscopic spleen bag was placed within the intra-abdominal cavity. The spleen was placed within the bag. This was then placed in the left upper quadrant. Next, the pancreas was placed in the endobag and was brought out through the 10 mm Hasson trocar. The pancreas was then sent to pathology, and frozen section of the proximal margin was obtained, and this was read to be negative.
The spleen was then morselized and removed again out of the 10 French Hasson trocar site. Attention was then focused to the stapled end of the proximal pancreas, and utilizing intracorporeal knots, 3-0 Prolene sutures were then placed along the staple line in horizontal mattress fashion. Approximately four to five horizontal mattress sutures were placed. The rest of the abdomen was inspected, and no other pathology or bleeding was evident. A 10 French Jackson-Pratt drain was placed through one of the five French trocar sites and secured to the skin with 2-0 nylon suture. All 10 mm trocar sites were closed with 0 Vicryl sutures. The skin was sutured and dressed sterilely. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
