腹腔镜下保留脾脏的胰体尾切除术的临床研究

目的:探讨腹腔镜下保留脾脏的胰体尾切除术的临床价值。方法:回顾分析2014年11月至2016年4月为3例胰腺体尾部肿瘤患者行腹腔镜下保留脾脏的胰体尾切除术的临床资料。结果:3例均成功施行腹腔镜下保留脾血管的保脾手术,无中转开腹,其中1例术中撕裂脾静脉,腹腔镜下缝合脾静脉撕裂处,成功止血,72 h后恢复进食。1例患者因囊性肿瘤巨大,术中囊液外溢,造成术后胰腺切除区形成直径3 cm包裹性积液,术后2周自行吸收。术后病理均回报为胰腺粘液性囊腺瘤。出院后随访3～12个月,未见远期并发症及复发病例。结论:腹腔镜下保留脾脏的胰体尾切除术目前已成为治疗胰体尾良性肿瘤安全、可行的新选择,因其创伤小、康复快,已成为治疗胰体尾良性肿瘤的常规手术,目前也可在基层医院开展,但此术式仍需严格遵守循序渐进的推行原则。     

Laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein: Report of three cases

Between March 2003 and March 2007, three patients with benign pancreatic tumors underwent a planned laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. Four trocars were placed, and an endoscopic linear stapler was used to transect of the pancreas. The perioperative data and surgical outcomes were examined. This procedure was successfully completed in three patients. The mean operative time was 158.3 min, with mean blood loss of 14.7 ml. The postoperative pathological diagnoses included one insulinoma, one solid pseudopapillary tumor, and one intraductal papillary-mucinous adenoma. The mean size of the tumors was 29.3 mm. Oral intake was initiated on day 1.7, and the length of postoperative hospital stay was 8.7 days on average. No morbidity or mortality was observed. A laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein is a safe and feasible treatment option without compromising the splenic function for benign or borderline malignant tumors in the distal pancreas.     

Hand-assisted laparoscopic distal pancreatectomy with minilaparotomy for distal pancreatic cystadenoma

Two patients with cystic tumors of the pancreas treated by laparoscopic distal pancreatectomy are presented. The first patient was a 34-year-old woman with a 6-cm cystadenoma of the tail of the pancreas treated with a complete laparoscopic distal pancreatectomy. After mobilization of the distal pancreas and spleen, the pancreas was transected proximally together with the splenic artery and vein using an endoscopic linear stapler. The second patient was a 71-year-old woman with a 6-cm cystadenoma of the body of the pancreas, treated by hand-assisted laparoscopic distal pancreatectomy with minilaparotomy because the tumor was adjacent to the portal vein and celiac axis. Using an upper median minilaparotomy, dissection of the gastrocolic ligament, division of the splenic artery, and transection and closure of the pancreas were performed. Division of the splenic vein and mobilization of the distal pancreas and spleen were performed via a hand-assisted laparoscopic approach. There were no postoperative complications (such as pancreatic fistulas) in either patient, and the postoperative courses were uneventful. The patients returned to normal activity within 1 week after the operation. Complete laparoscopic and hand-assisted laparoscopic distal pancreatectomy are preferable to conventional open surgery for benign tumors of the pancreas because of their less-invasive nature. Additionally, in tumors of the body of the pancreas, hand-assisted laparoscopic distal pancreatectomy might have the advantages of laparotomy and laparoscopy in terms of handling the splenic artery and vein just below the minilaparotomy site, suggesting an easier and safer procedure than complete laparoscopic distal pancreatectomy. Therefore, hand-assisted laparoscopic distal pancreatectomy can be recommended as a useful alternative to complete laparoscopic distal pancreatectomy for selected patients with benign tumors of the body and tail of the pancreas.     

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??Vascular disposal in laparoscopic spleen-preserving distal pancreatectomy??An analysis of 22 patients HUANG He-guang, CHEN Yan-chang, LU Feng-chun, et al. Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
Corresponding author: HUANG He-guang, E-mail: hhuang2@aliyun.com
Abstract Objective To investigate experience with the techniques of vascular disposal in laparoscopic spleen-preserving distal pancreatectomy. Methods The clinical data of 22 patients with benign or borderline pancreas pancreatic tumors performed a spleen-preserving distal pancreatectomy from February 2010 to December 2013 in Fujian Medical University Union Hospital were analyzed retrospectively. Results Among 22 patients, splenic artery and vein were conserved in 16 patients, while neither in 2 patients. Splenic artery was ligated with conservation of splenic vein in 2 patients. And splenic vein was ligated with conservation of splenic artery in 2 patients. All distal pancreatectomies with spleen preservation were completed laparoscopically. And all patients remained a good blood supply to spleen at a follow-up of 3 months to 4 years. Conclusion Depending on the relationship between tumors and vessels, the spleen can be safely preserved laparoscopically using different vascular disposal methods in benign or borderline pancreatic tumors.     

保留脾脏的胰体尾部良性肿瘤切除

目的探讨保留脾脏胰体尾切除的可行性和安全性以及并发症预防。方法回顾性分析总结2009年1月至2011年12月行保留脾脏胰体尾切除术5例资料,其中保留脾脏血管的开腹保脾胰体尾切除3例,切断(或切除)脾脏血管的保脾胰体尾切除术1例,腔镜下保脾胰体尾部切除术1例。结果本组无手术死亡,术后均未发生胰瘘、脾梗死、脾脓肿及脾出血等。随访3～6月,无并发症发生。结论胰体尾部良性肿瘤,应首选保留脾脏的胰体尾切除方法,手术安全,效果好,且避免了脾脏的不必要切除。     

Laparoscopic distal pancreatectomy with preservation of the spleen

We describe a case of chronic pancreatitis treated by laparoscopic distal pancreatectomy with conservation of the spleen involving the resection of the splenic vessels. A proximal ligation of the splenic artery and vein was performed, followed by transection of the body of the pancreas. Retroperitoneum was dissected to the left by mobilizing the stump of the transected pancreas. The entire distal pancreas was freed posteriorly. The distal splenic artery and vein were ligated and divided individually adjacent to the tail of the pancreas at the hilum of the spleen. The points of this operation were to ligate the splenic artery and vein at both sides of the resected pancreas and to save the spleen with the blood supply continuing through the short gastric vessels and the splenocolic ligament. This operation with splenic preservation is more suitable for a patient who is a candidate for laparoscopic distal pancreatectomy, which will minimize the operation time, preserve the useful immunologic role of the spleen, and obtain the intact resected specimen. Furthermore, this procedure is useful in chronic pancreatitis patients because it avoids the difficult dissection of the posterior pancreas off of the splenic vessels.     

Spleen-Preserving Distal Pancreatectomy Combined with Distal Gastrectomy for Distal Pancreatic Lesion and Gastric Cancer: Report of a Case

Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein was recently devised as a feasible operation. We report the case of a patient who underwent spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein, combined with distal gastrectomy, for gastric cancer and a distal pancreatic lesion. Thus, unnecessary total gastrectomy was avoided. The operative blood loss and operative time were 630 ml and 465 min, respectively. The patient's postoperative course was complicated by a minor pancreatic fistula, which required daily irrigation and drainage, but she recovered and was discharged from hospital. This case report demonstrates that spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein combined with distal gastrectomy can be performable synchronously and is a feasible alternative to avoid unnecessary total gastrectomy.     

Laparoscopic spleen-preserving distal pancreatectomy for solid pseudopapillary tumor with conservation of splenic vessels in a child

Laparoscopic spleen-preserving distal pancreatectomy (LSDP) with conservation of the splenic vessels is gaining acceptance as a reliable treatment for selected patients with low-grade malignant tumors of the pancreas in adults. The operation requires advanced laparoscopic skills to safely divide the fine branches of the splenic vessels. Laparoscopic spleen-preserving distal pancreatectomy with conservation of splenic vessels is rarely reported in children. We describe a 12-year-old girl with solid pseudopapillary tumor in the body of the pancreas that was successfully treated with LSDP, preserving the splenic vessels. The postoperative course was uneventful, and the functional and aesthetic results were satisfactory. Laparoscopic spleen-preserving distal pancreatectomy with conservation of splenic vessels may be a safe and feasible treatment option for children with pancreatic disease.     

Laparoscopy-assisted spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein

Herein, we report the successful performance of a laparoscopy-assisted spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for a patient with pancreatic cystadenoma, as a minimally invasive procedure with the preservation of function. The laparoscopy-assisted distal pancreatectomy procedure involved detaching the spleen and the distal pancreas from the retroperitoneum by a hand-assisted procedure, removing them from the peritoneal cavity through a small incision, and detaching the distal pancreas by ligating and transecting the short gastric artery and vein and the branches of the splenic artery and vein, while the spleen and main splenic artery and vein were preserved under direct view. The pancreatic parenchyma was transected with a stapling device (TL-30), and continuous suturing was added to the resected margin. The patients postoperative course was uneventful; the patient started to eat and walk on postoperative day 2 and was discharged on day 8. It is considered that the combination of hand-assisted and laparoscopy-assisted distal pancreatectomy, with conservation of the splenic artery and vein, is a minimally invasive and clinically useful technique for treating tumors of cystic disease of the pancreas with low-grade malignant potential, or benign solitary neuroendocrine tumors.     

Laparoscopic spleen-preserving distal pancreatectomy

Distal pancreatectomy with spleen preservation may be the preferred procedure for certain benign tumors and cystic lesions of the pancreatic body or tail. Alternatively, laparoscopic removal including either distal pancreatectomy with splenectomy or splenic-preservation with ligation of the splenic vessels have also been described. We describe, herein, our method to perform spleen-preserving laparoscopic distal pancreatectomy that preserves the splenic vessels and hence splenic function. The described technique of spleen-preserving distal pancreatectomy has been used in two patients with favorable results. Both patients underwent laparoscopic distal pancreatectomy with splenic conservation for an oligocystic serous cystadenoma and serous cystadenoma. Operative time was 3–6 hours with total blood loss of less than 200 cc in both cases. The length of stay in the hospital was 4–8 days and both patients returned to work within 3 weeks. Laparoscopic spleen-preserving distal pancreatectomy should be considered for younger patientswith select body or tail lesions that are not candidates for less extensive procedures.     

Spleen-preserving laparoscopic distal pancreatectomy after division of the splenic vessels

A 37-year-old woman with a history of syncope was hospitalized with a diagnosis of hypoglycemia due to insulinoma. Computed tomography (CT) and magnetic resonance imaging revealed an enhanced solid mass, 1.5 cm in diameter, at the tail of the pancreas. Angiography via the splenic artery revealed a hypervascular mass. Because the tumor was located deep in the pancreatic parenchyma, laparoscopic distal pancreatectomy was performed. The pancreas was exposed by dissecting the greater omentum, and the tumor was located by intraoperative ultrasonography. After division of the splenic artery, the pancreas, main pancreatic duct, and splenic vein were transected with an endoscopic linear stapler. The pancreatic pedicle was divided at the splenic hilum to preserve the spleen. The postoperative course was uneventful except for the appearance of splenic infarction on a CT scan 2 weeks after surgery but without any overt symptoms. Spleen-preserving laparoscopic distal pancreatectomy by division of splenic vessels is a feasible treatment option for benign pancreatic disease.     

腹腔镜保留脾脏胰体尾切除术的关键技术

腹腔镜保留脾脏胰体尾切除术适用于胰体尾部良性或低度恶性病变,避免了脾切除术后近、远期并发症,手术方式包括保留脾动静脉的Kimura手术和切除脾动静脉主干、保留胃网膜左血管等侧枝循环的Warshaw手术。腹腔镜下Kimura手术视野清晰,安全可行,术后并发症发生率低,应为保脾胰体尾切除手术的首选。术前检查或术中探查可疑为浸润性恶性病变或病灶与脾血管、脾门关系密切者,应果断放弃保脾术式,改行胰体尾联合脾切除术。     

Novel approach to laparoscopic resection of tumours of the distal pancreas

Background: Laparoscopic resection for small lesions of the pancreas has recently gained popularity. We report our initial experience with a new approach to laparoscopic spleen‐preserving distal pancreatectomy so that the maximum amount of normal pancreas can be preserved while ensuring adequate resection margins and preservation of the spleen and splenic vessels. Methods: Three patients underwent laparoscopic distal pancreatectomy with spleen and splenic vessel preservation over a 2‐month period. Surgical techniques and patient outcomes were examined. Results: All three patients were females, with ages ranging from 31 to 47 years. Two patients underwent resection using the conventional medial‐to‐lateral dissection as the lesion was close to the body or proximal tail of the pancreas. The third patient had a lesion in the distal tail of the pancreas and surgery was carried out in a lateral‐to‐medial manner. This new approach minimized excessive sacrifice of normal pancreatic tissue for such distally located lesions. The splenic artery and vein were preserved in all cases and there was no significant difference in clinical outcome, operative time or intraoperative blood loss. Conclusion: Laparoscopic distal pancreatectomy with preservation of the spleen and splenic vessels is a feasible surgical technique with acceptable outcome. We have shown that a tailored approach to dissection and pancreatic transection based on the location of the lesion allows the maximum amount of normal pancreatic tissue to be preserved without additional morbidity. Although the conventional ‘medial‐to‐lateral’ approach is recommended for more proximal tumours of the pancreas, distal lesions can be safely addressed using the ‘lateral‐to‐medial’ approach.     

保留脾脏胰体尾切除术的临床探讨

目的探讨保留脾脏胰体尾切除术的可行性和安全性。方法总结2006年2月—2010年8月1 6例胰体尾部良性和交界性病变实行了保留脾脏的胰体尾切除术的临床资料,其中15例为保留脾脏血管胰体尾切除,1例为切断脾血管保留脾脏胰体尾切除。结果术后发生胰瘘9例,切口感染1例,腹腔出血3例(其中1例为胰瘘后发生出血),胸腔积液2例。9例胰瘘者,8例经非手术治疗,3~7周痊愈,1例并发出血后行数字减影脾动脉栓塞止血,第17周痊愈。另2例腹腔出血者,1例经非手术治疗治愈,1例二次手术,见脾静脉分支出血,结扎止血。全组无死亡病例。结论胰体尾部良性和交界性肿瘤,可首先选择保留脾脏的胰体尾切除术,手术安全,疗效好。     

Spleen-preserving pancreatectomy for cystic pancreatic neoplasms.

Cystic neoplasms of the pancreas are an uncommon entity comprising fewer than 1 per cent of all pancreatic neoplasms. The guidelines for management of these tumors, specifically, the extent of resection, are unclear. Formerly, a distal pancreatectomy including the spleen was performed for tumors in the tail of the pancreas. The importance of preserving the spleen has been well documented; however, there are few reports of spleen-preserving pancreatectomy for cystic neoplasms of the distal pancreas. We report two patients who underwent spleen-preserving pancreatectomy for mucinous cystic neoplasms in the tail of the pancreas. Both patients were female, ages 39 and 65 years. Preoperative preparation included administration of vaccinations and subcutaneous somatostatin. Operative technique emphasized division of the splenic artery and vein beyond the tip of the distal pancreas without mobilization of the spleen. The pancreas was transected with a vascular stapler. Fibrin glue was applied to the margin of the pancreas. The operative blood loss, duration of operation, and postoperative hospital stay were 150 and 250 mL, 150 and 180 minutes, and 7 and 9 days, respectively. The pathology revealed both lesions to be mucinous cystic neoplasms. The patients recovered and at 6-month follow-up were without complaints and in good health. Spleen-preserving pancreatectomy is rapid and associated with minimal morbidity. This procedure should be considered in the surgical management of cystic neoplasms in the tail of the pancreas.     

机器人保留脾血管胰体尾切除术治疗儿童胰岛素瘤报道

目的报道国内外首例儿童机器人保留脾血管胰体尾切除术,探讨该方法治疗儿童胰腺良性疾病的可行性和安全性。 方法2016年7月收治1例儿童胰体尾胰岛素瘤病例,患儿女性,9岁,体质量24 kg,身高1.20 m。行机器人保留脾血管的胰体尾切除术。机器人操作时采用4孔法：自脐下缘微小切口置入气腹针建立气腹后缝合该切口,观察孔位于下腹正中脐下5 cm(10 mm),1臂位于左侧平脐水平与腋前线的交点(8 mm),2臂位于右侧脐水平下2 cm与腋前线交点(8 mm),辅助孔位于左侧锁骨中线脐水平下3 cm(12 mm)。用超声刀切开胃结肠韧带,显露胰腺,腹腔镜超声探查证实病灶位于胰尾,直径约2 cm;切断脾结肠韧带,结肠脾曲向下游离;用电凝沿胰腺下缘分离胰后间隙,向脾门进行,将胰尾与脾脏之间的粘连分开,于胰腺后方分离出脾静脉,胰腺上缘分离出脾动脉,逐一分离夹闭或缝合动静脉与胰腺之间的分支,使胰尾完全游离,距离肿瘤右侧约1 cm以直线切割闭合器蓝色钉仓切断胰体尾,胰腺断端以4-0 Prolene线连续缝合。标本装入一次性标本袋自辅助孔取出,胰腺断端放置乳胶引流管1根自腹壁右侧孔引出。 结果手术时间155 min,气腹时间120 min,术中出血量约10 ml,围手术期恢复顺利,无胰瘘、出血及腹腔感染等并发症。术后血糖恢复正常,空腹胰岛素及血糖比值小于0.4,胰腺MRI平扫及增强扫描显示胰腺无肿瘤残留。 结论机器人与传统腹腔镜相比,具有三维视野、操作灵活等优点,该病例的成功经验初步显示机器人保留脾血管的胰体尾切除术治疗儿童胰岛素瘤是安全、可行的。     

Robotic Spleen-Preserving Distal Pancreatectomy. A Case Report

Distal pancreatectomy (DP) is the removal of the pancreatic tissue at the left side of the superior mesenteric vein and it is traditionally approached by an open or laparoscopic exposure. Preservation of the spleen is optional but appears to have a better immunological outcome. We present the case of a 53-year old patient with a 2.4/2.2 tumor located in the tail of the pancreas, with high tumour marker values for whom we decided to perform a robotic spleen-preserving distal pancreatectomy (RSPDP). The postoperative outcome was satisfactory. In conclusion, we recommend this type of approach for small pancreatic tail lesions.     

Laparoscopic Spleen-Preserving Distal Pancreatectomy: The Technique Must Suit the Lesion

Splenic preservation is currently recommended during minimally invasive surgery for benign tumors of the distal pancreas. The aim of this study was to evaluate the outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy, with particular attention paid to the technique used for spleen preservation (splenic vessel ligation vs preservation). A review of consecutive patients who underwent laparoscopic distal pancreatectomy with the intention of splenic preservation was conducted. Patient demographics, operative data, and outcomes were collected and analyzed. Fifty-five consecutive patients underwent laparoscopic distal pancreatectomy with the intention of splenic preservation; 5 required splenectomy (9 %). Of the remaining 50 patients, 31 (62 %) had splenic vessel ligation, and 19 (38 %) had vessel preservation. Patient demographics and tumor size were similar. The vessel ligation group had significantly more pancreas removed (95 vs 52 mm, P?<?0.001) and longer operative times (256 vs 201 min, P?=?0.008). Postoperative outcomes, complication rates, and splenic viability were similar between groups. Laparoscopic spleen-preserving distal pancreatectomy is a safe operation with a high rate of success (91 %). Vessel ligation was the chosen technical strategy for lesions that required resection of a greater length of pancreas. We found no advantage to either technique with respect to outcomes and splenic preservation. Operative approach should reflect technical considerations including location in the pancreas.     

Laparoscopic resection of the pancreas and review of the literature

BACKGROUND: Laparoscopic pancreatic surgery still is not a common procedure worldwide. Postoperative complications such as a pancreatic leakage cause a serious condition. We report our consecutive laparoscopic pancreatic resections of islet cell tumors or benign diseases and their outcomes. METHOD: Laparoscopic pancreatic resections were attempted in three patients. Preoperative diagnoses were insulinoma in two patients and cystadenoma in one patient. The lesions were located in the pancreas body in two patients and the pancreas tail in one patient. Their sizes ranged from 1 to 6 cm in diameter (mean, 3 cm). RESULTS: We performed distal pancreatectomy using an endoscopic linear stapler with conservation of the spleen in two patients and enucleation in one patient. Of the distal pancreatectomies, the splenic artery and vein were preserved in one patient, whereas in the other they were divided. There were no perioperative complications in any of the cases. The mean postoperative hospital stay was 10 days (range, 7-14 days). There were no episodes of hypoglycemia or recurrence during the mean follow-up period of 25 months (range, 11-36 months). CONCLUSIONS: Although laparoscopic pancreatic resection of selected patients is a feasible and safe procedure in the hands of experienced laparoscopic surgeons, patients must be carefully observed after surgery to avoid serious conditions by pancreatic fistula.     

Hemodynamic changes of splenogastric circulation after spleen-preserving pancreatectomy with excision of splenic artery and vein

BACKGROUND: The safety of spleen conservation without preservation of the splenic artery and vein was proved on the basis of short-term observation, but the long-term results of this procedure have been uncertain. To clarify the hemodynamic changes of splenogastric circulation of patients undergoing spleen-preserving pancreatectomy with excision of the splenic artery and vein, we retrospectively analyzed patient outcome with particular reference to the assessment of hemodynamic changes of splenogastric circulation. METHODS: Ten patients who had undergone spleen-preserving pancreatectomy with excision of the splenic artery and vein were retrospectively analyzed. In all patients both the short gastric and left gastroepiploic arteries and veins were preserved. All patients were observed for a minimum of 52 months. Collateral venous pathways were evaluated by computed tomography and endoscopy. RESULTS: Early complications such as splenic infarction and atrophy did not occur in any of the patients, but computed tomography revealed perigastric varices in 7 patients (70%) and submucosal varices in 2 patients (20%). Endoscopy showed gastric varices in 2 patients in whom submucosal gastric varices were identified on computed tomography. Gastrointestinal bleeding from gastric varices occurred in 1 patient. In 1 patient without gastric varices, a gastrorenal shunt was demonstrated on computed tomography. CONCLUSIONS: This study confirmed that gastric varices frequently occurred in patients who underwent spleen-preserving pancreatectomy with excision of the splenic artery and vein.