Chung Ngai Tang (Hong Kong – China)

History:

1. PMH: HT, DM, PE on warfarin, History of tubal ligation
2. Incidental finding in PET-CT done for investigation of ?pyrexia of unknown origin?
3. PET-CT 28/6/2017
   Suspected pancreatic cystic neoplasm
   No obvious distant met. / vascular invasion
4. Ca 19.9/CEA normal
5. CT 3/9/2017
   • Thick walled macrocystic lesion measuring 3.6 x 3.3 x 3.7cm with peripheral calcification in pancreatic tail
   • Two further smaller cystic lesions measuring up to 0.8 x 1.3cm with peripheral calcification are noted in the pancreatic tail, closely abutting the larger lesion
6. Main pancreatic duct is not dilated

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Chung Ngai Tang (Hong Kong – China)

Hx of:
– Ca left breast with OT done in private 2010, postop given RT and aromatase inhibitor
– Incidental findings of 6cm pancreatic tail cystic lesion on follow up USG arranged by private surgeon
– No previous pancreatitis

FU CT and MRI showed
– Interval increasing in size to 7.8cm with high proteinaceous content, features suspicious of mucinous cystadenoma

CEA, CA19.9 normal

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Pier C. Giulianotti (Chicago – USA) Eduardo Fernandes (Chicago – USA)

Distal pancreatectom, neat dissection with minimal blood loss.

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Videopresentation Advanced Robotic Course Colorectal-HPB-Endocrine held in grosseto November 28 – December 02, 2011

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A.J. Moser

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F. Bianco

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Pier C. Giulianotti (Chicago – USA)

Summary:
We present the case of a 53-years-old female with a cystic lesion of the pancreatic tail, defined as IPMN at the final pathology. She underwent robotic-assisted spleen preserving distal pancreatectomy with the DaVinci Si HD: in supine position with parted legs and arms adducted, trocars were positioned along an arc with the center in the pancreatic region. After pancreatic transaction with harmonic scalpel, splenic artery and vein were preserved dividing all the small vessels coming from the pancreas. Finally, the spleen was left in place with a physiological vascular supply.

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A.J. Moser, Herbert J. Zeh III

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Enrique Fernando Elli (Chicago – USA)

Background/Hypothesis
Minimally invasive spleen-preserving distal pancreatectomy (SPDP) represents a safe and reliable surgical option for benign or borderline tumors of the body and tail of the pancreas. Two techniques are currently adopted for the preservation of the spleen, one entail the preservation of the splenic vessels whereas the other sacrifices the splenic vessels, leaving the short gastric vessels to supply the spleen. The latter technique has been associated with a higher rate of splenic complications. We report our approach to robot-assisted SPDP based on the principle of systematic splenic vessels preservation by medial-tolateral dissection.

Materials & Methods
A five trocar technique is used.The dissection begins at the neck of the pancreas in order to achieve control of the proximal splenic artery. The pancreatic neck is freed from the superior mesenteric vein, the splenomesenteric confluence, and the portal vein, thereby creating a retropancreatic tunnel between the posterior aspect of the pancreas and the portal vein. Then the neck of the pancreas is transected using the Harmonic shears and the proximal stumps is reinforced with 4/0 prolene interrupted stitches. The distal stumps is then lifted using two stay sutures and all the venous branches that connect the pancreas to the splenic vein are isolated and sutures ligated with prolene 4/0-5/0.

Results
Between June 2001 and July 2009 this technique has been used to perform SPDP in twelve out of twenty-four patients who underwent robot-assisted spleen-preserving distal pancreatectomy P. No conversion occurred. The mean operative time was 256 min (range 140- 340). The splenic vessels were preserved in all cases. The mean size of the lesions resected was 29mm (range, 12-60mm). Three patients developed a pancreatic fistula which was treated conservatively in all but one who required a percutaneous radiologic drainage.

Conclusions
Robotic SPDP is a safe and feasible for benign and borderline pancreatic tumours of the body and tail of the pancreas. A medial to lateral approach using the robotic assistance may facilitate the rate of splenic vessels preservation during minimally invasive spleen preserving distal pancreatectomy

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