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Step by step and tips for a safe distal pancreatectomy
We present the educational video of a surgery performed in a female, 66 years-old patient with complaint of unspecific abdominal discomfort. Laboratory showed a slight increase of amylase and lipase, with normal tumor markers. MRI revealed pancreatic tail atrophy and dilation of the main pancreatic duct with a transition point. Eco-endoscopy found a 1cm nodule in pancreatic tail, with an inconclusive FNA biopsy. She was then referred to surgery and a distal pancreatectomy with splenectomy was planned. The procedure started by opening the epiploon retrocavity, then splenic artery was dissected and stapled, pancreas was mobilized with identification of the splenic vein. Intraoperative ultrasound was performed finding a distally dilated Wirsung duct, delimiting the transition point at distal pancreatic body. Thus, we opted for a parenchyma preserving approach, with the transection plane at the level of the pancreatic body including splenic vein. Even using a reinforced stapler load, after the transection, a fracture in pancreas tissue was observed leading to a discussion on how to proceed then. Our option was to extent pancreatic resection to the level of the neck, along with the Portal tunnel, to reduce the risk of pancreatic fistula. The new transection plane showed a safer aspect of the pancreatic stump closure. Then, splenic vein was dissected and ligated, and procedure was finalized with splenic ligaments release and removal of surgical specimen protected by plastic bag. No surgical drains were used. Patient had a good evolution, with hospital discharge on POD 2. Pathologic report of resected specimen revealed a moderately differentiated pancreatic ductal adenocarcinoma, 0.9 cm, with negative margins and 0/25 lymph nodes.
Distal pancreatectomy, Step by step, Tips for surgery
Trato gastrointestinal alto*
DIEGO GREATTI VAZ DA SILVA, HEBER SALVADOR DE CASTRO RIBEIRO, SILVIO MELO TORRES, ALESSANDRO LANDSKRON DINIZ, ANDRÉ LUIS GODOY, IGOR CORREA FARIAS, WILSON LUIZ COSTA JR., FELIPE JOSÉ FERNÁNDEZ COIMBRA