Laparoscopic distal pancreatectomy is most often performed with four trocars. A hand assist port can be useful in some settings but its use may be limited in younger children with less abdominal domain. Subcostal and perixiphoid trocar positions are modified according to the size of the child. Working ports should accept 5 mm instruments and at least one port should accept endosurgical stapling devices. After achieving pneumoperitoneum, the lesser sac is entered through the gastrocolic ligament and omentum. The pancreas is then explored through the lesser sac. If the spleen is to be preserved, the short gastric vessels are preserved. To gain further exposure of the pancreas, the short gastric vessels can be taken up to the level of the gastroesophageal junction, however splenectomy will then be required if the splenic vessels are sacrificed. The splenic flexure is than mobilized to expose the inferior edge of the tail of the pancreas. The pancreas is then mobilized out of the retroperitoneum by incising the peritoneum from the inferior edge of the pancreas to the inferior pole of the spleen.The pancreatic tail is then mobilized and retracted medially. This dissection allows the splenic artery and vein to be isolated and divided with a vascular stapler or between clips.
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Review Lap Distal Panc- Surg Endosc.