Spleen preservation is advisable if feasible during distal pancreatectomy for benign pancreatic tumors. A 31 year old patient had a blunt abdominal injury. Computed Tomography (CT) scan showed an incidental tumor in the body of the pancreas. EUS-guided cytology revealed a solid pseudopapillary tumor with benign features.This video demonstrates the technical details during a minimally invasive excision of a rare tumor of the pancreas in a male patient. Very few cases have been reported in males.
Editor Recruited By: Jeffrey B. Matthews, MD
DOI: http://dx.doi.org/10.17797/cc7ot3ymd8
Diagnostic laparoscopy is performed and confirms the preoperative findings. Division of gastrocolic omentum is performed up to the area of fundus, safeguarding the short gastric vessels.. The pancreas is exposed and laparoscopic ultrasonography helps to delineate the tumor borders and its proximity to the underlying splenic vessels. Release of the splenic flexure of the colon is accomplished to expose the distal aspect of the body and the tail of the pancreas. The dissection of the pancreas is performed using a linear vessel sealing device (LigaSure¢¢) and the hook electrocautery in a clockwise fashion by dissecting its lower border, then the peritoneum covering the anterior aspect of the normal pancreas, 2 cm proximal to the tumor border, followed by dissection of the superior border of the pancreas safeguarding the tortuous splenic artery. A plane is created between the splenic vessels and the inferior surface of the pancreas proximal to the tumor. Transection of the body of the pancreas is accomplished using reinforced linear staple loads. Separation of the entire body and tail of the pancreas from the splenic vessels is performed, controlling all branches to the pancreas. The specimen is placed in a pouch and extracted. Operative time: 170 minutes. Blood loss: 50 ml. The patient tolerated food on postoperative day 2 and was discharged on postoperative day 4. Pathology: 6x5 cm benign solid pseudopapillary tumor with clear margins.
1.Pancreatic cancer
2.Vascular invasion
3.Pancreatitis involving the entire pancreas
4.Contraindications of general anesthesia like severe cardiac and pulmonary failure.
The patient is placed in right semi-lateral position. The surgeon stands on the patient¢s right side and two assistants on the left side. A Veress needle is placed in the upper abdomen and CO2 pneumoperitoneum is obtained. Four trocars are placed in a crescent fashion along the left costal margin. A 5mm trocar in the epigastric area, a 10 mm trocar midway between xiphisternum and umbilicus, a10 mm trocar at the left midclavicular area and a 5 mm trocar at the left anterior axillary line.
1.CT scan of the abdomen, pancreas protocol
2.Endoscopic ultrasonography (EUS) and Fine needle aspiration (FNA) cytology
3.Tumor markers (CA19-9 and CEA)
4.General labs including complete blood count, serum electrolytes, creatinine, glucose, albumin and prealbumin
1.Spleen preservation may not be possible if the tumor is invading or inseparable safely from the splenic vessels.
2.Sacrificing splenic vessels can be done in cases of uncontrollable bleeding or invasion provided short gastric vessels stay intact during dissection. Intact short gastric vessels can preserve blood supply to the spleen (Warshaw approach).
3.Robotic assisted approach is an alternative method of doing the procedure
4.Conversion to open approach is vital in case of uncontrollable bleeding, unstable patient and failure of laparoscopic approach.
Advantages:
1. Laparoscopic approach has specific benefits over open approach: less intraoperative blood loss, less pain, cosmetic benefit (smaller incisions), less incidence of incisional hernia, less incidence of wound infection, earlier return to normal activities of daily living
2. Preserving the spleen has a possible immunological benefit over splenectomy
Disadvantages:
1.Laparoscopic approach has longer operative time. Likewise, spleen preservation adds more time to the procedure
2.Laparoscopic approach is not advisable in patients with borderline intraoperative vital parameters
Intraoperative:
1.Bleeding when not easily controllable with laparoscopic means should be converted to exploratory laparotomy and possible ligation of main splenic vessels and splenectomy
2.Inability to preserve spleen due to tumor invasion or devascularization. This necessitates distal pancreatosplenectomy
Early postoperative:
1.Bleeding which could be treated by blood transfusion with or without operative hemostasis according to the amount of blood loss
2.Pulmonary complications such as atelectasis and pneumonia which may necessitate admission to the ICU and treatment accordingly
Late postoperative:
1.Pancreatic fistula. Incidence is approximately 5-8% and varies in severity. Minor leaks can be treated by drainage with expectant management. Moderate leaks require NPO with either TPN or nasointestinal feeding beyond the ligament of Treitz, and possibly somatostatin infusion. Major leaks that do not respond to the above methods may require ICU support and exploratory laparotomy for better drainage and possibly necrosectomy
2.Mortality is approximately 1% and depends upon age, comorbidities and response to treatment
3.Intraabdominal abscess collection (4-5%). This is mostly due to leak which can be treated by drainage with or without debridement.
4.Re-exploration incidence is 1-6%. This is usually for bleeding, debridement or better drainage.
5.Long hospital or ICU stay. Average stay is 6-9 days.
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1.Papavramidis T, Papavramidis S. Solid pseudopapillary tumors of the pancreas: review of 718 patients reported in the English literature. J Am Coll Surg. 2005;2:965¢72.
2.Yu PF, Hu ZH, Wang XB, et al. Solid pseudopapillary tumor of the pancreas: a review of 553 cases in Chinese literature. World J Gastroenterol. 2010 Mar 14;16(10):1209-14.
3. Speer AL, Barthel ER, Patel M. Solid pseudopapillary tumor of the pancreas: a single-institution 20-year series of pediatric patients. J Ped Surg. 2012;47: 1217¢1222.
4.Morikawa T, Onogawa T, Maeda S, et al. Solid pseudopapillary neoplasms of the pancreas: an 18-year experience at a single Japanese Institution. Surg Today. 2013 Jan;43(1):26-32.
5.Kleeff J, Diener M, Z'graggen K, et al. Distal Pancreatectomy, risk Factors for Surgical Failure in 302 Consecutive Cases. Ann Surg. 2007 Apr;245(4): 573¢582.
6.Shoup, M, Brennan M, McWhite K, et al. The Value of Splenic Preservation with Distal Pancreatectomy. Arch Surg. 2002; 137(2): 164-168.
7.Lillemoe KD, Kaushal S, Cameron J, et al. Distal Pancreatectomy: Indications and Outcomes in 235 Patients. Ann Surg. 1999 May;229(5): 693.
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Authors
Carol Li, MD1*, Apoorva T. Ramaswamy, MD1*, Sallie M. Long, MD 1 , Alexander Chern, MD 1 , Sei Chung, MD 1 , Brendon Stiles, MD 2 , Andrew B. Tassler, MD 1
1Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY 2Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
*Co-First authors
Overview
The COVID-19 pandemic is an unprecedented global healthcare emergency. The need for prolonged invasive ventilation is common amid this outbreak. Despite initial data suggesting high mortality rates among those requiring intubation, United States data suggests better outcomes for those requiring invasive ventilation. Thus, many of these patients requiring prolonged ventilation have become candidates for tracheotomy. Considered aerosol generating procedures (AGP), tracheotomies performed on COVID-19 patients theoretically put health care workers at high risk for contracting the virus. In this video, we present our institution’s multidisciplinary team-based methodology for the safe performance of tracheotomies on COVID-19 patients. During the month of April 2020, 32 tracheotomies were performed in this manner with no documented cases of COVID-19 transmission with nasopharyngeal swab and antibody testing among the surgical and anesthesia team.
Procedure Details
The patient is positioned with a shoulder roll to place the neck in extension. The neck is prepped and draped in a sterile fashion with a clear plastic drape across the jawline extending superiorly to cover the head. An institutional timeout is performed. The patient is pre-oxygenated on 100% FiO2. A 2-cm vertical incision is made extending inferiorly from the lower border of the palpated cricoid cartilage. Subcutaneous tissues and strap muscles are divided in the midline. When the thyroid isthmus is encountered, it is either retracted out of the field or divided using electrocautery. The remaining fascia is then cleared off the anterior face of the trachea.
Prior to airway entry, the anesthesiologist pauses all ventilation and turns off oxygen flow. The endotracheal tube (ETT) is advanced distally past the planned tracheotomy incision, without deflating the cuff, if possible. If necessary, the endotracheal cuff is deflated partially to advance the tube, with immediate reinflation once in position. The surgical team then creates a tracheotomy using cold steel instruments. The cricoid hook is placed in the tracheotomy incision and retracted superiorly for exposure of the lumen. The tube is withdrawn under direct visual guidance, without deflating the endotracheal cuff if possible. The tracheotomy tube is placed, and to minimize aerosolization of respiratory secretions, the cuff is inflated prior to re-initiation of ventilation. The tracheotomy tube is then sewn to the skin using 2-0 prolene suture. A total of five simple stitches are placed around the tube to prevent accidental decannulation.
Indications/Contraindications
Candidacy for tracheotomy was determined on a case by case basis with consideration for progression of ventilator weaning, viral load, and overall prognosis. All patients who underwent tracheotomy were intubated prior to the surgery for a minimum of 14 days, able to tolerate a 90-second period of apnea without significant desaturation or hemodynamic instability, and expected to recover. Optimal ventilator settings included FiO2 = 50% and PEEP = 10 cm H20.
Instrumentation
A standard tracheostomy instrument tray was utilized, including the following: tonsil dissector, DeBakey forceps, right-angle retractors, cricoid hook, and tracheal dilator. Bovie electrocautery was also utilized.
Setup
Please refer to the diagrams depicted in the accompanying video.
Preoperative Workup
An apnea test was performed for 90 seconds to ensure that the patient had adequate reserve. Ventilator settings were optimized. If possible, systemic anticoagulation was paused.
Anatomy and Landmarks
Important landmarks include the thyroid cartilage, cricoid cartilage, and sternal notch. A high-riding innominate artery can be detected on imaging and with palpation during the surgery.
Advantages/Disadvantages
Given the unique benefits of tracheotomy in avoiding the laryngeal trauma associated with prolonged intubation, decreased dead space, and ease of trialing patients off of the ventilator, there is high motivation to perform tracheotomies in COVID-19 patients requiring intubation and prolonged mechanical ventilation. Major disadvantages include the risk of virus transmission among the surgical and anesthesia team.
Complications/Risks
Short-term complications include bleeding and infection, such as peristomal cellulitis. Long-term complications of tracheostomy include cartilage destruction or deformity, granulation tissue formation, and superficial scarring.
References: N/A
As technique and technology have evolved in the modern age, surgical emphasis has shifted steadily towards minimally invasive alternatives. In colon surgery, laparoscopy has been shown to improve multiple outcome metrics, including reductions in post-operative morbidity, pain, and hospital length of stay, while maintaining surgical success rates. Unfortunately, despite the minimally invasive approach, elective laparoscopic sigmoidectomy typically requires an abdominal wall extraction site, leaving a large incision in addition to the laparoscopic port sites. It also utilizes three different types of intestinal staplers, leading to an anastomosis that may have multiple intersecting staple lines, thereby potentially influencing the anastomotic integrity, as well as increasing procedural costs substantially.
We present a case of a totally robotic sigmoidectomy utilizing a single stapler technique and natural orifice specimen extraction in a patient with multiple, severe, recurrent episodes of sigmoid diverticulitis over a 2-year period.
Disclosure/ Conflict of interest: The authors whose names are listed above certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers ’bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Review Spleen Preserving Laparoscopic Distal Pancreatectomy for a Solid Pseudopapillary Tumor.