Laparoscopic Distal Pancreatectomy for Traumatic Transection

Resection versus non-operative management for traumatic pancreatic transaction is still somewhat controversial. Our pediatric surgery service strongly prefers an early distal pancreatectomy in cases of transection, which was typically done through a laparotomy. In this video, we demonstrate the first laparoscopic distal pancreatectomy for trauma. The patient was a 4 year old boy. He suffered blunt abdominal trauma when shelves carrying a television fell on his abdomen as he was reaching for a remote. He was hemodynamically stable at presentation but had significant epigastric pain and tenderness. Pancreatic enzymes were elevated. CT scan showed a clear pancreatic transection at a point to the left of the spine. The patient underwent the operation approximately 10 hours after admission. A 3 trochar approach was used a 12 millimeter trochar at the umbilicus for camera, stapler, and specimen extraction, and 25 millimeter upper abdominal trochars for grasping and dissection. The lesser sac is widely opened using the ligature to reveal the posterior wall of the stomach. A large curved needle is brought through the abdominal wall. Takes a large bite of stomach and exits the abdominal wall again more medially. This is tied outside to keep the stomach retracted anteriorly. Mobilization of the distal pancreas starts at its inferior margin. The site of transaction is quickly identified. The field is remarkably clean. The pancreas is only holding by a thin superior bridge of tissue. The transaction is completed with the sealing device. A rec gauze is left at the site of transaction to soak up any oozing that results during the remainder of the dissection. The pancreas is then elevated off the splenic vessels starting from the transaction site and proceeding laterally. The ligature serves as an excellent dissecting device, minimizing instrument exchange. Thin retroperitoneal attachments are divided, and the splenic vein is clearly visualized. Traction on the pancreas tents up the vein and reveals its tributaries to the pancreas. Each tributary is well skeletonized prior to ligation and division. The posterior wall of the stomach can be seen above the splenic vein. The spleen can be seen. The inferior pole is ischemic, but this had no clinical consequences. The resection is completed after dividing the last Venus tributary. The proximal pancreas is further mobilized for approximately 1 centimeter to allow for closure of the pancreatic duct using a vascular stapler. A Jackson Pratt drain is placed in the pancreatic bed, and fibrant sealant is injected over the staple line. The patient was fed on the 2nd postoperative day. The drain was removed on the 4th postoperative day, and the patient was discharged home on the 5th postoperative day. Follow up at one year continued to show an excellent outcome.