Case report
A 12-year-old girl was referred to our hospital with an incidentally
found tumor located in the pancreatic tail. Computed tomography (CT)
revealed a well-circumscribed, hypovascular, 7.5 cm-solid mass in the
pancreatic tail (Figure 1A). Carcinoembryonic antigen and carbohydrate
antigen 19-9 levels were not elevated and SPN was suspected. No distant
metastases were confirmed by positron emission tomography (PET)/CT.
Dynamic CT revealed that the splenic artery (SpA) originated from the
celiac artery (Type I, Adachi’s classification) running along the
superior edge of the pancreas (SpA type B, Inoko’s classification)
[3]. Laparoscopic spleen-preserving distal pancreatectomy was
planned.
The patient was placed in a lithotomy position, and the scopist stood
between her legs. A 12-mm camera port was placed at the umbilicus. Three
5-mm ports were placed at the right upper quadrant, left upper quadrant,
and left flank. Another 12-mm port was introduced at right flank. After
dividing the gastrocolic ligament, the inferior border of the pancreas
was mobilized to secure adequate proximal resection margin; therefore,
the root of the splenic artery, left gastric vein, and inferior
mesenteric vein remained unexposed. The left gastroepiploic vessels were
preserved [1]. Splenic artery was running the superior edge of
pancreatic parenchyma, hence we approached it from above (anterior
approach) [1,4] (Figure 1Ba). The dorsal dissection border of the
pancreas was maintained along the anterior layer above the Gerota’s
fascia. After splenic artery and vein were encircled individually, we
carefully dissected the splenic vessels from the pancreatic parenchyma.
(Figure 1Bb) [1,4]. We preserved the splenic vessels (Kimura
technique) to decrease the risk of complications [1,4]. After
compressing the pancreatic parenchyma with intestinal clips (Figure
1Bc), the pancreas was divided using an automatic stapling device
(Figure 1Bd). The resected specimen was retrieved through a Pfannenstiel
incision (operative time, 301 minutes; estimated blood loss, little).
Histopathological diagnosis revealed SPN with negative surgical margins.
The patient recovered uneventfully except for a biochemical leak [5]
and localized discoloration in the superior pole of spleen requiring no
intervention. She was discharged on day 7. She is alive and well with no
signs of recurrence 1 year after the operation.