Introduction: Distal pancreatectomy and splenectomy is utilized to resect lesions in the body and tail of the pancreas. It has become common for this procedure to be performed using minimal invasive techniques. Often, the splenic vein is thrombosed as a sequelae of the disease process in the pancreas, leading to portal hypertension and intraabdominal varices. In this video, we keys for success and pitfalls to avoid during key steps of a distal pancreatectomy and splenectomy in the setting of portal hypertension.

Video Description: Portal hypertension presents a risk of increased bleeding from engorged varcies in the gastrosplenic ligament during dissection for distal pancreatectomy and splenectomy, which can limit visualization and be difficult to control laparoscopically. This video discusses techniques to decrease the pressure in the intraabdominal varices prior to dissection, thus avoiding blood loss. The key step is to ligate the splenic artery earlier than is standard. Other techniques including performing a small sleeve gastrectomy to bypass large varices in the splenic hilum and making liberal use of a vascular stapler. This video provides a step-by-step approach for implementing these techniques to successfully complete a distal pancreatectomy and splenectomy in the setting of large varicosities.

Conclusion: Intraabdominal varices present unique challenges to performing a laparoscopic distal pancreatectomy and splenectomy. A thoughtful stepwise approach, as demonstrated in this video, will allow the surgeon to overcome these challenges and safely perform a minimally invasive resection in the patient with portal hypertension.