Left subcostal incision
gastrocolic omentum reflecting superiorly and anteriorly.
This reveals the posterior surface of the omentum as it attaches to the transverse mesocolon.
dissect the attachments between the omentum and the transverse colon.
There is characteristically some amount of adhesion between the appendices epiploicae and the transverse mesocolon, and these must be carefully separated until the lesser sect can be entered (Figure 47-3).
omentum is mobilized along the transverse colon,
possible to extend the dissection well over to the right of the midline if necessary to establish a wider entry into the lesser sac.
reflect the stomach superiorly and anteriorly,
revealing the anterior surface of the body of the pancreas.
The omentum dissection can be carried to the left,
mobilizing the splenic flexure of the colon in this fashion.
It may be helpful to
reflect the splenic flexure of the colon inferiorly to delineate the inferior border of the spleen and the inferior border of the tail of the pancreas.
splenic artery on the superior border of the pancreas. This maneuver may facilitate control of hemorrhage
peritoneal attachments, lateral to the spleen, are incised using electrocautery,
mobilization of the spleen and the tail of the pancreas toward the midline.
continue medially along the superior border of the spleen.
As one turns the dissection in an inferior direction on the medial (hilar) aspect of the spleen, one encounters the short gastric vessels
mobilization between the kidney and the adrenal glands posteriorly and the spleen and the tail of the pancreas anteriorly.
a vascular attachment at the inferior border of the pancreas between the spleen and the splenic flexure of the colon.
This should be divided between clamps and tied using 3-0 or 2-0 silk ties.
the vascular attachments between the greater curvature of the stomach at the fundus and the spleen, the short gastric vessels, are divided between clamps and tied using 2-0 and 3-0 silk ties.
Caution should be taken not to place a tie on the wall of the stomach, because this may result in a necrosis of the greater curvature.
After this amount of mobilization, it should be possible to separate completely the spleen and the tail of the pancreas from its retroperitoneal attachments further toward the midline.
Typically this dissection is carried until one has reached a minimum of 3 cm medial to the mass that is anticipated for resection
At this point, the decision needs to be made regarding preservation of the spleen.
If no plans are made to preserve the spleen, it should be possible to separate and ligate the splenic artery and the splenic vein. One must always divide the artery before dividing the vein to prevent any engorgement and bleeding of the spleen
If one is planning on preserving the spleen, then the small vascular attachments between the splenic artery and the tail of the pancreas and body of the pancreas and between the splenic vein and the body and tail of the pancreas must be carefully divided and tied using 3-0 silk ties.
It is during this dissection that one may conclude that a splenectomy is safer than the hemorrhage that could at times result from this dissection in a patient who has had a significant history of pancreatitis
At this point, one should have separated the tail of the pancreas from the splenic artery and vein or should have divided the splenic artery and vein,
the only remaining attachments should be the parenchyma of the pancreas.
We prefer a fish mouth opening to the body of the pancreas. This involves angling at approximately 45 degrees toward the head of the pancreas, along the anterior border of the body of the pancreas to approximately half the depth of the body of the pancreas. We then go to 90 degrees in the opposite direction, again with a 45-degree angulation, and incise toward the tail of the pancreas.
This permits apposing the ends of the divided pancreas in the hopes of preventing a pancreatic fistula (Figure 47-8). ♦
At this point, one must carefully identify the pancreatic duct. This may be accomplished by gently massaging the body of the pancreas and expressing pancreatic juice through the duct
ligate with 4-0 prolene
pancreas reapproximated using interrupted 2-0 Prolene sutures.
two drains are placed in the retroperitoneum, just lateral of the divided body of the pancreas.