Journal of Visceral Surgery (2020) 157, 249—253

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SURGICAL TECHNIQUE

Laparoscopic central pancreatectomy:

Surgical technique
S. Dokmak ∗, B. Aussilhou , F. Samir Ftériche ,
O. Soubrane , A. Sauvanet

Department of HPB surgery and liver transplantation, Beaujon Hospital, University Paris 7
Denis Diderot, Assistance publique—Hôpitaux de Paris, 100, boulevard du Général-Leclerc,
92110 Clichy, France

Available online 6 June 2020

Advances in imaging have led to more frequent diagnosis of pancreatic lesions of low malig-
nant potential, some of which require surgical resection. These lesions must be resected
with parenchymal sparing techniques in order to limit the risk of endocrine and exocrine
insufficiency [1]. For lesions that are located in the left pancreas for which enucleation is
not possible, central pancreatectomy (CP) is theoretically an excellent alternative, par-
ticularly if the remaining distal pancreas is more than 5 cm in length. As CP is more morbid
than distal pancreatectomy [2], this intervention should be reserved for patients at low
risk of pancreatic fistula or other complications. Contraindications to CP include fatty
infiltration of the pancreas and high risk of pancreatic fistula, age > 70 years, length of the
residual distal pancreas < 5 cm, patients with pre-existing diabetes and/or use of therapeu-
tic anticoagulation medications. The applicability of the laparoscopic approach for CP is
very high, due to the absence of vascular and oncological contraindications [3]. In addition
to the preservation of pancreatic function, there are also general and parietal benefits,
especially since these laparoscopic CPs are most often performed in young women.
In this article, we describe a modal technique of CP for lesions located at the level
of the pancreatic isthmus. It should be noted that there are other techniques of CP with
technical variations that will not be covered in this description, e.g., CP for lesions located
in the pancreatic head just to the right of the gastroduodenal artery (CP extended to the
right), in the body of the pancreas (CP extended to the left) or CP including resection of
the splenic vessels.

∗ Corresponding author.
E-mail address: safi.dokmak@aphp.fr (S. Dokmak).

https://doi.org/10.1016/j.jviscsurg.2020.04.009
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 250
The patient is positioned supine with the right arm along-
side the body and the left arm extended at an angle of less
than 90◦ to the trunk, with the legs apart (Fig. 1). The first
trocar is inserted by open technique, and two 12 mm trocars
and four 5 mm trocars are eventually introduced. Trocars 1
and 2 are for the operator, trocars 3 and 4 are for the assis-
tant, and trocars 5 and 6 are for the double gastric hanging.
The operator stands on the patient’s right, the assistant
between the legs and the nurse stands to the operator’s
right. We avoid the crossing of arms between the opera-
tor and the assistant in all cases. Thermofusion and bipolar
forceps as well as clips are necessary for hemostasis.
The gastrocolic ligament is opened widely into the lesser
sac, preserving the gastro-epiploic arcade (Fig. 2). This
opening should be extended to the right to expose the isth-
mus and to the left out to the gastro-splenic ligament but
sparing the short gastric vessels, since some patients may
eventually require resection of the splenic vessels. Colo-
epiploic detachment is to be avoided because it takes longer
to perform and always carries a small risk of colonic injury.
A double gastric hanging is then carried out to provide good
exposure of the pancreas, the isthmus, the gastroduodenal
artery, and collaterals of the celiac trunk. After division of
the gastro-colic ligament, the stomach is rotated around
its horizontal axis bringing the posterior wall to the front
in order to move the omentum away from the operating
field. A first suspensory loop is introduced through a left
para-xiphoid trocar (Fig. 1, trocar 5) to encircle the stom-
ach to the right of the left gastric vessels and pull it up
to the abdominal wall while a second loop through the
Figure 1. Patient Set-up.
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S. Dokmak et al.
right subcostal trocar (Fig. 1, trocar 6) retracts the antrum
(without however bringing it up against the abdominal wall).
This allows excellent exposure of the body and tail of the
pancreas [4,5]. Release of the duodeno-jejunal angle is not
necessary but some fulldown mobilization of the colonic
splenic flexure may facilitate the positioning of drains on
the left.
Dissection begins with release of the lower edge of the
pancreas in order to find the correct dissection plan and to
allow a better grasp of the pancreatic gland without tearing
it (Fig. 3). Small venous collaterals located at this level are
controlled, allowing identification and release of the ante-
rior surface of the mesenteric axis and the termination of the
splenic vein. Lymph node dissection is then performed from
the origin of the hepatic artery and the left gastric pedi-
cle, thus allowing the identification of the hepatic artery
and the upper edge of the pancreas. This gesture is made
very easy by the double gastric hanging and retraction of the
gastric antrum, which also allows identification of the ante-
rior aspect of the portal vein as it passes behind the hepatic
artery.
At this stage, the retro-isthmic passage is developed
using a dissector and the isthmus is elevated with an
absorbable suture ( the absorbale material is used to over-
come an accidental grasping of the suture by the mechanical
stapler)(Fig. 4). The retro-isthmic passage is widened with
a dissector to allow passage of a 60 mm mechanical sta-
pler (2.5 or 3.6 mm staple load) to divide the pancreas
(Fig. 4a). Additional hemostasis, if necessary, is obtained
by bipolar electrocautery. If dissection of the retro-isthmic
 Laparoscopic central pancreatectomy: Surgical technique 251

Figure 2. Double gastric hanging. Figure 3. Control of the isthmus and lymph node dissection.

passage is difficult (lesion near the gastroduodenal artery,
inflammatory adhesions or vascular invasion around the
mesenterico-portal axis, etc.), we recommend a more pre-
cise, progressive division of the pancreas in order to better
identify the vascular structures and avoid stapling of the
gastroduodenal artery. In this case, the section is mainly car-
ried out with the thermofusion forceps (Fig. 4b). The divided
right gland is closed with interrupted sutures and with elec-
tive ligature of Wirsung’s duct if possible. Before dividing the
pancreas, pulsation in the hepatic artery must be checked.
The artery adjacent to the isthmus is the hepatic artery, not
the splenic artery!
The pancreas is freed from right to left, retracting the
specimen to the left and cephalad or caudad to release

Figure 4. Division of the pancreas on the right side.

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 252 S. Dokmak et al.

Figure 5. Freeing (Mobilization?) of the pancreas.

Figure 7. Pancreatico-gastric anastomosis.

the lower and upper edges of the pancreas respectively and
then downward and leftward on the other side on the meso-
colon (Fig. 5). As CP is at high risk of pancreatic fistula and
post-operative hemorrhage, we recommend ligation of arte-
rial collaterals originating mainly from the splenic artery
and the superior mesenteric artery. Small venous collat-
erals can be controlled with clips or thermofusion/bipolar
forceps. The pancreatic liberation is extended beyond the
first loop of the splenic artery in order to have a safe resec-
tion margin on the left and to mobilize the distal pancreas
sufficiently for pancreatico-gastric anastomosis. In certain
specific cases, particularly if preservation of the splenic ves-
sels is difficult (intra-operative injury, inflammation, tumor,
etc.), one can ligate the splenic vessels in association with

Figure 6. Division of the distal pancreas.

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 Laparoscopic central pancreatectomy: Surgical technique
Figure 8. Omentoplasty and drainage.
the CP. The distal pancreas will then receive its vasculariza-
tion via the short gastric vessels, which is why these vessels
should always be preserved when the gastro-colic ligament
is opened.
The pancreas is divided to the left of the lesion with
a margin between 1—10 mm depending on the nature of
the lesion (Fig. 6). This transection is performed with the
thermofusion forceps while the main pancreatic duct is
divided with scissors (Fig. 6a). Hemostasis of the divided
edge is done mainly with bipolar forceps. In certain cases
where Wirsung’s duct is well identified, it is possible to
insert a small lost drain, mainly to avoid incidental liga-
tion of the duct during the pancreatico-gastric anastomosis.
Meticulous hemostasis should be assured before starting the
pancreatico-gastric anastomosis, particularly at the level of
the pancreatic transection, and the splenic vessels (Fig. 6b).
The first loop of the double gastric hanging is partially
relaxed allowing good exposure of the posterior surface of
the gastric fundus (Fig. 7). We perform a pancreatico-gastric
anastomosis in a single layer with interrupted sutures of 2-0
silk. Suturing commences (starts?) at the upper edge of the
pancreas and then we alternate stitches along the anterior
and posterior rows and finish with the lower edge, which is
the more accessible.
The right corner of the greater omentum is freed and
then interposed between the two pancreatic transections in
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253
order to protect the exposed vessels and to separate the two
potential sites of pancreatic fistula (proximal transection
line and distal anastomosis), thus facilitating post-operative
management (Fig. 8). One can also use the round ligament
to cover the proximal transection line and the vascular
axes, as has already been described for pancreatoduodenec-
tomy [6]. The two pancreatic transections are drained by
a multi-tubular flat drain and by a suction drain, which
are positioned adjacent to the anastomosis and the right
transection, respectively. The double gastric hanging is
released. The specimen is removed in a bag through the
right paramedian 12 mm trocar site, which can be enlarged if
necessary.
In conclusion, this intervention is most often performed
in young women (59—73%) (47—52 years) and mainly for
neuroendocrine tumors, intraductal papillary and muci-
nous neoplasia of the pancreas, solid and pseudo-papillary
tumors, and mucinous cystadenomas. The first published
series reported an operating time varying from 190—350 min
with conversion and transfusion rates < 5% [3,7,8]. There
was no reported mortality but morbidity consisted mainly
of grade B and C pancreatic fistulas (20—31%) and hem-
orrhage (15—25%). The average hospital stay ranged from
14—24 days. The long-term risk of endocrine insufficiency
was 6—8% [3,7,8].
Disclosure of interest
The authors declare that they have no competing interest.
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