Laparoscopic Spleen-preserving Distal Pancreatectomy for Grade III Pancreatic Injury: A Case Report
1–3Department of Surgical Gastroenterology and MIS, Sahasra Hospital, Bengaluru, Karnataka, India
Corresponding Author: Srikanth Gadiyaram, Department of Surgical Gastroenterology and MIS, Sahasra Hospital, Bengaluru, Karnataka, India, Phone: +91 9880109971, e-mail: email@example.com
How to cite this article: Nachiappan M, Thota R, Gadiyaram S. Laparoscopic Spleen-preserving Distal Pancreatectomy for Grade III Pancreatic Injury: A Case Report. World J Lap Surg 2022;15(3):262–265.
Source of support: Nil
Conflict of interest: None
Received on: 03 February 2022; Accepted on: 08 May 2022; Published on: 07 December 2022
Aim: This article reports a case of grade III pancreatic injury managed by laparoscopic spleen-preserving distal pancreatectomy (SPDP). It also discusses the management options available, the timing of surgery, and the surgical options with the review of available literature.
Background: Pancreatic surgery represents one of the most challenging areas in gastrointestinal surgery. Isolated pancreatic injury is uncommon following abdominal trauma. Pancreatic transection with duct disruption following blunt abdominal trauma could be managed by both conservative and surgical approaches. Complete pancreatic transection with duct disruption carries high morbidity and mortality. Distal pancreatic resection along with splenectomy is the preferred surgical procedure. Laparoscopic distal pancreatectomy has gained worldwide acceptance in recent years for non-traumatic cases. We report a case of grade III pancreatic injury in a 15-year-old girl managed with laparoscopic SPDP.
Case description: A 15-year-old girl presented to us with around 24 hours of blunt trauma to the upper abdomen. She was hemodynamically stable. On examination abdomen was tender and there was voluntary guarding. Evaluation with contrast-enhanced computed tomography (CECT) showed grade III pancreatic injury. There was no pneumoperitoneum. The rest of the solid organs were normal. After resuscitation in line with advanced trauma life support (ATLS) protocols, she underwent a laparoscopic SPDP after written informed consent. She made an uneventful recovery and was discharged on the sixth postoperative day. At the last follow-up, eight years after the surgery, she had no symptoms of endocrine or exocrine insufficiency.
Conclusion: Laparoscopic SPDP for pancreatic trauma, though technically demanding and time-consuming, is a feasible undertaking in hemodynamically stable patients.
Clinical significance: This case highlights that SPDP for grade III pancreatic injury could be accomplished laparoscopically. A minimally invasive approach is feasible in patients with no associated injuries and hemodynamic stability. Early diagnosis and surgical management are crucial for optimal outcomes.
Keywords: Duct disruption, Laparoscopy, Pancreas, Trauma.
Pancreatic surgery represents one of the most challenging areas in the field of gastrointestinal surgery. Isolated pancreatic injury is uncommon following abdominal trauma. Pancreatic transection with duct disruption following blunt abdominal trauma could be managed by both conservative and surgical approaches. Complete pancreatic transection with duct disruption carries high morbidity and mortality. Distal pancreatic resection along with splenectomy is the preferred surgical procedure. Laparoscopic distal pancreatectomy has gained worldwide acceptance in recent years for non-traumatic cases. We report a case of grade III pancreatic injury in a 15-year-old girl managed with laparoscopic SPDP.
A 15-year-old girl presented to us around 24 hours of blunt trauma to the upper abdomen. She was hemodynamically stable. On examination, the abdomen was tender and there was voluntary guarding. Evaluation with a CECT showed a hematoma at the pancreatic neck and an enhancing pancreatic tissue in the distal body and tail of the pancreas suggestive of complete pancreatic transection and ductal disruption – grade III injury (Fig. 1A). There was no pneumoperitoneum. The rest of the solid organs were normal. After resuscitation in line with ATLS protocols, she was taken up for laparoscopic SPDP under general anesthesia in a leg-split position after written informed consent. The port placement was as shown in Figure 1B. Surgery was completed as discussed in the following steps:
Step 1. Exposure of the lesser sac: Gastrocolic omentum was taken down, hematoma visualized (Fig. 1C), and gastric traction suture was used to tag the stomach to parieties (Fig. 1D).
Step 2. Evacuation of the hematoma with gentle suctioning.
Step 3. Identification of the splenic vein: Splenoportal confluence was identified after clearing the hematoma.
Step 4. Dissection of the pancreatic body from the splenic artery and splenic vein: Branches and tributaries of the splenic artery and splenic vein, respectively, were taken down with harmonic (Figs 2A to C).
Step 5. A sliver of the pancreatic body attached at the cranial part near the neck of the pancreas was staple transected using 45 mm Endo GIA 3.5 mm thick cartridge.
Step 6. The specimen was retrieved via a 12 mm port site using an endo bag (Fig. 2D).
Step 7. Application of fibrin glue on the proximal transected surface of the pancreas.
Step 8. A thorough peritoneal lavage was given, and an abdominal drain was placed through the right-hand working port.
She made an uneventful recovery; the abdominal drain was removed after checking drain fluid amylase on the third postoperative day and she was discharged on the sixth postoperative day. At the last follow-up, eight years after the surgery, she had no symptoms of endocrine or exocrine insufficiency.
Blunt abdominal trauma or penetrating trauma could lead to pancreatic injury. An isolated pancreatic injury is a rare event given the location of the pancreas in the retroperitoneum. Pancreatic injuries are classified by the American Association of the Surgery of Trauma (AAST) pancreatic organ injury scale classification into five grades based on the extent of the injury. Lesser grades (<grade II) of pancreatic trauma are not associated with a ductal injury. They are managed with conservative measures if there is no associated injury. Higher grades (≥grade III) are associated with disruption of the duct.1 These injuries require a surgical procedure that is guided by the location, extent, associated injury to the duodenum, and the hemodynamics of the patient. Grade III AAST injury is one in which there is a hematoma with transection of the pancreas to the right of SMA along with ductal injury, like in the present case. Traditionally, surgery is the modality of choice when grade III or more AAST pancreatic organ injury scale is diagnosed.
The management of these injuries is challenging as they could have a delayed clinical presentation and there are no specific diagnostic modalities.2 Ductal disruption could be missed on focussed assessment with sonography in trauma (FAST) evaluation. CECT is the investigation of choice in patients who are hemodynamically stable as it distinguishes between viable and non-viable pancreatic tissue.3 The loss of ductal continuity, which, if not obvious on the CT (hematoma with viable pancreatic tissue on either side of it) could be evaluated either with magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP). The ERCP could also help in the therapeutic stenting of ductal disruption. However, it may not be available at all centers emergently.
Few retrospective reviews have suggested conservative management of pancreatic trauma.4,5 In a small retrospective analysis of a selected cohort of nine children managed with nonoperative treatment – there was no mortality but the median hospital stay was 24 days, the time to tolerate a full diet was two months, pseudocyst formation was seen in four, and interventions as percutaneous drain placement was required in five patients. At follow-up, there were no insufficiencies but the scan showed an atrophic gland in 75%.4 In another review of conservative management of 34 patients with pancreatic trauma, good clinical outcomes were demonstrated. However, the mean duration of hospital stay was 24 days, pseudocyst formation was seen in nearly half the patients, and half of these required drainage procedures. In addition, they do not delineate the grades of injury in all patients, and in graded patients, the majority fell under minor injuries.5 Thus, there is no firm evidence to support nonoperative management in these patients and surgical management remains the treatment of choice.
Surgical management depends on the hemodynamic status of the patient and the amount of viable pancreatic tissue distal to the injury. The options include hemostasis and drainage in hemodynamically unstable to reconstructions/resections in stable patients. Reconstructions such as pancreaticojejunostomy and resections including distal pancreatosplenectomy and SPDP are based on the amount of viable tissue of the pancreas distal to the injury.6
Around 50% of acute pancreatitis in children is trauma induced.7 Presentation of isolated pancreatic injury is usually delayed as the initial symptoms are vague. The timing of the intervention has a bearing on the outcomes. Surgical intervention undertaken prior to the setting-in of pancreatitis could lead to a better result. However, there is no clear definition of “early surgery.”8 In a retrospective review of 51 patients managed for pancreatic transections, Nadler et al. reported that surgery within 48 hours of the injury resulted in a significantly shorter hospital stay, whereas Meier et al. in their review found better results up to 72 hours.2,9 Further, Lin et al. reported that all the mortality in their patients with grade III injuries was in whom the management was delayed by over 24 hours.6 Thus, early aggressive management of pancreatic transections following pancreatic trauma reduces hospital stays, decreases complications, and expedites the return to good health.
Splenectomy is usually done along with distal pancreatic resection as it is technically less demanding and shortens the operative time. Spleen preservation can be done by two methods – the Warsaw technique and the Kimura technique. In the Warsaw technique, the splenic vessels are sacrificed like in the usual distal pancreatosplenectomy and the blood supply to the spleen is maintained by the short gastric vessels. Inherently, this method has the chance of splenic infarction and abscess formation and subsequently may require a splenectomy. In the more demanding Kimura technique, where the branches and tributaries of the splenic artery and vein, respectively, to the pancreas, are taken down, thus preserving the splenic vessels, the chances of postoperative splenic infarction are significantly less. These are well-defined for benign lesions of the body and tail of the pancreas.10 In the setting of trauma, Eastern Association for the Surgery of Trauma (EAST) practice guidelines could not make a recommendation regarding routine splenectomy in adult patients with pancreatic trauma.11 In the retrospective review of the trauma databank, SPDP on multivariate analysis was found to have a significantly lesser extent of hospital stays compared to those undergoing splenectomy. Complications, intensive care unit (ICU) stay and mortality were all non-significant. They recommended that in younger patients who are hemodynamically stable and those with low injury burden, splenic preservation has to be considered if surgical expertise is available. In a review series, nine patients with grades III and IV injuries were managed with spleen preservation as compared to 22 who underwent splenectomy. There was one mortality in each group. There were fewer complications in the group undergoing splenic preservation.6 The long-term benefits of splenic preservation have not been clearly reported in the literature. The incidence of OPSI, though lesser in cases of trauma splenectomy compared to pathological splenectomies, still remains.12
There have been few reports of SPDP done entirely laparoscopically or with hand-port assistance.7,8,13–17 Improved vision during the laparoscopy may make the difficult dissection slightly easy. There is reduced postoperative pain, early recovery, and better cosmesis with laparoscopy.
Laparoscopic SPDP for pancreatic trauma, though technically demanding and time-consuming, is a feasible undertaking in patients who are hemodynamically stable. Early management of pancreatic transections with surgery provides good clinical outcomes.
This case highlights that SPDP for grade III pancreatic injury could be accomplished laparoscopically. Minimally invasive approach is feasible in patients with no associated injuries and hemodynamic stability. Early diagnosis and surgical management are crucial for optimal outcomes.
Murugappan Nachiappan https://orcid.org/0000-0001-8687-3096
Srikanth Gadiyaram https://orcid.org/0000-0001-6676-2030
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