Name: robotic spleen-preserving distal pancreatectomy: the warshaw and kimura techniques
Uploaded: 2024-05-24T03:56:19
Description: Spleen-preserving distal pancreatectomy offers an alternative surgical approach to the traditional distal pancreatectomy combined with splenectomy for ...

The authors have no acknowledgments.

NOTE: Both patients provided written and oral informed consent for the use of medical data and operative videos for educational and scientific purposes. The protocol was approved by our institution (Amsterdam University Medical Centers).
1. Case 1 (Warshaw technique)
<ol>
	<li>Positioning
	<ol>
		<li>Place the patient in a supine position with legs split in a French position.</li>
		<li>Abduct the left arm to 90&#176; and lower the right arm alongside the body.</li>
		<li>Ti...

<ol>
	<li>Navez, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Distal+pancreatectomy+for+pancreatic+neoplasia:+is+splenectomy+really+necessary?+A+bicentric+retrospective+analysis+of+surgical+specimens.">Distal pancreatectomy for pancreatic neoplasia: is splenectomy really necessary? A bicentric retrospective analysis of surgical specimens.</a> HPB (Oxford). 22 (11), 1583-1589 (2020).</li><li>Lee, S. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spleen-preserving+distal+pancreatectomy.">Spleen-preserving distal pancreatectomy.</a> Singapore Med J. 49 (11), 883-885 (2008).</li><li>Weledji, E. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Benefits+and+risks+of+splenectomy.">Benefits and risks of splenectomy.</a> Int J Surg. 12 (2), 113-119 (2014).</li><li>Jain, G., Chakravartty, S., Patel, A. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spleen-preserving+distal+pancreatectomy+with+and+without+splenic+vessel+ligation:+a+systematic+review.">Spleen-preserving distal pancreatectomy with and without splenic vessel ligation: a systematic review.</a> HPB (Oxford). 15 (6), 403-410 (2013).</li><li>Moekotte, A. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Splenic+preservation+versus+splenectomy+in+laparoscopic+distal+pancreatectomy:+a+propensity+score-matched+study.">Splenic preservation versus splenectomy in laparoscopic distal pancreatectomy: a propensity score-matched study.</a> Surg Endosc. 34 (3), 1301-1309 (2020).</li><li>Nakata, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+preservation+versus+splenectomy+during+distal+pancreatectomy:+a+systematic+review+and+meta-analysis.">Minimally invasive preservation versus splenectomy during distal pancreatectomy: a systematic review and meta-analysis.</a> J Hepatobiliary Pancreat Sci. 25 (11), 476-488 (2018).</li><li>Shi, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Splenic+preservation+versus+splenectomy+during+distal+pancreatectomy:+A+systematic+review+and+meta-analysis.">Splenic preservation versus splenectomy during distal pancreatectomy: A systematic review and meta-analysis.</a> Ann Surg Oncol. 23 (2), 365-374 (2016).</li><li>Juo, Y. Y., King, J. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+spleen+preserving+distal+pancreatectomy:+A+technical+review.">Robotic-assisted spleen preserving distal pancreatectomy: A technical review.</a> J Vis Surg. 3, 139 (2017).</li><li>Warshaw, A. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Conservation+of+the+spleen+with+distal+pancreatectomy.">Conservation of the spleen with distal pancreatectomy.</a> Arch Surg. 123 (5), 550-553 (1988).</li><li>Kimura, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spleen-preserving+distal+pancreatectomy+with+conservation+of+the+splenic+artery+and+vein.">Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein.</a> Surgery. 120 (5), 885-890 (1996).</li><li>Kim, E. Y., Choi, H. J., You, Y. K., Kim, D. G., Hong, T. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spleen-preserving+distal+pancreatectomy+with+vein+scarifying+and+artery+saving+as+an+alternative+for+Warshaw+Method.">Spleen-preserving distal pancreatectomy with vein scarifying and artery saving as an alternative for Warshaw Method.</a> J Gastrointest Surg. 25 (6), 1556-1558 (2021).</li><li>Eshuis, W. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Early+postoperative+hyperglycemia+is+associated+with+postoperative+complications+after+pancreatoduodenectomy.">Early postoperative hyperglycemia is associated with postoperative complications after pancreatoduodenectomy.</a> Ann Surg. 253 (4), 739-744 (2011).</li><li>Giardino, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=C-reactive+protein+and+procalcitonin+as+predictors+of+postoperative+inflammatory+complications+after+pancreatic+surgery.">C-reactive protein and procalcitonin as predictors of postoperative inflammatory complications after pancreatic surgery.</a> J Gastrointest Surg. 20 (8), 1482-1492 (2016).</li><li>Kacmaz, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+enucleation+of+an+intra-pancreatic+insulinoma+in+the+pancreatic+head.">Robotic enucleation of an intra-pancreatic insulinoma in the pancreatic head.</a> J Vis Exp. (155), e60290 (2020).</li><li>de Rooij, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+versus+open+distal+pancreatectomy+(LEOPARD):+A+multicenter+patient-blinded+randomized+controlled+trial.">Minimally invasive versus open distal pancreatectomy (LEOPARD): A multicenter patient-blinded randomized controlled trial.</a> Ann Surg. 269 (1), 2-9 (2019).</li><li>Bjornsson, B., Larsson, A. L., Hjalmarsson, C., Gasslander, T., Sandstrom, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+the+duration+of+hospital+stay+after+laparoscopic+or+open+distal+pancreatectomy:+randomized+controlled+trial.">Comparison of the duration of hospital stay after laparoscopic or open distal pancreatectomy: randomized controlled trial.</a> Br J Surg. 107 (10), 1281-1288 (2020).</li><li>Korrel, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+versus+open+distal+pancreatectomy:+an+individual+patient+data+meta-analysis+of+two+randomized+controlled+trials.">Minimally invasive versus open distal pancreatectomy: an individual patient data meta-analysis of two randomized controlled trials.</a> HPB (Oxford). 23 (3), 323-330 (2021).</li><li>Vining, C. C., Skowron, K. B., Hogg, M. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+gastrointestinal+surgery:+learning+curve,+educational+programs+and+outcomes.">Robotic gastrointestinal surgery: learning curve, educational programs and outcomes.</a> Updates Surg. 73 (3), 799-814 (2021).</li><li>Korrel, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Short-term+outcomes+after+spleen-preserving+minimally+invasive+distal+pancreatectomy+with+or+without+preservation+of+splenic+vessels:+A+pan-european+retrospective+study+in+high-volume+centers.">Short-term outcomes after spleen-preserving minimally invasive distal pancreatectomy with or without preservation of splenic vessels: A pan-european retrospective study in high-volume centers.</a> Ann Surg. 277 (1), 119-125 (2021).</li><li>Paiella, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long+term+outcome+after+minimally+invasive+and+open+Warshaw+and+Kimura+techniques+for+spleen-preserving+distal+pancreatectomy:+International+multicenter+retrospective+study.">Long term outcome after minimally invasive and open Warshaw and Kimura techniques for spleen-preserving distal pancreatectomy: International multicenter retrospective study.</a> Eur J Surg Oncol. 45 (9), 1668-1673 (2019).</li><li>Zhu, A., Greene, B., Tsang, M., Jayaraman, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparing+the+Warshaw+technique+with+vessel-preservation+in+laparoscopic+spleen+preserving+distal+pancreatectomy:+is+there+a+better+approach.">Comparing the Warshaw technique with vessel-preservation in laparoscopic spleen preserving distal pancreatectomy: is there a better approach.</a> HPB. 25 (1), 109-115 (2022).</li><li>Hang, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Splenic+vessels+preserving+versus+Warshaw+technique+in+spleen+preserving+distal+pancreatectomy:+A+systematic+review+and+meta-analysis.">Splenic vessels preserving versus Warshaw technique in spleen preserving distal pancreatectomy: A systematic review and meta-analysis.</a> Int J Surg. 103, 106686 (2022).</li><li>Granieri, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Kimura's+vs+Warshaw's+technique+for+spleen+preserving+distal+pancreatectomy:+a+systematic+review+and+meta-analysis+of+high-quality+studies.">Kimura's vs Warshaw's technique for spleen preserving distal pancreatectomy: a systematic review and meta-analysis of high-quality studies.</a> HPB (Oxford). 25 (6), 614-624 (2023).</li></ol>

The critical steps concerning spleen-preserving robotic DP include positioning and robot docking, mobilization, intraoperative ultrasonography (if necessary), dissection and management of the splenic vessels, spleen assessment and drain placement. In the case of uncontrollable bleeding, conversion to laparotomy is recommended. The assessment of the spleen&#39;s viability should be performed before exsuflating the abdomen.
Modifications of the technique include the use of a second assistant tro...

Distal pancreatectomy (DP) is performed to remove benign and malignant lesions located in the pancreatic body and tail. Traditionally, DP is combined with splenectomy1. However, a spleen-preserving approach is recommended when resecting benign and low-grade/pre-malignant lesions of the distal pancreas to avoid short and long-term complications associated with splenectomy2. Such complications include hemorrhage, thrombocytosis, thromboembolic incidents, pulmonary hypertension, and overwhelming post-splenectomy infection (OPSI)3. Nevertheless, spleen preservation can lead to complications such as splenic infarction, splenic vein thrombosis, and abscess formation. Secondary splenectomy, described in 0-2% of the cases of initially intended spleen preservation, is a potential complication4,5,6,7.
Spleen-preserving distal pancreatectomy can be achieved using two different approaches8. The first approach, the Warshaw technique (WT), initially described by Warshaw in 1988, is a vessel-resecting technique9. In WT, the splenic artery and vein are resected and ligated, and perfusion of the spleen is provided by the left gastroepiploic artery and the short gastric vessels.The second technique, a vessel-preserving approach described by Kimura (KT) in 199610, involves ligating the small splenic branches posterior to the pancreas while preserving the splenic artery and vein. Recently, a third alternative that preserves the spleen with splenic vein scarifying and splenic artery preservation has been proposed by Kim et al.11. Patient anatomy plays a crucial role in deciding which approach to follow. The Kimura technique is more feasible when the splenic vessels are found in an extra-pancreatic position. However, if the splenic vessels cannot be separated from the posterior surface of the pancreas, the Warshaw technique is performed. Intraoperative findings and incidents can also alter the initial operative plan.
Here, we present two cases of robotic spleen-preserving distal pancreatectomy. Details about the patients are described below.
The first patient is a 36-year-old female presenting with atypical abdominal symptoms. She underwent a computed tomography (CT) that revealed a 26 mm round lesion in the pancreatic body without pancreatic duct dilation and without vascular involvement (Figure 1). The original differential diagnosis included a neuroendocrine tumor (NET) and an accessory spleen due to the lesion&#39;s enhancement. Consequently, the patient also underwent scintigraphy with Technetium-99m (99mTc) labeled heat-denatured erythrocyte scan, which was negative for splenosis. A positron emission tomography (PET) scan revealed strongly elevated somatostatin receptor expression in the lesion (Figure 2). Based on these results, an indication for a robotic spleen preserving distal pancreatectomy was determined. Due to the patient&#39;s anatomy and proximity of the splenic vessels to the posterior surface of the pancreas, the Warshaw approach was considered more suitable.
The second patient is a 76-year-old male with chronic pancreatitis, complaining of the pain in the lower left abdomen for the past 18 months. No history of acute pancreatitis or excessive alcohol use was reported. Initially, he underwent a CT colonography due to reported lower gastrointestinal symptoms. The scan did not show any pathological findings in the colon but described a suspected obstructive stone in the distal pancreas with a focally dilated main pancreatic duct. Endoscopic ultrasonography (EUS) confirmed the diagnosis of chronic pancreatitis but also found a lesion suspicious for a papillary tumor. Nevertheless, the fine needle aspiration (FNA) pathology revealed a low-grade adenoma. His most recent CT scan revealed an image of chronic pancreatitis with a dilated pancreatic duct in the tail up to 7 mm and an abrupt transition between the tail and the body of the pancreas. Multiple coarse calcifications were also present (Figure 3). The patient was scheduled for a robotic spleen preserving distal pancreatectomy. The patient&#39;s anatomy favored the selection of the Kimura technique, as the splenic vessels were in an extra-pancreatic position.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Arietta V70 Ultrasound</td>
			<td>Hitachi</td>
			<td>-</td>
			<td>The ultrasound system.</td>
		</tr>
		<tr>
			<td>Robotic ultrasonography transducer</td>
			<td>Hitachi</td>
			<td>L43K</td>
			<td>Used for intraoperative laparoscopic ultrasonography.</td>
		</tr>
		<tr>
			<td>Cobra Liver Retractor Diamond-Flex</td>
			<td>CareFusion</td>
			<td>89-6216</td>
			<td>Retracting the liver for optimal exposure of the surgical site.</td>
		</tr>
		<tr>
			<td>da Vinci Surgeon Console</td>
			<td>Intuitive Surgical</td>
			<td>SS999</td>
			<td>Used to control the surgical robot.</td>
		</tr>
		<tr>
			<td>da Vinci Vision Cart</td>
			<td>Intuitive Surgical</td>
			<td>VS999</td>
			<td>The vision cart houses advanced vision and energy technologies and provides communications across da Vinci system components.</td>
		</tr>
		<tr>
			<td>da Vinci Xi</td>
			<td>Intuitive Surgical</td>
			<td>K131861</td>
			<td>The surgical robot: &#39;patient side-cart&#39;.</td>
		</tr>
		<tr>
			<td>da Vinci Xi Endoscope with Camera, 8 mm, 30&#176;</td>
			<td>Intuitive Surgical</td>
			<td>470027</td>
			<td>The camera of the da Vinci robot.</td>
		</tr>
		<tr>
			<td>ENDOEYE Rigid Video Laparoscope, 10 mm, 30&#176;</td>
			<td>Olympus</td>
			<td>WA50042A</td>
			<td>To see within the intra-abdominal cavity.</td>
		</tr>
		<tr>
			<td>ENDOWRIST Fenestrated Bipolar Forceps</td>
			<td>Intuitive Surgical</td>
			<td>470205</td>
			<td>Used for dissection and coagulation.</td>
		</tr>
		<tr>
			<td>ENDOWRIST HOT SHEARS</td>
			<td>Intuitive Surgical</td>
			<td>470179</td>
			<td>Used for cutting and coagulation.</td>
		</tr>
		<tr>
			<td>ENDOWRIST Permanent Cautery Hook</td>
			<td>Intuitive Surgical</td>
			<td>470183</td>
			<td>Used for coagulation.</td>
		</tr>
		<tr>
			<td>ENDOWRIST PROGrasp Forceps</td>
			<td>Intuitive Surgical</td>
			<td>470093</td>
			<td>Used for dissection.</td>
		</tr>
		<tr>
			<td>LigaSure Dolphin Tip 37cm</td>
			<td>Medtronic</td>
			<td>LS1500</td>
			<td>Used for vessel sealing and dividing.</td>
		</tr>
		<tr>
			<td>Autosuture Endo Clip applier 5 mm</td>
			<td>Covidien</td>
			<td>176620</td>
			<td>Clip applier</td>
		</tr>
		<tr>
			<td>ECHELON FLEX ENDOPATH 60mm Stapler</td>
			<td>Ethicon</td>
			<td></td>
			<td>Powered surgical stapler with gripping surface technology</td>
		</tr>
	</tbody>
</table>

robotic spleen-preserving distal pancreatectomy: the warshaw and kimura techniques

Spleen-preserving distal pancreatectomy offers an alternative surgical approach to the traditional distal pancreatectomy combined with splenectomy for removing benign and low-grade malignant lesions in the distal pancreas, avoiding complications associated with splenectomy. This procedure can be accomplished either by resecting and ligating the splenic vessels (Warshaw technique) or by preserving them (Kimura technique). Currently, the widespread use of minimally invasive surgery has established laparoscopic and robotic approaches for spleen-preserving distal pancreatectomy as valid and safe options for treating such conditions. Our protocol aims to describe how the Warshaw and Kimura techniques of spleen-preserving distal pancreatectomy can be performed robotically. The first patient is a 36-year-old female with a neuroendocrine tumor (NET) in the pancreatic body who underwent a spleen-preserving distal pancreatectomy with the ligation of the splenic vessels (WT). The second patient is a 76-year-old male with chronic pancreatitis presenting with a dilated main pancreatic duct in the tail of the pancreas who underwent a spleen-preserving distal pancreatectomy with a vessel-preserving approach (KT).

For the patient undergoing the Warshaw technique (Patient 1), the total operation time was 190 minutes with 200 mL of blood loss. No drain was placed. On the third and fourth POD, C-reactive protein was measured, showing a non-decreasing trend. Hence, a CT scan was performed revealing a hypodense fluid collection of approximately 5 cm which was drained percutaneously using a 10 French pigtail catheter. The fluid contained high amylase (24.109 U/L, International Study Group of Pancreatic Fistula grade B). The patient was ...

Here, we present a step-by-step protocol of robotic spleen preserving distal pancreatectomy, with and without preserving the splenic vessels (i.e., the Kimura and Warshaw techniques, respectively).

Robotic Spleen-Preserving Distal Pancreatectomy: The Warshaw and Kimura Techniques

Spleen-preserving distal pancreatectomy offers an alternative surgical approach to the traditional distal pancreatectomy combined with splenectomy for ...

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