title: En bloc mobilization of the pancreas and spleen to facilitate resection of large tumors, primarily renal and adrenal, in the left upper quadrant of the abdomen: techniques derived from multivisceral transplantation.
abstract: BACKGROUND
  The left upper quadrant of the abdomen may be occupied by a wide range of urologic pathology. When these lesions are large, safely resecting them often presents a significant technical challenge, with the possibility of resultant morbidity and mortality.
  
  
  OBJECTIVE
  We describe a technique derived from our experience with multivisceral transplant and organ procurement, which provides excellent exposure of this anatomic region.
  
  
  METHODS
  From May 1999 to April 2006, 70 patients underwent en bloc mobilization of the spleen and the pancreas and, as necessary, the stomach for masses in the left upper retroperitoneum. Pathology included malignant and benign lesions, including renal cell carcinoma (RCC) with or without inferior vena cava (IVC) involvement, adrenal tumors, retrocrural lymphadenopathy from testicular cancer, and transitional cell carcinoma of the renal pelvis.
  
  
  METHODS
  An extended subcostal transabdominal approach was used to resect large tumors in the left upper abdomen. This approach offers significant advantages over conventional approaches, including a flank, thoracoabdominal, or midline transabdominal incision with reflection of the descending colon.
  
  
  METHODS
  Intraoperative variables, including operative time, blood loss, transfusion rate, and extent of mobilization were recorded. Postoperative complications, including prolonged intubation, ileus, and deep venous thrombosis were also noted.
  
  
  CONCLUSIONS
  Mean estimated blood loss during surgery was 973 ml. There were no perioperative deaths. No patients had pancreatitis or acute renal failure. Deep venous thrombosis was not seen. Cardiopulmonary bypass was used in one patient with an atrial thrombus. At a median follow-up of 42 mo, two patients died due to metastasis.
  
  
  CONCLUSIONS
  Techniques acquired from organ harvesting as well as our experience at multivisceral transplant, such as en bloc mobilization of the spleen, pancreas, and stomach, can be utilized safely and effectively to gain excellent exposure to the left upper retroperitoneum via an extended subcostal incision with no additional morbidity for the patient.
authors.affiliation: Department of Surgery, Division of Transplantation, University of Miami School of Medicine, Miami, Florida 33101, USA. gciancio@miami.edu
authors.forename: Gaetano
authors.initials: G
authors.lastname: Ciancio
authors.forename: Anil
authors.initials: A
authors.lastname: Vaidya
authors.forename: Samir
authors.initials: S
authors.lastname: Shirodkar
authors.forename: Murugesan
authors.initials: M
authors.lastname: Manoharan
authors.forename: Tariq
authors.initials: T
authors.lastname: Hakky
authors.forename: Mark
authors.initials: M
authors.lastname: Soloway
mesh_terms: D034841:Abdominal Cavity / Q000601:surgery; D000310:Adrenal Gland Neoplasms / Q000473:pathology / Q000601:surgery*; D000315:Adrenalectomy / Q000379:methods; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical; D002292:Carcinoma, Renal Cell / Q000473:pathology / Q000601:surgery; D002295:Carcinoma, Transitional Cell / Q000473:pathology / Q000601:surgery; D015331:Cohort Studies; D004210:Dissection / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D009392:Nephrectomy / Q000379:methods; D016377:Organ Transplantation; D010179:Pancreas / Q000033:anatomy & histology; D011183:Postoperative Complications / Q000517:prevention & control; D012189:Retrospective Studies; D018570:Risk Assessment; D013154:Spleen / Q000033:anatomy & histology; D013270:Stomach / Q000033:anatomy & histology; D016896:Treatment Outcome; D047368:Tumor Burden; D019043:Vascular Neoplasms / Q000556:secondary / Q000601:surgery*; D014682:Vena Cava, Inferior; D055815:Young Adult