title: Spleen and splenic vessel preserving distal pancreatectomy for bifocal PNET in a young patient with MEN1.
abstract: MEN1 patients requiring resection of neuroendocrine tumors (pNET) are frequently young, active patients in whom a minimal access approach minimizes perioperative morbidity and splenic preservation decreases the risk of post-splenectomy sepsis. Laparoscopic spleen preserving distal pancreatectomy can be performed with removal (Warshaw's technique) or preservation of the splenic vessels, the later having a higher rate of successful splenic preservation.
  
  
  
  This is an active, 16-year-old Jehovah's Witness with trifocal nonfunctioning neuroendocrine tumor in the proximal body and tail of the pancreas as part of MEN1 syndrome. A spleen preserving distal pancreatectomy was performed with the final pathology showing three pNET with low mitotic count and three lymph nodes free of cancer (final stage pT2pN0).
  
  
  
  This video demonstrates patient and trocar positioning as well as operative tactics for a laparoscopic distal pancreatectomy with preservation of splenic vessels. Intraoperative ultrasound is crucial in assessing pNETs' relation to critical vessels, pancreatic duct, and to exclude synchronous lesions. The video focuses on safe laparoscopic creation of the retropancreatic tunnel and dissecting the pancreas off the splenic vessels using novel energy devises to control direct splenic venous branches into the pancreas.
  
  
  
  Improvements in laparoscopic techniques and technology have enabled surgeons to preserve the major splenic vessels to avoid splenic infarcts, abscesses and re-operations, and minimize the risk of left-sided portal hypertension. Splenic preservation is particularly important in young MEN1 patients undergoing laparoscopic pancreatectomy for pNET due to the increased risk of overwhelming post-splenectomy sepsis.
authors.affiliation: Division of Surgery, Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1484, Houston, TX, 77030, USA. cconrad1@mdanderson.org.
authors.forename: Claudius
authors.initials: C
authors.lastname: Conrad
authors.affiliation: Division of Surgery, Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1484, Houston, TX, 77030, USA.
authors.forename: Lilian
authors.initials: L
authors.lastname: Schwarz
authors.affiliation: Division of Surgery, Department of Surgical Oncology, Surgical Endocrinology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.
authors.forename: Nancy
authors.initials: N
authors.lastname: Perrier
authors.affiliation: Division of Surgery, Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1484, Houston, TX, 77030, USA.
authors.forename: Jason B
authors.initials: JB
authors.lastname: Fleming
authors.affiliation: Division of Surgery, Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1484, Houston, TX, 77030, USA.
authors.forename: Matthew H G
authors.initials: MH
authors.lastname: Katz
authors.affiliation: Division of Surgery, Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1484, Houston, TX, 77030, USA.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Aloia
authors.affiliation: Division of Surgery, Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1484, Houston, TX, 77030, USA.
authors.forename: Jean-Nicolas
authors.initials: JN
authors.lastname: Vauthey
authors.affiliation: Division of Surgery, Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1484, Houston, TX, 77030, USA.
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Lee
mesh_terms: D000293:Adolescent; D006801:Humans; D006975:Hypertension, Portal / Q000517:prevention & control; D033221:Jehovah's Witnesses; D010535:Laparoscopy / Q000379:methods; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology; D018761:Multiple Endocrine Neoplasia Type 1 / Q000601:surgery*; D009378:Neoplasms, Multiple Primary / Q000601:surgery*; D018358:Neuroendocrine Tumors / Q000473:pathology / Q000601:surgery*; D059351:Organ Sparing Treatments; D010180:Pancreatectomy / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000473:pathology / Q000601:surgery*; D011183:Postoperative Complications / Q000517:prevention & control; D012086:Reoperation; D018805:Sepsis / Q000517:prevention & control; D013154:Spleen; D013157:Splenic Artery; D013162:Splenic Vein; D016896:Treatment Outcome
keywords: Adolescent patient; Distal pancreatectomy; Laparoscopy; Multiple endocrine neoplasia type 1; Spleen preserving; Splenic vessel preservation