Open Distal Pancreatectomy for Pancreatic Cancer

CHAPTER 1

I'm Carlos Fernandez-del Castillo. I'm a surgeon at Mass General. I'm the Director of the Pancreas Surgery Program. The case that we're going to be doing is, has some unique features. First of all, it's an unusual indication. This is a woman who, two years ago, was diagnosed with metastatic pancreatic cancer. She had a cancer in the body of the pancreas and a single liver metastasis that was biopsy proven. This a situation that normally carries a bad prognosis with a median survival of six months if no treatment is done, and perhaps a year with treatment. This patient received treatment with chemotherapy. The liver lesion initially did not appear to respond, so she was changed to a different chemotherapy. She initially received FOLFIRINOX and then received Gem Abraxane. With Gem Abraxane, the liver lesion disappeared. Her tumor marker, which was elevated, normalized, and she continued to get Gem Abraxane for many cycles. In fact, for about a year and a half. And seemed to have a very good response. Because of this, we reevaluated her for the potential for resection. We elected to give her a course of radiotherapy to give her a honeymoon from the chemotherapy and see how things were. With five weeks of radiotherapy, her tumor marker remained normal. A repeat CAT scan showed no evidence of progression, and we decided to do the operation that we'll do today. Patients who get radiation for pancreatic cancer often have a lot of fibrosis. This is a tumor located in the body, and although it was not involving the hepatic artery, it was very close to it. And this patient had a unique arterial anatomy. So she had a superior mesenteric artery originating right at the celiac trunk, and from which the hepatic artery completely arose. So she had a completely replaced common hepatic artery, and we knew this would be a challenge. We now often do many distal pancreatectomies minimally invasive. This is a case that we would elect to do open and what, that's what we're gonna do with her. So the steps that you will see is through a midline incision. We're gonna first and foremost, explore the abdomen carefully to be sure there's no metastasis. Oftentimes we can miss these by imaging. Although this patient has had many, many different episodes of imaging that are negative. And after we confirm there's no metastasis, in this case, we're gonna open the lesser omentum and begin our dissection from the top part of the pancreas. We're gonna expose the hepatic artery. We're gonna follow it to its origin. We know that this origin will be the superior mesenteric artery, and we want to see it very carefully and preserve it. The same is true for the splenic artery.And after we have done this, we're going to develop a plane behind the neck of the pancreas. In this case, the tumor is a few centimeters away from the neck of the pancreas,so our side of transection will be the neck of the pancreas. We're gonna send a margin, and then before we tie the splenic vein, we're gonna tie the splenic artery, and then tie the splenic vein and develop the retropancreatic plane. This tumor originally seemed to be growing posteriorly, so we want to do a plane that is deep enough over the renal vein. We're gonna follow the renal vein towards the left and once this is accomplished, we're gonna approach this from a different venue, going from below through the gastrocolic omentum, taking down the short gastric vessels, mobilizing the spleen, and then delivering the specimen.

CHAPTER 2

May we begin? Yep. Incision. Okay. Can we get the table up a little bit higher please? Yep. The more adipose tissue on the outside, the less on the inside, so it's all good. Do me a favor and just go a tiny bit more here. Sure. Beautiful. Pickup to me. Okay pickup to me as well, please. So, if you get your thumb and thin, then you'll always watch what's important, see? Very good. So simply here, you know, you just thin out like this, right? Okay. Abdominal wall retractor, please.

CHAPTER 3

So we gotta examine first the liver. Oh my gosh. This is a huge, Nicolette, huh? And here's the lesser omentum. You can see and feel the pancreas. I don't feel anything. I don't feel any tumor. That's great. That's awesome. Gonna be very nice exposure there. Let's look here at the left side of the liver, right. Nothing there. Nothing here. The porta hepatis looks and feels good. Now down here. There's her appendix. You want to take it out? Probably not. Okay, Bookwalter, please. Look at those there, looks like Mickey Mouse ears. Sorry, as high as you can. We want it a little bit more towards this, right? It should be out of here because… Could I please have a short - a long straight, actually. Could we please put the patient in reverse Trendelenburg. Perfect, thank you. Give another short figure. NG tube is in a good position. So if you want to tape it there, you can. Okay. Pickup to you, and Bovie.

CHAPTER 4

This is right. Look at there. Isn't that gorgeous? I can't resist myself. What is this that we're seeing here, eh? Your best guess? Is that the IVC? Yes. No abbreviations, right? The inferior vena cava. And here's your pancreas, God's favorite organ. Now we can do this. Give me actually just a short straight. One is to find and dissect out the hepatic artery. Okay, and… There's your pancreas, inferior border, superior border. And we're seeing here probably the portal vein, which means that our hepatic artery is right here. So I'm feeling it there. And here's where the tumor was, feel it. Almost nothing left. It's an amazing response. Yep. Another short straight. And another one. Splenic artery. There's no other short straight? So we start filming again because there's no other short straight. Give me a bladder blade. I think we're gonna be okay. We don't need to aspirate. Oh, can I have a little blue towel?

CHAPTER 5

We got beautiful anatomy here, right? Like we couldn't even ask for more. So get your pickup, and pickup, we're gonna dissect that, this is gonna be our neck of the pancreas. But we have to find the hepatic artery, okay? Pickup to me. And get a scissor to start, Metzenbaum. And then you can get the… Exactly. And you can put it right angle if you want to, right? Baby. Actually give it to me first here. Bovie. Okay, now you gonna keep going with your right angle until you see the hepatic artery, which is right here. Okay, common. A baby right, you're right. Gently, right? Staying on top of… Okay, you can do that. Bovie. I think we could use the short thing for the Bovie, if you don't mind. Okay, come in this direction. Stay on top of that. Do you have vessel loops, Nicolette? We're going to need them. You're seeing there. Maybe a tiny bit more there. Okay, sorry. So this is? I don't feel a pulse, though. I feel the pulse of the splenic, but not of the… The hepatic artery is back down here, running behind the portal vein, again, behind. Okay, get your baby right and start uncovering that. Towards here. Just take more of the clamp. Metz. Take your pickup off. Remember what I told you? You cut and then you take advantage. Just gently. A little bit, right? Two knots, because it's coming out. Well. you can do three if you want to, but… Just humor me for a second here. This made me happy. Beautiful. And I want us to continue on the hepatic artery until we reach its origin, okay? Perfect. Did we get the blood for research or no? We did, yeah. Thank you. I don't - I feel it deeper here, but… Yeah. Straight down. Yeah, so it's very unusual the way it's running. So keep on taking some of this tissue here until we - Yep. Right angle. I think it's something there. Okay. All the way up to here. Remember to use your scissor. Okay, so I would want take a little more there, yeah. Right angle. Exactly, just peritoneum. You see, you have a lot of tissue there on top of the vessels still, right? All that is tissue that we need to get into and find the right plane. Okay, so you'll see the superficial things here, right? A lot of lymphatics. Yes. Nothing yet of the vessels, huh? No. But we'll see… Surprising how well we see the portal vein. Yeah, and how not well. And how poorly we see the arteries, right? Two knots. I see the artery now, you see it? Yeah, it's right there. Yeah, just try to get your scissor underneath, gently. That's it, you're starting to develop the plane. Okay. I think I'll Bovie this, yes. Bovie. Beautiful. Is the artery all the way back here? And this is something else? You mean this, here? Okay, right, very, very close back here. I don't know. No, the artery is here. Okay, so take the tissue there. Exactly. You think that's too deep, or is that okay? No, I think it's okay. Just don't take a lot because we don't know where this splenic origin is, right? Very tough. I can imagine. There, it has to come through there. Scalpel. 15. So, very fibrotic tissue. Huh? Oh read these, too. Well, not now because she's cutting. She needs to practice changing blades. Close to the top one, yeah. Close to the top one, yeah. Very fibrotic. Extremely. Take advantage. Take advantage. You see that deep, and just gently, exactly. Now you know your next move. Baby right. More fibrotic tissue there. Yeah. I just don’t know where the splenic artery is. Right? The origin. What reference point could you see here that, that you would love to feel? That would tell you, well, it's unlikely that the splenic artery is in this area, yet. It's the aorta right? Which is right here. You're gonna put your finger, and you're gonna feel it and you're gonna say, "ah." Of course, the splenic artery could still swing to this side, but not… Here, all that tissue above here, right? Please put your finger here and feel the powerful aorta, right? Okay, so we know we're heading in the direction of it, right? We got this tissue here. So from here to here. Exactly, exactly, exactly. More if you can so we can maximize our moves if we can. And we could, you see? Extraordinarily fibrotic. I think a Metz will be okay. Yeah. Close to the top, okay? Yes.

You wanna send that as a biopsy just in case? This over here? Giver her a blade. Yes. The thing over there. 15 blade. I didn't get very much. I would get a little more. So put it there, and we're gonna call this… Can I have my forceps back too? Preaortic tissue. Preaortic tissue. For frozen actually. I need the knife back. Thanks. There's more tissue to take. And very soon, we're gonna get close to the celiac. Two knots. You have some tissue here that you can get, that top there, yeah. Right angle. Metz, 3-0 ties, please. Two knots. Okay, I'm seeing a bunch of stuff here. Right? Gotta be a little cautious there because - yes. Very, very fibrotic. I'm gonna take a small bite. Yeah, exactly. Scalpel to me. You can use that a second time. Doesn't give you much freedom, right? But you saw your next move is that tissue there. We're gonna get there. Don't worry. This is pulsating. Yeah. No, no the artery's there. The artery's there. There's no question. And I see more artery there. You can even get a Schnidt and you're gonna see a lot more, but… Let me get you this tissue first, and then we're gonna get this issue, okay? I see another artery. You see the splenic now originating? I think. Beautiful. Open and close, open and close, open and close. Gently, gently at the same time. Yep, beautiful. Okay. Metz. I feel a big artery here. So, right angle to me. I just want to see them. Right? Like we've seen them other times. Just not showing them. Nothing. Yet. You can buzz this one. Here's the aorta, by the way. I think the celiac is going in this direction. Right? So this is… Okay, come on, I want to see it. I know, I keep thinking, maybe this will be the time. You know how it is that we- sometimes open the plane and bingo, it's there. So beautiful. Not yet. So please feel here and feel your aorta. And then you say, well the celiac ought to be coming up here. Right here, probably. Probably here, yeah. So wee, you get a sense that there's something there, right? And that maybe from here, is this coming up to here, right? So that's when we're getting the sense, that maybe you're gonna come from… That looks okay? Yeah. I think we're right on top of… Yeah, we are right on top. Ah hah! Ah hah! That's what we wanted to see, right? So you see your next move, right? Before you do that one, let me just get this here. I think we're gonna be, happy - yeah. Wanna buzz that or no? Sure. Slow. Very slow. So I'm seeing artery and perhaps the gastric region, maybe? Not really. But it doesn't make much sense. Right? Because the portal vein is there, but we gotta follow the artery direction. So I was thinking this. Yes, but stay on top of the artery. Yeah. Yup, yup, yup, yup. Firm, eh? Mhm. Extremely firm. Scalpel. There we go. I used to find a soft spot. They always give in, they always give in. Well, not always give in, but - interesting that we didn't see more artery, but that's okay. It looks like there's a little bit of a… Oh, that's okay. So this is the common hepatic and it's still going a little bit more medial. The celiac is very displaced. This is the aorta on that stitch. So pickup to me, Metzenbaum to her. See the plane that I want you to get? Yep. You don't even - yep. Yep. You can just support yourself with the Metz. Deal with that with a DeBakey, right? Beautiful, you're just making the space, so that you're gonna' need a vessel loop that Nicolette has ready for you, since she's had it for a while. She says. And if she says, it must be true. Beautiful dissection. Very nice. A little stuck, right? Because that's very close to where the tumor was, but… When you think you're ready, you get your baby right angle, and you put a vessel loop. Gotta go super easy, right? Open and close, moving one direction, then the other. We know our technique. Okay, I think it, yep. Mosco? That's okay, no problem. No problem, I told you it would be okay.

CHAPTER 6

Okay, I would keep on taking tissue on top of the hepatic artery, right? Or this tissue here, right? At one point, we're gonna find the splenic, right? Stay close to the artery. Very firm tissue. Oh yes, we're very close where the cancer was. You need some help? I think I can get through it right here. 15. My tips are right there. Yeah. Now we definitely need to change it. Cut it close to the top one, obviously, right? So that, yeah. Okay - advantage of your scissor, advantage of your scissor, you see, all that beauty that you have there, especially next to the artery, next to the artery. Echo, echo, echo. It's spreading a little bit. Right? Nice. And then you know your next move already, right? 3-0 tie. We saw the hepatic around here somewhere. I wonder where it's emerging from. Should be very close to it, though. So, because she got radiation, she has a lot of edema and we're doing sort of a very sensitive dissection. So at one point a little quality would be a good idea. So I would say, so the celiac is here. And I don't know where the splenic is arising. Right? It's gonna be arising around here somewhere, right? I wonder if you can stay on top of the artery and take this tissue there. Okay, take advantage of your exposure. Even if I repeat it a hundred times, but if I make you change your style - you see how beautiful - you know your next move. That's gonna be for next move, right? You're not gonna cut that, right? I think I see something under there too. I think I do. Yeah. But I'm not 100% sure. Looking nice, no? I'm starting to feel something. Yes.Much better than before. So I see - I want you to get over that tissue. I don't know if that's over celiac or not, but this little bit of tissue. Right on top of the vessel. Stay on top of the vessel. Echo, echo, echo. Beautiful. Beautiful. Okay. You don't see the splenic yet, no. I think it may be coming here. I think it may be. No, maybe it's there and it's curving in this direction, but we'll see. We have to keep on dissecting the hepatic artery from the upper border of the pancreas, right? Because we're not trying to take it. Exactly. Deep, deep, very good. That's not the splenic, right? No. No. Doesn't feel like there's a pulse there, but… No, neither do I. Maybe start with this, do more superficial here. Yeah. Okay, give me a baby right. I think I see a good plane. Let me see. Not gonna be a cowboy. Now I'm going through the artery now. I don't feel… I think it just looks fibrotic. Okay, just buzz that very slowly. Slowly because we might embarrass ourselves and get a big gush of blood. Try not to touch my clamp, right? Okay, well I guess it was not, right? Same thing, you think? Yeah. It just keeps arcing so much on the clamp. I know. What is the Bovie at? 35, you want 30? No. Looks good. Yeah, I think the edge of the artery is right here. Oh, is it, okay, so we're okay, no? Feel okay? Yeah. Okay. A nice little plane here, right? Pick it up. Yeah, pick it up. Okay. Now, we are in a very good place. Now come from here towards - there is the… Baby right? As much as you can so we have a nicer move because soon we are gonna clamp. I think. Right angle. 3-0 tie. Beautiful. I think I see the splenic artery. I think it's this. See it? And it's probably gonna be covering right? I think the artery's here. You see it pulsing in here, right? Quick. Yep. Okay. That I don't know. Just take the superficial, yes. More, more, more, open, close, open, close, open, close. That here is okay. Bovie, open wide. Okay. Definitely the portal. This is the splenic artery, so - it's coming from the celiac there and it's curving upwards, okay? So, we need this tissue here. So that tissue, yes. More if you can. Very tough tissue. Yep, 15? Here it is. Baby. It's between the two, this tissue. Yes, between the two arteries. Yeah. Okay. That was a good move. Because now, you see the splenic? We're gonna be able to surround it, very close to its origin, right? Almost. Tie. Okay, I think you can clear a little bit of this tissue. Baby right to me. Yeah, there's a little vein there. Yeah, I see that. Or a lymph node, yeah, vein with lymph node, right? You want to - just cut it. Close to the top. It's a lymph node, no? Yeah, looks like it. Put more on the side that's encasing the splenic artery, I want you to get alongside the splenic artery and get this tissue there. Right? So you see the plane beautifully. Echo, echo, perfect, love it. Right angle. Gonna send this as - celiac lymph nodes.

We got the preaortic tissue... but it shows it's negative… Thank you. You're welcome. So, you want me to just kind of, excise this? Yeah, excise, yeah, with a scalpel or with a scissor, whatever you want. Scissors is fine. These are right next to the celiac trunk, so we can call this celiac lymph nodes, right? This celiac looks interesting, right? Oh you know what it is? The fiducial that they used. Oh. You know what they're made of? Gold. I'm not making this up. Johanna, who's just been bored right now, can probably dissect it out. Try to clear these off. I think, unless they didn't use fiducials on her, but… Let's see - the celiac lymph node. Let's see if Johanna can, there's like a clip or something in there, I think. Maybe not. I don't know. No, maybe not. Could it just be anthracotic lymph node, maybe? So you can - all of you are gonna feel splenic artery and you're gonna say "my gosh, this is so wonderful." Yes. So both of you, the three of you, please feel the splenic artery. It's the pulse is impressive, the thrill. You can pinch it. Impressive, no? This is the hepatic artery, and this is the splenic artery. Come here and just pinch it between two fingers like this. So I want you to clean it up a little bit and then pass the vessel loop behind it, okay? Pickup to me. So you can clean it that way or with a scissor. Yeah. Metzenbaums. If you want to. I think you're... I mean, pretty close. Yeah, you're pretty close to it, you don't have to super clean it, but it's nice when you see it a little bit more, right? There you go. You see, you can get behind this with a big right angle? Yeah. The only thing that might hold us up is if there's some fibrotic tissue on this side of it. No, I think you're gonna be okay. I think. There you go, boom, boom. Okay, sorry. I got you there. Mo, do you need a scalpel, or? That's all right. Sorry. Don't give up. 15. There you go. Vessel loop. Okay, we're gonna obviously transect this splenic artery, but I want to get the plane of the portal vein. I think this patient may have had a complete response, yeah. Okay, beautiful. So here it is. Not on Mo's copy, because I'm not gonna ask for a mosquito. I'm gonna ask just for a plain old snap. I knew it. You knew it?

CHAPTER 7

So now we're going to get behind the portal vein, right? Which is right here. We're gonna transect the pancreas, and then we're gonna begin dissecting there. But before we take the splenic vein, obviously we're gonna take this splenic artery, right? Okay, so I need this plane. So, pickup and a scissor to her. Because you're not ready to - quite for it, right? Pickup to me. This is… You can take that little band if you want or you can clamp if there's any doubt, right? Yeah, baby right angle. Scissors, 3-0 ties. You don't wanna stitch that one? No, I don't think it's a branch. And if it is a branch, we're not gonna be pushing at it, right? It's different than when you're doing the dissection. Right. And then we're gonna get the inferior border, okay? This is where the tumor is. And the tumor is described as engaging the splenic artery, but obviously not at its origin. Because this is its origin, and we're seeing it very well. You see the inferior border of the pancreas now? Pickup to me. Spread, oh, such nice… You see, when you do the savannas of this world, you get rewarded with these. I think you need a baby right angle to get some of that. Open and close. Take both, take both, if you can. Wrangle. Echo, echo, echo, echo, echo, echo. Oh, sole mia, look at that. Almost have the vein, right? Almost have the vein. You're gonna get ready, a little bit more, and you're gonna pass your right angle. The big one and your Penrose. We will use the stapler. Okay. The 45, purple. Gonna clean that. Oh, here's your vein, right? So I think you can probably get through now, if you wanna get your big right angle.

CHAPTER 8

With a seam guard would be nice. Like it? And this feels completely soft, right? So there's no tumor there. You can all feel it if you want to, right? Very nice, right? We're gonna put stitch, stitch, stitch, stitch, and then we're gonna transect with the stapler. Okay. This is your handle. Let me know if you want a longer needle, there I just gave you the shorter one. I think we're fine with the shorter. I don't know, whatever she wants. Donation. Beautiful. Love it. Cut. And then a snap. Remember what I told you, when you're up here in the air, use the back part of the scissor, right? Pronate, pronate, pronate, and get underneath. No. No, you're not doing it, Morgan, see, see what you're doing. Nope. Just underneath it's… Echo, it's all the difference, right? It's all in your wrist. Snap, cut. In here, pronating a lot. Full-thickness, right? Snap, cut. When you do a figure of eight, Morgan, the first loop needs to be tense. You see how it's loose? If you don't tense it, it won't tense with your knot. Needle back. And cut. Okay. Stapler two. All right, so we're gonna transect. We're gonna send the margin, but we're gonna keep on working, right? They haven't called us back about, oh no, they did call us back. So look at this, this is splenic artery also, you see it? Yeah. So it's coming from here and curving all the way, like here, like a question mark, right? Yeah. Like a candy cane. Advance it more. That's good. That's good. Okay, so you have to - more to that side, yeah. You clamp it, yep. And then we wait for a minute. Can you tell us a minute, Johanna, please? Okay. Now 30 seconds, please, yeah. Do you want to staple the spleen? No, no, no, God forbid. God forbid. No. Yeah, yeah, yeah, Then you go one and you wait 30 seconds. And then you go another and you wait 30 seconds. That's the technique that is recommended. Okay. Although here we haven't done anything, right? Yep. It's just pressing, but… It's actually very hard from my side of the table. I don't wanna yank on it. Just because I have a bad angle. Tell us 30 seconds, please. Another 30 and then we're gonna be done. You can finish it up. Okay. Good. Your button, yeah. Okay. Careful. Pickup. Heavy scissor. Cut this here. Okay, do you have the stapler? Yeah, I have it, I'm holding it here. Okay. And here. And then this. Well, we're gonna, you cut here, and we're gonna send in the margin. We need a 10 blade, please.

Can I have a forceps? How much length? A little bit, a little bit more, yeah. Without getting your stitches. Right? Pancreatic transection margin. And after this, we need a 2-0 silk stitch, probably. Transection margin. Yes, for frozen. Did you want to mark it or no? No. Okay. Bovie to her. Just touch it, just touch it. And try to lift it, okay. We can also give a big stitch, right? We cut the... Yep. 2-0 silk stitch. Big bite. Merciless. Full-thickness, right? Pronate a lot, and closer to here. Boom. There. But you wanted to get to the back of the clamp. Doesn't matter, don't repeat it. Cut. Snap and cut. Okay, and so now… Snap.

CHAPTER 9

I think we discussed this the other day. So here we have the splenic vein, right? Right. Which is gonna dissect very quickly - Bovie. Where is the Bovie? Bovie right here. So we need to see the splenic vein. Baby right, to me. Where is it? I think it's right underneath you there. You wanna Bovie that, or? It's very superficial, very - you're taking too much, I think. Careful. I don't see it. Do you see it? Okay. That's clearly okay. Bovie. I think it's gonna be it right here. It must be small, right? Because it's also occluded by the tumor, right? But we need to surround it when the time comes for the taking. But we're not gonna take it right now because if we took it… Give me a big right angle. Where's those 2-0 ties? What vein are we seeing there, Areet? The splenic vein. No. This puny little one is not the splenic vein. It's going in the wrong direction. It's going away from the pancreas. The splenic vein should be right next to the pancreas. Is that the left gastric? Down here below the pancreas? No. The right gastrocolic? Nope. The ileal? The ileal? I'm not sure. No. It is the inferior mesenteric vein. So the inferior mesenteric vein can drain directly into the splenic, right? Or it can drain into the superior mesenteric vein, which seems to be what it is doing this time. So how are we gonna - we have to see the plane. Baby right. I wonder if there's a little window there. I agree. You can do that, or you can do that - yep, there's a little branch or something, right? Open and close. Wow, wrangle, baby. Got it? 3-0 tie, please. I think it's gonna be this puny thing. It's just gonna be… Yeah, because it was probably thrombosed, yes. Occluded. Or thrombosed. Probably thrombosed, I agree. I see where it ends, you see? Right here, you see this? No behind, behind that, behind, behind. Right here? Right there? Further down, further down, deeper. Yes. Okay. You see? Something… Want the big right angle or no? Yeah, I think it's not gonna reach with this one. It's also less pointy, right? So it's no, I don't think you're in the right place. No. Oh be careful, careful, careful, careful. Pickup to me. I'm not sure you're in. I think you're, yes, you're fine. You see the plane now? Yes. Careful. It's right there. Can you go deeper, or no? Go back and try again. It's gonna' be exactly the same place. Trying to go further back, right here, if possible, right? That's okay. Okay. So that's it, right? So it's really very thrombosed, right? So, this is it. So, I don't want to clamp it until we tie the… Okay, I guess we're gonna, I don't wanna do it because it's bad technique. Give me a vessel loop. All right, let me just do it there for a second. Because you should get this first. Otherwise you get hypertension. I know it doesn't matter in this particular case because it's so… Bovie to me. If we take it off, it's gonna bleed you think? Or no? There's just a - I don't think it's bleeding from - I think it's bleeding from behind the pancreas. Okay. We can then go and get the artery. Come on, let’s go back then. You want me to take this out? I think so, because it's not making much difference, right? Okay, here you go.

Get the artery now. The splenic artery. You see it? You've got it because you discovered it, right? Okay, so big right angle to her. Ah, no. Here's one. I find you a vessel loop. I found you one. Look. Isn't that nice of us? Right angle to me. I'm not - sorry. Open wide. For some reason, I can't get in. Okay, yep, got it. Come out. Okay. See the tips? All the way because otherwise, we're gonna have a big… There you go. Okay. I just wanna move it up a bit. Yeah, there. Yeah. Scalpel followed by a 2-0 silk stitch, SH. A little bit more. Posteriorly or no? That there. Yes. That's a tiny little bit. That little band that you see down there, yes. This? Yes, just a little bit so that you have enough to tie. You think you have enough to tie? Okay, yes you do. 2-0 silk stitch. True figure of eight. And she's gonna pierce it twice. So when you do that, you pass it, the first time, there you go. Again through the center. Now you're gonna tie behind. And Areeta is gonna cut this with a little bit of a tail, correct? Pull, pull, pull, pull, pull, pull, pull. There you go. Four knots just for my peace of mind there, okay? This becomes loose, the patient will die. Here is the needle. The tip is barely seen there. Just give her another stitch and just do the same thing, right? Okay. Then come from behind because you're seeing the heel very well. Whereas you don't see the front very well. Now go to the center again. And then when you bring your knot, you know how to bring it in the front, right? You're gonna just force your finger because you, you sort of feel the tip, but you don't see it. Especially as you bring it down. Okay. Beautiful. So the pulse we had here has disappeared. We're gonna use a 3-0 silk stitch, non pop-up for the splenic vein, okay? Cut that also with a little bit of a tail just so we can identify it if we need to, right? Okay, go behind your splenic vein again. Sorry that we had done, making you do this twice, but… Big right angle. It's thrombosed, and this is why. But we're pursuing the inferior mesenteric vein, which is kind of nice. You already were there. What's happening? I was here. You see it? Oh, good for you. Right angle, big. Can you push forward a little bit? Okay. So get me back. Okay. Yeah. You have the 3-0, non-pop? Perfect. Same deal, right? In general, when you do it for a vessel, you don't do a true figure of eight because you don't wanna put it in distress. But we have a lot of fibrosis next to this. We're just playing it safe. Pull, pull, pull, pull, pull, pull, pull. Beautiful. There you go. Are we okay to tie the other side? Yeah, we're just gonna tie it. Keep the needle back. Here's your next move, this tissue here, right? And a few more moves, and then it'll be very easy for the rest of this.

CHAPTER 10

Baby right. Right angle. There we go. 2-0 ties. So, we don't really need those ties in the pancreas, and I want to be sure that we don't pull on them, right? By accident. You want to cut them? Because we don't need them anymore, right? I mean, unless the margin were positive, but in that case we can always… Put them back in? Okay, well no, we don't want to put them back in. But you're right, let's leave them there until the margin comes back. So feel what's coming here, right? The other big vessel that we need to feel soon-ish would be the superior mesenteric artery, which should be very displaced. All right, so it's not… Right angle to me. I think it's gonna be down. Yeah, it's gonna be further down. All this instead of burning and also because there's lots of lymphatics here, right? So we should have taken bigger bites, but tying them, avoids the chyle leak. So this is our next move, right? So we're gonna take this peritoneum and then take this tissue. We'll be there soon. Right angle. Thank you. It was what? No evidence. Negative from a - thank you. I honestly didn't under- you heard it? Okay, so I would get all this tissue with a big right angle, right? Okay, big right angle. All the way back there. Bovie. Big right angle. Yep. Cut that. Beautiful. And you get your plane here, right? With a - so we can Bovie the peritoneum there. Pickup to me. There you go. Yeah, up here. Right? You see the vein underneath, right? Sorry. Echo. Now you know where you're going for this. Big right angle. You're going through a vessel. So stay short of it. Right angle. Yep, got it. It's okay. 2-0 ties. And who's peeping the head there? The same one we saw the other day. Remember? The jejunum. The first loop of jejunum. Which you don't necessarily always see either. Well, I mean here, the mesocolon is so fused with this, right? That we're necessarily taking a little bit of the mesocolon here as we're doing this, which is fine. Doesn't matter. Two knots. So we're gonna be getting into, very soon into the other plane from behind because we gotta take the short gastric vessels anyhow, but… This has to come out. Big right angle. Big right angle. Right angle. Okay, show me the tip again. Beautiful, perfect. Take advantage. Take advantage. Exactly, exactly, exactly. You can Bovie that if you want to, right? Because you have the exposure, right? So who do you see back there? Tell me, please. Who's that? Morgan? Yeah? What am I seeing there? Is it the left renal vein? Yes, ma'am! Yes, ma'am! What would you say? It looks big. It is big, of course it's big! Cut. Tie. Okay. I would say you want to do this now as we have it right here, right? Still feeling for SMA? So it's very interesting because the SMA in this case is coming - I don't know where the SMA is coming from. I think I would've expected to have seen it already by now, right? Unless it's this one coming - this is a very unusual arrangement, right? We would have to look at the CAT scan again. This is clearly hepatic, but this is going down here. I don't know. We need to look at the CAT scan again because I did not see that, right? And because the aorta is so lateralized… I don't know where the superior mesenteric artery is. Okay, this has to come out. Big right angle. And then we're going to… Bovie? Big right angle, no big right angle. Or I was just gonna come through. Okay, and then there's gonna be one more here, and then we're gonna go and get the rest from the other side. So now that the margin is negative, we can cut those tags, right? It's very interesting because this is the hepatic, but there's a big branch going here behind. Yeah, and it's huge. And it's huge. So that's - the superior mesenteric artery is coming from the common hepatic, which is kind of unusual. We gotta - we'll see that because I'll make you guys more interested, right? Yeah, I think this is the one that I talked about in pancreas rounds where it looked like, to me, the proper hepatic came off the SMA, and the SMA came off really close to the celiac. Yeah, so this is it. Because the aorta - I have my finger - the aorta's right here. And if you feel down, there's nothing there. And if you go up, then you're coming right up to that. Yeah, so this is the SMA going here, and giving the hepatic artery, yes. There you go. Okay, very good. And then remember when you mention that… Big right angle. Yeah, it was hard to see on the most recent CT. But in the original one… Yeah, so we didn't really show - I didn't show it very well in pancreas rounds, but it was just something, I think I just mentioned. Okay, well that's it. So that's interesting because we can comment when you discuss the case, right? Yep, that's it. That's the explanation for this patient. No, it's a very atrophic pancreas. That makes sense. Huh? Yeah. Cut. Cut this, 2-inch tail. All right, boom and boom.

CHAPTER 11

And now we're gonna go to the other side of the world. Yeah, lift this up here. And we're going to - why are we finding adhesions? That's interesting. Bovie. Okay, there you go. We wanna preserve our gastroepiploic arcade, right? As much as we can. So right here. You see it? You see where it ends up right there, right? Okay, oh no, it continues, I'm sorry. It continues here. Okay, can we tilt the table away from me towards Morgan, please? It keeps going here. Thank you. So work this up. Yeah, that's good. Pickup to me. Bovie. Or Metz. Or Bovie? Bovie. I'm Chris, by the way, new anesthesia resident. If you need anything I'll be here until then end. Thank you, yeah, hopefully it won't be too long, Chris. Thank you. How much blood loss do we have, Chris? How much? Blood loss? Let's see. We've given 1100 fluid, 250 of albumin. And blood loss. Pretty minimal when I walked in. Yeah, very very minimal. Okay. 25-50. Okay, wow. Big right angle. No, no, no, no, we haven't. We haven't had any major vessel - just minimal. Very minimal. Okay? Yep. Get there. We'll start taking the short gastric vessels very soon. No. No. There's my finger, and then… Yep. Careful now. Beautiful. Okay. Okay, we gotta start taking the short gastrics. Big right angle. Scissors. Silk tie. Yeah so when we comment about the case, we need to comment also using the original CAT scan to describe the unusual anatomy. Okay, there you go. Now, get your right angle. You see where the vessel is going all the way back there? Yep, very good. You see the spleen near our Rich? Big right angle. Beautiful. Yep. Okay. Okay, so there you go. So lift up there, get your right angle. Exactly. you plan it. You see, I don't want to get into… Okay, you're gonna' take it out and you're gonna put both of them. So you hold it, you hold it steady. Here you go, open. And it's so easy. You just go right next to it. Yeah, I think, yeah, Right next to it should be a sliding - it's so easy, right? It's so easy! It is so easy! (laughing) It is so easy. That you say, "Well, that's the way we should do it all the time," right? Because it's, instead of doing this dance of… Beautiful. 2-0 tie. Areet, we have a little problem. Yes. That Dr. Morgan L. Hennessy, does not remember - just keep on tying. Oh no. Scissor. I'm sorry, what does the message say? The problem is she doesn't remember the five attachments of the human spleen. So she's counting on you to say, "Oh, come on, no big deal. Here they are: one, two, three, four, five." The splenophrenic, the gastrosplenic, the splenorenal, the splenocolic, and the splenopancreatic. And the most important, right? The one that goes towards the pancreas. Of those five, and you did beautiful, right? You could also have said lienorenal, lienophrenic, a little bit more elegant, but it's okay. It doesn't matter. That's just, you know, I'm old fashioned, but. Okay, so you got a little bit more short gastric, left up your stomach, right? Of those, and there's one here, which is actually, this is called Warshaw's vein because it doesn't go to the spleen, it goes to the pancreas. Of those five, right now we're taking the one, the ones to the stomach, all the way towards you, right? You're good, you're good, you're good. Second one to her. She loves this. Now she becomes like so independent. There you go. Look, she doesn't need anybody. She can operate alone. What about me? Yeah, she does need you. Which ones can she take bluntly? Which ones can she not take bluntly? Which one will she not have to take at all? In this case. The splenopancreatic, she doesn't have to take. That's right. Because it's gonna come - the spleen is gonna come together with the pancreas. Very good. Very sharp answer. I am actually - I didn't offer you an extra point, but that's okay. I won't… Scissor. The splenophrenic she can take bluntly. Yes. And she is, she is. She has a little, you know like, like those just fighting roosters that have a little blade on their thing. That's what she's gonna do. She's gonna take it out automatically. (fighting sound effects) And then take it as she puts her nice hand in there. Which else is she gonna take bluntly? She can take splenorenal. Very good. Those typically come out bluntly, right? Then to the stomach is all the short gastrics. So those you can't take bluntly. Right? Of course you can take it with a harmonic and do this a lot faster, but it's okay. And you know, she needs to learn how to tie. And then you're missing one. The splenocolic. That usually has some vascularization, right? So, it's good to clamp it. How many splenectomies have you done in your lifetime, Dr. Morgan Hennessy? Maybe three. For trauma, some, or? And one for a thrombosed spleen. Three or four. Good. So it's not a mystery to you. I'm surprised at how many senior residents have never done a splenectomy. Yeah, we don't get that... So they come and they say, "Wow, this is like a mystery to me," right? And they're all like... But we never operate - we don't operate on spleens so much anymore. We don't. Yes, no. Yeah. You know what the best way to preserve the spleen is? In formalin? Yeah, exactly. (laughing) Oh, wow, I didn't know that one. That's a good one. (laughing) Okay, so there you go. Okay. Okay, so you gotta figure out that here's your pancreas, right? Yeah. It's coming here, and here's some, actually some chunky lymph node that is coming. Here's the… We got this to take out still, so that can come out. Yeah. Big right angle to me. And then you're gonna get your hand in there, and do the honors to watch Areet's head, she gave a very good answer, Areet. Tie. Beautiful. Be careful - because there, the adrenal is there. You see it? Pickup to me. She doesn't believe me. Oh, oh, oh, yes. Okay, now I see it, yes. So we don't want to take the adrenal, you know, we're gonna have to take the spleen. You think we can come above it? From here to here, yes. Give a big right angle. Oh, if you take a little bit of the adrenal, it doesn't matter. Like this? Yes, yes, and all the way up to here. Deep, deep, deep, deep. Right? Because this has to come out, right? Unless you think you're gonna be able to free it from here. Well, that's what I was wondering. Oh, is it? Okay, okay. If we could try from here this way. Right angle. Yes, we will. So this is all adrenal. Yeah. This makes it hard for me, but it's okay. Take advantage of your exposure if you can. I don't know what that is. That's adrenal vein! The adrenal vein! Oh, holy cow. I was gonna send you into the mouth… Of the tiger. Of the tiger. But it is the adrenal vein, isn't that cool? There it is, the adrenal with its vein. It does exist. It does exist. I'm gonna get a handheld retractor. She's gonna go for the lienophrenic and the lienorenal and bring up the lienocolic, clamp it, and bing, bang, boom, bada boom. I think. This is one of the most pleasurable things there is in surgery is when you take the spleen out. Abdominal wall. And I hate this one just for the record. It's so big, and I don't know whoever uses it. I don't even think the trauma surgeons use it. You feel it? The curvature? Yes. Very stuck, or no? The spleen should be larger right now at this point. You think it's large? Just because she had a vein thrombosed. I would assume. Well I would say, it's probably small right now because we tied the splenic artery about 45 minutes ago. When we started? Yeah. She's making it so anticlimactic. Is it very stuck still, or no? Just deliver the goods, if you can. It's stuck down a little bit. Towards the kidney, towards the diaphragm, or colonsky wise? It's just the attachments to the diaphragm a little. I think I can Bovie. I have it on my finger. Okay, Bovie or take out your little knife. You know, the knife of your nail. The rooster knife. I'm almost there. Can you get your hand and bring out, bring it together with the pancreas, or no? Bovie. Very good. Yeah, remember there could still be a few little vessels back there, right? Yeah, this feels a little thicker. Okay, but bring out everything if you can. If you can. I'm not saying that it's… I don't wanna do it for you, but… Right? Because you're luxating it. Luxating is the word, or? Here to luxate. So if you can bring it - because all you're doing here is a splenectomy, and I don't want that. I want you to bring it out with this. For example, this is attached to it, right? So, start taking this. You probably need a Schnidt, right? Yeah. On the keeper side, at least, or… Bing, bang, boom. These are splenocolic, by the way. It's gonna bleed a little bit, but just clamp it. Okay. Because you know, you got such a nice feel that. So think about it as a function, I want to get it together with the pancreas, okay? Okay. Okay, yes, beautiful. It's almost out. Can I Schnidt that too? You need to Schnidt that too. So feel, where's the pancreas coming? Where is it? It's here. You can deliver these two here. You can let these two… Okay. So now it's here. And it's there, but all these attachments here to the spleen need to come out so that this delivers. Okay, there you go. Where's the pancreas? I have it in my hand right here. So why isn't it coming up? Okay. Okay, so the move is right here. Put your hand here. That has to go first, okay, boom. Big right angle. Cut. Beautiful. Almost out. Two knots because it's coming out. More attachments, right? But also this is still stuck down here. Why? Well, feel it. What is stuck so that you can free it, right? And you know your anatomy, you know there's nothing else there, that could be… Suction. This then here. You can get a right angle if you want to, so that you see the adrenal up there, right? Boom. Yes. Right angle. Probably can Bovie the top, if you want to, or not, that's okay. Here it comes, here it comes. Here's your pancreas together with your spleen. And there's more attachments here. I'm thinning him out. So maybe you can Bovie that, right? You see the adrenal vein back here. You're not gonna get into it, right? Yes. Okay, so what else? What else is holding you? This attachment, feel it. Right? Yeah, it's still kind of a lot there. Yeah, a lot. I don't know why she's got so much, but you can get your fingers, you can thin out, all right? And then you say, "Okay, I'm just gonna clamp." Bovie. Give her a Kelly. Just clamp because there's one, right? And then you… The specimen's about to come out, okay? Yeah, you can say, "Well, what else is gonna hold it? because if it's very little, I might as well just put another Kelly and finish the work." Right? You wanna just… Bovie that? Yeah, or cut it. Cut it. It's not gonna... Okay, scissor. It's gonna be very little now. It's okay. Another Kelly there. Kelly. Yep. Yep, beautiful. And then what else is missing? It's still stuck. I don't know why. Okay, tie this, sorry. Yep. Tie this, I don't know why. Boom. Okay, okay. Please feel it, and then make a decision on what you need to do, please. Okay, give me an abdominal wall retractor. Okay, feel where the pancreas is, I'm curving the pancreas. I don't wanna leave any pancreas behind, right? Yeah. It's still pretty thick there. Okay, well is that pancreas, or no? This right here? I don't think so. I don't think so because then you just get it by layer, right? Get the top part here, which this is not. I don't know why it's so… Okay. Yeah, I mean that's basically it right there. Okay. All right. Okay. Decide what to do. Do two Kellys. Okay. Cut, sorry. Beautiful, beautiful. Another Kelly. Oh, there's a little low band there. Another Kelly. I got my glove. Cut. I just… Schnidt. Bovie. Or Bovie or whatever. Okay. Distal pancreas and spleen. All right, five. Give me a long straight for the bookie. And ties, and then we need warm water, please.

CHAPTER 12

The distal pancreas was very atrophic, remember? Do you want this to go for permanent, or? For frozen because, that way it... What do you want it to be called? Distal pancreas and spleen. Can you call the lab on it? 65129. 65129. Then we need one water. Then we need one #7 flat Jackson-Pratt drain. Was it more oozy than you would expect, or? No. It's just gonna ooze a little bit from where we did the spleen. And we're gonna check right now for bleeders, of course, right? It kind of feels like sometimes you're like, am I in? Am I, you know, bluntly dissecting in the right spot? Yeah, and then you end up with a little raw area. Yeah. And sometimes it's a raw area no matter what, right? because the base of implantation to the diaphragm or to the kidney, is wide and there's no capsule on it, right? Okay, there's your stomach, right? So you always check first your short gastrics. Lap pad. Like this, for example, to see if there's no bleed. No bleeder. No bleeder, no bleeder. Let's see. Hold this there. Need a bigger suction. There's the adrenal gland. Beautiful, yeah? Get a lap pad there, dry, and then just go. Yeah. Okay, that's the end of our blood loss, if you want to quantify it for us. Somewhere between 50 and 100. Okay, beautiful. There's your adrenal. There's a little spot right there that's bleeding too, right there. Okay, well let's pick it up. Pickup. Bovie her. You can touch the tops of my forceps. Beautiful. Nice. There's something red here. There's something else. Dry lap pad. Here. Right here. Give me a big right angle. Nope, Nope. Is a 3-0 okay? Or a 2? No, 2-0. See the adrenal, Areet? Or so-so? I think so. Right there. Yeah. Feel it, touch it. It has a very typical consistency, a very typical color. Oh, wow. Okay. It's soft. Right there, you see it? There you go. Oh, yeah. Johanna, there's the adrenal. Now, the patient has released plenty of adrenal steroid. Okay, very nice. You put a lap pad? Look at the adrenal vein. Yeah, I know, look at that. It is so… Look at the renal vein here, also. Wow. Pickup to me. Let me show it here on the… Adrenal, and here's our SMA, arising from the celiac, right? Going down here and giving out the common hepatic. Right? And here's our portal vein. That's so cool. It looks good, no? Okay. Now we can… Here's her stomach, looks good. Irrigation. Okay. Look's great, beautiful anatomy. And there's your portal vein, there's your stump of the pancreas, superior mesenteric vein. I did the pop quiz myself. Isn't that honorable of me? (laughing) Instead of asking the intern or the student? You see the renal vein, you saw it well, Johanna? And the adrenal vein coming from the adrenal, look at that. Okay. I think we're done now. Okay. Okay, so take this out.

CHAPTER 13

We're gonna start to close gentlemen. Love it. Here's your ring. Okay, scalpel. There's a band here now. Knife back. Schnidt. Cut. Heavy scissor. Heavy scissor. Yep. Put it where it belongs. And where would you put it? In front of the stomach or behind the stomach? It's your call. I think behind the stomach. Yes, so you know your stomach is open over here, so you bring it through here, right? Now there's colon. It was over here in this window. Yes, this is your window. Right? And then once you pass it there, get it to this side and then you can put it where you know that it should go, right? All right, we'll leave it there. We pull this back so that we don't… And a drain stitch, please. And a 0 Maxon to Dr. Morgan Hennessy So leak rate after a distal pancreatectomy, is about 20-25%, right? So whenever I do that, I always leave a little window on my stitch, right? Because if I'm gonna advance the drain, as I have a leak, I don't have to put a new stitch. You see what I did? Just a little… Right? So I don't have to torture the patient by… Cut. Tail, boom. Oh my gosh, that's so unaesthetic. Look at that. Do you like that? No. That's nicer. Heavy scissor. Here you go. And tertiary, the dershi, the dershi. Echo. Do you guys have a lap pad there? I have a lap pad right here. Beautiful. There you go. If you can get both, get both sheaths, right? Echo. Does it make sense, Areet, for you to close your JP bulb right now, or no? We're done irrigating, I don't know. I guess not. Why not? Because we're open to air. Yeah, of course we're open to air, right? So it's gonna suck the air. It hasn't so far, but it's gonna suck it in a second, right? What makes more sense is to connect it to the suction, right? To disconnect it from the bulb, and then empty the fluid you have there, right? So that when he goes to recovery, he doesn't suddenly suck, you know, 100 cc of, and then they call you. Thank you. Could I have a Kocher for us, please? Thank you. Areet, if you don't mind, there you go, look at that. You put a Kocher in the corner, and then suddenly everything becomes a lot easier, right? You always approximate the subcutaneous? I like doing the Vicryls, but I don't know. Maybe that's just me. I never do them, but you can do as whatever you want. Yeah, I don't know. Okay. Okay. Pull, pull, pull, pull, pull, take your Kocher off. Cut one strand. Then come backwards, right? Through the center, into my side. You have to lift it with the - there you go. Through the center and then to my side, yeah. There you go. And nine knots. Beautiful. Very nice dissection, Morgan, very nice. Thank you.

CHAPTER 14

So as we explored this patient, we first of all found that there was no evidence of metastatic spread, which was good news for her. And we began a retroperitoneal dissection, and this proved to be quite laborious. The tissues in the retroperitoneum and surrounding the vessels were very fibrotic. At one point, we sent a frozen section of the tissue surrounding the hepatic artery, and this came back negative, just fibrosis and nerve tissue. And all this was very encouraging, so we continued dissecting all the vessels until we had them completely exposed and separate from the pancreas. We did find that the tumor was very soft, and this is something we see in patients who have a very good response to chemotherapy. Sometimes in association with Losartan, which is a drug that we have been using, in addition to the chemotherapy. The operation actually went very well. The blood loss was minimal. It was less than 100 cc for the entire case. Everything was very controlled. This is the way to approach these patients. The dissection over the renal vein went uneventfully. We saw the adrenal, preserved the left adrenal vein, and really things went as planned. So let's see what the final pathology shows. Sometimes in these patients, we see a complete, or near-complete, pathologic response. This would be very good news for the patient, who now is two years since her initial diagnosis of metastatic pancreatic cancer.