Distal Pancreatectomy
What the Examiner Expects
Resection of the body and/or tail of the pancreas, typically with splenectomy for malignant disease (the splenic artery and vein run along the posterior-superior surface of the pancreas). The examiner expects you to know the indications, describe the operative technique (mobilize the spleen and pancreatic tail from lateral to medial, identify and ligate the splenic artery and vein, transect the pancreas with a stapler or sharply with suture closure), and understand that the pancreatic fistula rate is higher than after Whipple because there is no downstream intestinal drainage of the pancreatic stump. For benign or borderline lesions, a spleen-preserving approach is preferred: Kimura technique (preserving splenic vessels) or Warshaw technique (dividing splenic vessels, relying on short gastric collaterals).
Key Examiner Focus Points
- Resects body and/or tail of pancreas; usually includes splenectomy for cancer
- Spleen-preserving approach for benign/borderline lesions (Warshaw or Kimura technique)
- Pancreatic fistula rate is high (20–30%) — staple line management is key
- Indications: pancreatic body/tail cancer, symptomatic cystic neoplasms (MCN, IPMN), chronic pancreatitis, trauma
- Celiac axis involvement for body tumors may require modified Appleby procedure
Common Curveballs
After spleen-preserving distal pancreatectomy (Warshaw), the spleen appears congested and dusky
Splenic venous congestion from ligation of the splenic vein without adequate short gastric collateral drainage. If the spleen does not improve with observation, splenectomy may be required. The Warshaw technique has a 5–15% splenectomy conversion rate due to vascular insufficiency.
Postop drain output is high amylase fluid on POD 3
Pancreatic fistula from the staple line. Classify by ISGPF criteria. Manage with drain maintenance, octreotide, and nutritional support. Most grade A/B fistulas resolve with conservative management over 2–6 weeks. Ensure adequate percutaneous drainage of any fluid collections.