Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein

Figure 1 Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for chronic pancreatitis. A Puestow’s procedure with removal of the tail of the pancreas.

Figure 2 The fusion fascia of the head of the pancreas in an autopsy case.

Figure 3 During development, the pancreas is divided into two buds representing the ventral and dorsal anlagen. The ventral anlage of the pancreas then moves around the duodenum until it comes in contact with the dorsal bud.

Figure 4 The membrane of the ventral bud and that of the inferior vena cava and abdominal aorta become fused. The fusion fascia of the head of the pancreas is known as the "fusion fascia of Treitz" and that of the body and tail of the pancreas is called the "fusion fascia of Toldt".

Figure 5 Histological findings of the "fusion fascia" of the pancreas.

Figure 6 A posterior view of the head of the pancreas in an autopsy case. The posterior surface of the pancreas is covered with fusion fascia of Treitz.

Figure 7 When the fusion fascia of Treitz is ablated from the parenchyma of the pancreas, an important pancreatoduodenal vessel, for example the PSPDV, is revealed. A posterior view of the head of the pancreas after ablation of the fusion fascia of Treitz.

Figure 8 Sagittal section through the neck of the pancreas. The fusion fascia is indicated by the dotted line.

Figure 9 When the pancreas was ablated from the retroperitoneum, the pancreas and splenic vein are covered with the fusion fascia of Toldt.

Figure 10 The fusion fascia of Toldt is longitudinally cut above the splenic vein.

Figure 11 The branches from the splenic vein on both sides should be carefully ligated and divided.

Figure 12 The splenic vein in the body of the pancreas is removed from the pancreatic body.

Figure 13 The splenic artery is removed from the spleen toward the head of the pancreas. Then, the distal pancreas can be removed.

Figure 14 Case No. 1: A 79 yr-old patient with simultaneous gastric carcinoma and IPMN in the body and tail of the pancreas. Endoscopic examination and MRCP. A: Stomach: Early carcinoma; B: Pylorus-preservingdistal gastrectomy; C: Spleen-preserving distal pancreatectomy.

Figure 15 Case No. 1 The operative and histological findings, and egg like appearance by intraoperative pancreatoscopy. A: IPMN of the pancreas; B: Body: Carcinoma, noninvasive; C: Body: Egg like appearance; D: After stomach resection and spleen-preserving DP.

Figure 16 Case No. 2: A 54-yr-old patient with a diagnosis of IPMN in the body of the pancreas. CT scan. The cystic dilatation of the branch duct with protrusive lesions in the body of the pancreas. The main pancreatic duct is not dilated.

Figure 17 Endoscopic examination revealed the slight dilatation of the papilla of Vater. Endoscopic ultrasound revealed the cystic dilatation of the branch duct with protrusive lesions in the body of the pancreas. A: Slight dilatation of the orifice of the papilla of Vater; B: The cystic dilatation of the branch duct with protrusive lesions in the body of the pancreas. The main pancreatic duct is not dilated.

Figure 18 Case No. 3. A 25 yr old male. The imaging procedures such as abdominal CT scan, EUS and MRCP suggested a branch type of IPMN.

Figure 19 The operative and histological findings, and cut surfice of the tumor.