A 30° or 45° camera is introduced and the abdomen is explored systematically for the completion of operative staging. Then the patient is rotated to the right and placed in steep reverse Trendelenburg, and the splenic flexure is lowered using an electrothermal dissector (ultrasonic shears or electrothermal bipolar tissue sealing device). As the operation progresses, the lesser sac is entered and the omentum is separated from the greater curvature of the stomach (Fig. 17.2). The stomach is grasped and held up to expose the plane of dissection for the operating surgeon. If the short gastric vessels are to be divided, take care to completely encompass these vessels with the electrothermal device to avoid partial transection, which can result in significant bleeding. When splenectomy is planned, the dissection is carried up to the fundus of the stomach to free the spleen completely from the stomach.

Once the greater curvature is freed, the stomach can be retracted out of the field under the left lateral segment of the liver. The use of a fixed hand or liver retractor here can facilitate this retraction, which will free the left hand of the assistant. Now that the pancreas is exposed, the dissection begins with freeing of the inferior and superior borders of the pancreas (Fig. 17.3). The inferior border of the pancreas is carefully dissected out by dividing the overlying peritoneum with an electrothermal dissector. The pancreas is then lifted up bluntly with a grasper to facilitate further dissection and careful identification of vascular structures. Laparoscopic ultrasound can help identify small PNETs if necessary to assist with determining the point of parenchymal division, which should be approximately 2 cm proximal to the tumor [8]. Inferiorly, the transverse mesocolon is lowered either laterally from the splenic flexure or medially at the point of transection, using a combination of careful blunt and bipolar dissection. Take care to dissect behind the pancreas carefully, which will allow visualization of the superior mesenteric vein (SMV), inferior mesenteric vein (IMV), and splenic vein (Fig. 17.4). This maneuver is not necessarily performed to assess resectability, but rather to allow these structures to be identified and protected during further dissection and transection of the pancreas. The SMV can be found anatomically by tracing the right gastroepiploic and/or middle colic veins superiorly.

The goal of the dissection at the superior aspect of the pancreas is to identify the splenic and left gastric arteries and to completely free the lesser curvature of the stomach off of the pancreas. Injury to the coronary or left gastric vein during this part of the operation can lead to severe hemorrhage and must be avoided. Identify the splenic artery, which most commonly arises superiorly off of the celiac axis; it is often tortuous and should not be confused with the hepatic artery takeoff (Fig. 17.5). It is important to have the patient’s cross-sectional imaging available to help correctly identify vascular structures and the relationship of these structures to the tumor. The splenic artery does not have to be isolated at the takeoff unless there is concern for proximity of the tumor to the celiac axis. Once the splenic artery is confirmed, it can be taken more distally, when coursing superiorly along the pancreatic parenchyma. The vessel is freed in order to facilitate stapler placement, completing the dissection of the pancreas and major vascular structures.