Distal Pancreatectomy
Updated On: July 23, 2026
Anesthetic Approaches
Vascular access and monitoring - The splenic vessels run along the gland being resected, and a tear at the portal confluence bleeds where nobody can compress it: large-bore access and an arterial line for open, oncologic, or re-operative cases. Central access is not routine here.
Splenic vessel hemorrhage - The event that turns a scheduled resection into a crisis, usually mobilizing the tail off the splenic hilum, or a stapled artery stump retracting out of reach. Have blood in the room and checked before incision on oncologic and re-operative cases, and keep a rapid infuser primed.
Bleeding under laparoscopy - Treat an abrupt fall in end-tidal CO2 during dissection as blood loss until the surgeon says otherwise, and raise conversion early: a laparoscopic bleed not controlled within a minute is an open case.
Glycemic control - The body and tail carry much of the islet mass, so beta-cell reserve falls with the resection. Check a glucose at induction and every 1 to 2 hours after; stress and a dexamethasone antiemetic push it up. In a long case use an infusion; subcutaneous insulin absorbs unreliably in a cold patient.
Functioning islet cell tumors - With an insulinoma the glucose swings are the case, not a background concern: hypoglycemia while the tumor is still perfused, then a rebound rise within 30 to 60 minutes of devascularization. Check every 15 to 30 minutes around the resection.
Standing dextrose infusions - Do not paper over the pre-resection lows with a dextrose infusion you then forget, because the post-resection rise is what the surgeon reads as evidence the lesion is out.
Fluid strategy - No pancreatic anastomosis needs protecting here, but liberal crystalloid still buys bowel wall edema. Drive boluses by stroke volume or pulse pressure variation, but do not run dry either: an under-filled patient on an epidural gets vasopressor for a volume problem.
Pneumoperitoneum and tilt - Minimally invasive cases mean an hour or more of pneumoperitoneum with reverse Trendelenburg and a left-side-up tilt: reduced venous return, a climbing end-tidal CO2, and a risk of sliding cephalad. Nothing can be repositioned once the robot is docked.
Left hemidiaphragm and pleural entry - The splenic flexure and short gastrics sit under the left hemidiaphragm, where the pleura is easy to enter. Rising peak pressure with falling saturation and quiet left-sided breath sounds is a pneumothorax; tell the surgeon, who can often see the defect from inside.
Analgesia plan - Open midline and subcostal incisions score high for pain, and a thoracic epidural around T7 to T9 remains the reference for the open approach. A bilateral subcostal TAP or rectus sheath block covers laparoscopic and robotic incisions well.
Neuraxial catheter timing - Where a catheter is planned, timing relative to pharmacologic thromboprophylaxis is the decision point; verify it against current ASRA guidance for the exact agent and dose in use.
Epidural hypotension versus bleeding - A working thoracic epidural drops systemic vascular resistance, and the hypotension looks identical to early hemorrhage. Trend heart rate, pulse pressure variation, and the surgical field together, and load the catheter after the major vascular dissection.
Emergence and disposition - Long cases in a patient often thinned by a pancreatic mass, so temperature decides the first hour: forced-air warming from before incision, and extubation with the stomach decompressed. If a gastric tube went in for exposure, confirm whether it stays.
High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.
Reverse Trendelenburg Position (general considerations): Improves access to the organs of the upper abdomen. To avoid patient slipping, use a foot board if an extreme angle is used. This position results in blood pooling in the abdomen and lower extremities. Reductions will be seen in stroke volume, cardiac filling, and cardiac output. The greater the angle, the greater these affects. Increases will be seen in FRC and compliance, which will be especially the case with obese patients. Ulnar nerve injuries can result if pressure is placed on the ulnar groove at the elbow. Any bump, rise, or IV pole along on the arm board between the elbow and the shoulder can result in radial nerve injury. Pad all pressure points (emphasis on head, sacrum, elbows, and heels) and ensure any straps used to secure limbs are loose enough to allow normal blood flow. Ensure the patient is not lying on IV tubing, monitor lines, or knots.
Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also, consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.
High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.
Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.
High Blood Loss RISK (general considerations): Though most of these cases don't result in a high blood loss, there is a high blood loss RISK. Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra IV push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.
Bispectral Index Scale (BIS) monitor (general considerations): The recommended values under general anesthesia are 40-65. Values of 65-85 are recommended for sedation.
Distal pancreatectomy removes the gland to the left of the superior mesenteric vein - the body and tail - for lesions that live there: mucinous cystic neoplasms, intraductal papillary mucinous neoplasms (IPMN), neuroendocrine and islet cell tumors, adenocarcinoma of the body and tail, and focal chronic pancreatitis or trauma. The splenic artery runs along the superior border of the gland and the splenic vein along its posterior surface, so the spleen is commonly taken with the specimen; spleen-preserving variants either dissect those vessels free or divide them and rely on short gastric collaterals. Two consequences drive the perioperative course. The body and tail carry a large share of the islet mass, so beta-cell reserve falls with the resection. And the cut stump has no anastomosis - it is stapled or oversewn - so the dominant complication is a pancreatic fistula from the transected duct rather than an anastomotic leak.
Positioning and access - Supine with arms out. Open cases use an upper midline or left subcostal incision; laparoscopic and robotic cases use four to five ports with the table in reverse Trendelenburg and the left side elevated.
Exposure - The gastrocolic ligament and short gastric vessels are divided to enter the lesser sac, lifting the stomach off the anterior surface of the pancreatic body and tail.
Assessment - Intraoperative ultrasound localizes the lesion and defines its relationship to the splenic vessels and the pancreatic duct, which decides whether the spleen can be preserved.
Splenic vessel control - In the standard resection with splenectomy, the splenic artery and vein are individually ligated near their origins. Spleen-preserving variants either peel the vessels off the gland or divide them and rely on short gastric collaterals to keep the spleen perfused.
Transection - The pancreas is divided to the left of the superior mesenteric vein and portal confluence, either with a stapler or with cautery and hand-sewn duct ligation.
Mobilization - The specimen, distal pancreas with or without spleen, is lifted off the retroperitoneum. Oncologic resections may take Gerota's fascia and the left adrenal for a posterior margin (radical antegrade modular pancreatosplenectomy).
Closure - The stump is buttressed or oversewn, a closed-suction drain is usually left near it to control a pancreatic leak, and the abdomen is closed.
Neoadjuvant chemotherapy - Body and tail adenocarcinoma increasingly reaches the OR after FOLFIRINOX or a gemcitabine-based regimen, so ask what they had and when. Oxaliplatin leaves a cold-triggered peripheral neuropathy: document any existing deficit before a block or before positioning, so a pre-existing finding does not become yours postoperatively. Anthracycline or fluoropyrimidine exposure is a reason to look for a recent echocardiogram rather than assume a normal ventricle, and recent cycles justify a current CBC before you commit to a neuraxial technique.
When the spleen goes with the specimen - The anesthesia-relevant piece is intraoperative, not the vaccination schedule and counseling the surgical and floor teams own. Splenic mobilization is where the bleeding lives, so keep the resuscitation plan active through that step. The one downstream item worth carrying is the marked reactive thrombocytosis these patients develop over the following week, which is worth knowing if they come back to you for drainage of a fistula or a re-operation inside that window.