Minimally Invasive Left Pancreatectomy With the Critical View of Safety and the Caudal Approach: A Standardized Technique for Training

Background: Minimally invasive left pancreatectomy improves the postoperative outcomes compared with an open approach. Vascular dissection during this procedure can be challenging, especially in cases of large tumors or misleading anatomy. Methods: In this video article, we describe a standardized technique for MLP based on 2 technical key points: the critical view of safety (CVS) and a caudal approach. A central vascular dissection to get a critical view of safety (CVS) for splenic vessels is pursued. The left gastric vein should clearly be seen separating the common hepatic vein and the splenic (CVS for splenic artery). A caudal approach with extensive retropancreatic dissection before pancreatic neck transection is used to isolate the splenic vein (CVS for splenic vein). Splenic vessels are then sectioned (or dissected in cases of preservation). Results: The technique presented was standardized in 25 consecutive patients with borderline and malignant pancreatic tumors. Conversion to open surgery occurred in one case due to tumor infiltration of the left colic flexure. No intraoperative blood transfusions were required. The median body mass index (BMI) was 22.7 kg/m 2 (17.2 to 48.5 kg/m 2 ), and 3 patients (21.4%) had BMIs > 30 kg/m 2 . Type of resection performed included left pancreatectomy with splenectomy (n = 11), left pancreatectomy with splenic vessels preservation according to the Kimura technique (n = 11), left pancreatectomy with splenic vessels resection and spleen preservation according to the Warshaw technique (n = 3). Diagnoses included neuroendocrine tumors (n = 8), pancreatic ductal adenocarcinomas (n = 4), mucinous cystadenomas (n = 6), intraductal papillary mucinous neoplasm (n = 4), and other (n = 3). No intraoperative blood transfusions were required. The median operation time was 225 minutes (90 to 330 min). The overall morbidity rate was 30%, and there was no mortality. Conclusions: A formal standardized method for MLP is presented, entailing a caudal approach to splenic vessels and a critical view of safety before vascular ligation. This approach could be an educational aid to reduce the learning curve for trainee surgeons.