Surgical approach to borderline resectable tumors of the left pancreas

Resections of the pancreas typically involve removal of either the pancreatic head or varying portions of the pancreatic body and tail depending on the actual location of the tumor. The line of transection during a typical pancreaticoduodenectomy is constant in most cases and is that region of parenchyma directly overlying the SMV/portal vein, often called the pancreatic neck. Occasionally, that line of transection will move to the patient’s left should the tumor extend out of the pancreatic head. However, from a surgical anatomy standpoint the pancreatic head is defined as all of the pancreatic tissue lying to the right of the SMV/portal vein. Similarly, the left pancreas is defined as all of the pancreatic tissue lying to the left of the SMV/portal vein. It contains both the body and tail of the pancreas as is commonly depicted in anatomy texts. Traditionally, the line of parenchymal transection for tumors of the left pancreas is not always constant and can move leftward from the SMV/portal vein with more distal locations of disease (i.e., those located in the tail.) Thus, a distal pancreatectomy is a more nebulously defined concept in comparison to the typical Whipple procedure when referring to the actual location of parenchymal transection. In this chapter we will be discussing what we believe is the optimal approach to the oncologic resection of the left side of the pancreas. We advocate for a modular approach employing a constant transection line in typical resections of malignant tumors of the left pancreas. That line is at the SMV/portal vein. Thus, the entire left pancreas is removed regardless of the tumor’s location within the body or tail. Occasionally, the pancreas will require division at the union of the head and neck in order achieve a negative margin.