 Hi, today we will see how do we perform a standard Norton Ramps Laparoscopic Distal Pantreatic Ostronectomy. The first step is to gain entry into the lesser sac Just we have to pull the stomach up so that the gastrocolic momentum can be seen Once the gastrocolic momentum is seen in size the gastrocolic momentum the first two layers of the greater Romantum to gain access into the lesser sac as you can see in the video We are cutting the first two layers of the gastrocol gastric momentum Once the lesser sac is entered the stomach is lifted up and the third and the fourth layer of the greater momentum is incised Once you incise the third and the fourth layer of the greater momentum you gain access to the pancreas now you can see the lesion in the body and the tail of the pancreas and The overlying fascia is nothing but third layer of the greater momentum Which is now cut. It is important to mobilize the stomach As far as possible this helps in good traction and hitching the stomach up onto the antirebdominal wall In this case, we were not sure of the Resection margin and hence the stomach was mobilized right up to The gastrodeodontal artery as we can see here with the red arrow That is the gastrodeodontal artery running on the superior surface of the pancreas once The stomach mobilization is done The whole of the pancreas Comes right into the vision for further dissection. The second step is to cut the root of the misentry of the transverse colon and expose the inferior border of the pancreas Now you can see by incising the root of the misentry of Transverse colon which runs from the second part of the deodenum right up to the tail of pancreas We expose the inferior border of the pancreas The whole of the root of misentry is Cut all along the inferior border right up to the tail as far as possible Underneath you can see the fascia and the deodenum. This is a relatively avascular plane And a combination of blunt and sharp dissection is performed To lift off the inferior surface and the inferior border of the pancreas from the underlying gerotas fascia You can see that by just performing the blunt dissection This avascular zone Can be easily dissected Now the next step is to understand whether the splenic vein and the splenic artery is free or not The stomach is hitched to the anterior abdominal wall So that minimum trauma Occurs to the stomach This helps in keeping the stomach away from the dissection area Also, it reduces one of one port The root of the misentry Is cut and is continued as distally towards the tail as possible Making sure that the whole of the inferior surface of the pancreas Is lifted off from the underlying fascia Covering the deodenum and the gerotas fascia slowly and steadily making sure With the help of a gauze piece That no trauma at any given point of time occurs To the tumor This is a young lady Who who was diagnosed with pseudo papillary tumor of the pancreas cystic neoplasm of the pancreas Now you can see the under surface of the normal pancreas being lifted off From the gerotas fascia Subsequently, we are also trying to assess Whether the splenic artery and the splenic vein can be separated in order to preserve the spleen However, in this case the size is around five to six centimeter and is engulfing not Not engulfing but actually In close proximity and a butting the splenic artery and the splenic vein Now we are cutting the lower polar division of the splenic artery Which took off early This was seen on ct angiography Now the splenic vein and the splenic artery are identified From the inferior aspect or the inferior surface of the pancreas In order to minimize the tumor handling One should be sure of minimizing the tumor handling Once the inferior dissection has taken place The splenic artery is now dissected from the superior border of the pancreas Now you can see the main splenic artery Running all around All along the superior border of the pancreas This splenic artery is identified Looped and ligated with the help of Hemologue clips This part of the step is performed only when you are when you are assured That the tumor is closely abutting And saving the spleen may result into A positive radial margin The remnant attachments of the splenic artery with the pancreas Is cut with the help of a vascular loop And the remaining attachments Are cut In order to separate The whole of the splenic artery From the pancreas as is being shown in the video Once the splenic artery is ligated and cut Rest of the procedure is relatively avascular The splenic vein is completely mobilized With the help of a gauze piece The tumor is retracted To be sure that none of the laparoscopic instrument perforate the tumor The splenic vein is mobilized in order To have space for the vascular Staplers to go through For the ligation of the splenic vein This is a curved tip Laparoscopic stapler Of johnson and johnson Which helps in easy maneuverability For stapling of this splenic vein Once the artery and the vein are ligated and cut This the pancreas Is lifted up In order to separate the inferior surface Of the pancreas From the Gerotas fascia This pancreatic parenchyma Is lifted off Taking care Taking care So that The tumor is not perforated At every given point of time The traction should be gentle With the help of a gauze piece Or The traction should be put At the normal pancreas As you can see now in the video The whole of the pancreas Is now lifted up And the superior attachments Along The stomach and the pancreas Are cut right up to the spleen Once all the attachments superior and inferior are cut The spleenocolic ligament And the gastro splenic Short gastric vessels Are cut And the pancreatic parenchyma is ready For division by the stapling technique Our experience of dividing The pancreatic parenchyma With stapling technique has been very good And we have not observed High leak rates This is a very important step In which The stapling is Before stapling is done the compression Is put for 10 minutes And half of the pancreatic parenchyma is divided And not the whole of the pancreatic parenchyma The rest of the half Is again compressed for 10 minutes And then again staple is fired This ensures complete and safe stapling Of the whole of the pancreatic parenchyma Along with a good margin As you can see in the video The division of the pancreatic parenchyma is done The rest of the mobilization of the pancreas and the spleen is a very simple and safe procedure This ensures complete dissection of the pancreatic osplenectomy procedure Thank you