Published: 2021-10-28

Importance of the vessel distribution at splenic hilum for laparoscopic Warshaw procedure

Shinichiro Ono, Tomohiko Adchi, Amane Kitasato, Masaaki Hidaka, Akihiko Soyama, Koji Natsuda, Takanobu Hara, Riccardo Pravisani, Mitsuhisa Takatsuki, Tamotsu Kuroki, Susumu Eguchi


The laparoscopic Warshaw procedure (LWP) is a considered to carry a risk of splenic infarction and perigastric varices formation. We retrospectively analyzed the clinical outcomes and relationship between the distribution of the splenic hilum vessels and splenic infarction in patients who underwent LWP from February 2007 to February 2017.  A total of 19 patients underwent LWP, and the median follow-up duration was 78 months. The median operative time and blood loss were 295 min and 200 gr. Six patients with splenic partial infarction and 3 with gastric varices were detected, but they have not needed any treatments. According to the classification by Michels, the distribution of splenic vessels were divided as distributed type and magistral type at the splenic hilum. In our study, 16 patients were distributed type and 3 were magistral type. Three of the 16 patients developed splenic infarction in distributed type. In contrast, all of magistral patients showed splenic infarction. Although LWP is a safe procedure, there is a high risk of splenic infarction if the splenic vessel distribution is a magistral type. Understanding the type before surgery leads to the identification of an appropriate vascular dissection position and reduces postoperative complications.


Laparoscopic Warshaw procedure, Splenic vessels distribution, Spleen preserving distal pancreatectomy, Splenic infarction

Full Text:



Shoup M, Brennan MF, McWhite K, Leung DH, Klimstra D, Conlon KC. The value of splenic preservation with distal pancreatectomy. Arch Surg. 2002;137:164-8.

Kimura W, Inoue T, Futakawa N, Shinkai H, Han I, Muto T. Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. Surgery. 1996;120:885-90.

Warshaw AL. Conservation of the spleen with distal pancreatectomy. Arch Surg. 1988;123:550-3.

Venkat R, Edil BH, Schulick RD, Lidor AO, Makary MA, Wolfgang CL. Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis. Ann Surg. 2012;255:1048-59.

Kim H, Song KB, Hwang DW, Lee JH, Shin SH, Jun ES, et al. A single-center experience with the laparoscopic Warshaw technique in 122 concecutive patients. Surg Endosc. 2016;30:4057-64.

Miura F, Takada T, Asano T, Kenmochi T, Ochiai T, Amano H, et al. Hemodynamic changes of splenogastric circulation after spleen preserving pancreatectomy with excision of splenic artery and vein. Surgery. 2005;138:518-22.

Tien YW, Liu KL, Hu RH, Wang HP, Chang KJ, Lee PH. Risk of varices bleeding after spleen-preserving distal pancreatectomy with excision of splenic artery and vein. Ann Surg Oncol. 2010;17:2193-8.

Ferrone CR, Konstantinidis IT, Sahani DV, Wargo JA, Fernandez-del Castillo C, Warshaw AL. Twenty-three years of the Warshaw operation for distal pancreatectomy with preservation of the spleen. Ann Surg. 2011;253:1136-9.

Louis D, Alassiri A, Kirzin S, Blaye-Felice S, Chalret du Rieu M, Julio CH, Bloom E, et al. Gastric bleeding risk following spleen preserving distal pancreatectomy with excision of the splenic vessels: a long-term follow-up. HPB (Oxford). 2017;19:345-51.

Michels NA. The variational anatomy of the spleen and splenic artery. Am J Anat. 1942;70:20.

Lynch AM, Kapila R. Overwhelming postsplenectomy infection. Infect Dis Clin North Am. 2012;10:693-707.

Moffett SL. Overwhelming postsplenectomy infection: managing patients at risk. JAAPA. 2009;22:36-9.

Linet MS, Nyrén O, Gridley G, Mellemkjaer L, McLaughlin JK, Olsen JH, et al. Risk of cancer following splenectomy. Int J Cancer. 1996;66:611-6.

Goh BK, Tan YM, Chung YF, Cheow PC, Ong HS, Chan WH, et al. Critical appraisal of 232 consecutive distal pancreatectomies with emphasis on risk factors, outcome, and management of the postoperative pancreatic fistula: a 21-year experience at a single institution. Arch Surg. 2008;143:956-65.

Kleeff J, Diener MK, Z'graggen K, Hinz U, Wagner M, Bachmann J, et al. Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg. 2007;245:573-82.

Jain G, Chakravartty S, Patel AG. Spleen-preserving distal pancreatectomy with and without splenic vessel ligation: a systematic review. HPB (Oxford). 2013;15:403-10.

Kim H, Song KB, Hwang DW, Lee JH, Shin SH, Jun ES, et al. A single-center experience with the laparoscopic Warshaw technique in 122 consecutive patients. Surg Endosc. 2016;30:4057-64.

Boselli C, Barberini F, Listorti C, Castellani E, Renzi C, Corsi A, et al. Distal pancreatectomy with splenic preservation: A short-term outcome analysis of the Warshaw technique. Int J Surg. 2015;21:S40-3.

Song KB, Kim SC, Park JB, Kim YH, Jung YS, Kim MH, et al. Single-center experience of laparoscopic left pancreatic resection in 359 consecutive patients: changing the surgical paradigm of left pancreatic resection. Surg Endosc. 2011;25:3364-72.

Elabbasy F, Gadde R, Hanna MM, Sleeman D, Livingstone A, Yakoub D. Minimally invasive spleen-preserving distal pancreatectomy: Does splenic vessel preservation have better postoperative outcomes? A systematic review and meta-analysis. Hepatobiliary Pancreat Dis Int. 2015;14:346-53.

Partelli S, Cirocchi R, Randolph J, Parisi A, Coratti A, Falconi M. A systematic review and meta-analysis of spleen-preserving distal pancreatectomy with preservation or ligation of the splenic artery and vein. Surgeon. 2016;14:109-18.

Matsushima H, Kuroki T, Adachi T, Kitasato A, Hirabaru M, Hidaka M, et al. Laparoscopic spleen-preserving distal pancreatectomy with and without splenic vessel preservation: the role of the Warshaw procedure. Pancreatology. 2014;14:530-5.

Yoon YS, Lee KH, Han HS, Cho JY, Ahn KS. Patency of splenic vessels after laparoscopic spleen and splenic vessel-preserving distal pancreatectomy. Br J Surg. 2009;96:633-40.

Hwang HK, Chung YE, Kim KA, Kang CM, Lee WJ. Revisiting vascular patency after spleen-preserving laparoscopic distal pancreatectomy with conservation of splenic vessels. Surg Endosc. 2012;26:1765-71.