Unusual Case
Thoracoscopic splanchnicectomy as a palliative
procedure for pain relief in carcinoma pancreas
Arun Prasad, Piush Choudhry, Sunil Kaul, Gaurav Srivastava, Mudasir Ali
Indraprastha Apollo Hospital, Department of General and Minimal Access Surgery, Department of Surgical Sciences, New Delhi,
India
Address for correspondence: Dr Arun Prasad, Room No. 1202, Surgical OPD Block, Indraprastha Apollo Hospital, New Delhi - 110 076,
India. E-mail: surgerytimes@gmail.com
Abstract
Thoracoscopic splanchnicectomy has been used
for the management of upper abdominal pain
syndromes as an alternative to celiac plexus block
for conditions such as chronic pancreatitis or
supramesocolic malignant neoplasms, including
unresectable pancreatic cancer. This procedure
is similar to the percutaneous block with a higher
degree of precision and avoids the side effects
associated with the local diffusion of neurolytic
solutions. Thoracoscopic splanchnicectomy
appears to be a better treatment in such cases as
the procedure is done under direct vision and less
dependent on anatomical variations.
Key words: Cancer, pain, palliation, pancreas,
thoracoscopy, splanchnicectomy, VATS
DOI: 10.4103/0972-9941.55106
Introduction
With limitations of the celiac plexus block and
less associated morbidity with this procedure,
thoracoscopic splanchnicectomy appears to
be the surgery for palliation for conditions
such as chronic pancreatitis or supramesocolic
malignant neoplasms, including unresectable
pancreatic cancer.[1] The first reported laparoscopic
splanchnicectomy was performed in 1943 by
Mallet-Guy, while excision of supraphrenic part
of celiac nerve from thoracotomy access was
reported by Ston and Chauvin (1990) and later
by Melki et al. (1993) pioneered in thoracoscopic
37
splanchnicectomy. Few cases have been reported
though with encouraging results. Celiac plexus is the
largest sympathetic plexus located at L1 level posterior
to the vena cava on the right side and just lateral to the
aorta on the left side. The plexus is composed of a dense
network of interconnecting presynaptic sympathetic
nerve fibres derived mainly from the greater (T5T9),
lesser (T10–T11) and least (T12) splanchnic nerves. It
also receives parasympathetic fibres from the vagus
nerve. Splanchnic nerve neurolysis or neurolytic celiac
plexus block for the treatment of chronic abdominal pain
was first reported by Kappis in 1914. In 1918, Wendling
was the first to report an anterior transabdominal
technique, and the techniques were improvised in tune
with the radiological advances but the complications
associated with the procedure often outweighs the
benefits. Thoracoscopic splanchnicectomy is yet in
the incipient stages of minimal access procedures and
further data are required before it can be documented
as a procedure for palliative surgery.
CASE REPORT
A 64-year-old male presented with complaints of pain
upper abdomen on and off since last 4 months. Pain was
moderate to severe in intensity, radiating to back and
relieved by bending forward. There was loss of weight
and appetite. No other significant history of medication
or hospitalization was found.
CT scan of the abdomen done on 28.08.08 revealed
pancreatic body mass lesion with extension into
peripancreatic fat encasing adjacent vessels. CT guided
FNAC was suggestive of adenocarcinoma pancreas.
Journal of Minimal Access Surgery | April-June 2009 | Volume 5 | Issue 2
Prasad, et al.: Thoracoscopic splanchnicectomy
During surgery the tumour was found to be arising
from the body and tail of pancreas infiltrating into
the duodenojejunal flexure, roof of mesocolon and
encasing the middle colic and SMV, thus making the
tumour unresectable.
The patient was referred to the pain management
clinic where splanchnicectomy was advised. Bilateral
thoracoscopic splanchnicectomy was performed with
10 mm port in the sixth ICS space for the telescope
and two 5 mm ports made in the second ICS and fourth
ICS anteriorly. The sympathetic trunk was identified
and the greater splanchnic nerve seen at the T8 level
crossing over towards the right crus of the oesophageal
opening into the diaphragm [Figure 1]. The splanchnic
nerve was divided using cautery together with its
connections to the main sympathetic trunk [Figure 2].
Similar procedure was repeated on the left side.
The patient reported less pain on visual analogue scale
VAS 2/10 as compared to preoperative VAS 8/10 in the
immediate postoperative period; the patient is now
relieved and is on mild analgesics.
DISCUSSION
Celiac plexus blocks have been used for the treatment
of chronic abdominal pain for nearly a century now,
and the excision of nerve fibres has been shown
to decrease the pain significantly. Even though
these techniques have been improvised with the
advances in the field of radiology, there have been
documented evidences of complications including
Figure 1: Thoracoscopic view of nerves
Journal of Minimal Access Surgery | April-June 2009 | Volume 5 | Issue 2
sexual dysfunction, pneumothorax, retroperitoneal
haemorrhage, retroperitoneal abscess, kidney damage,
rarely paraplegia besides postural hypotension and
diarrhoea.[2] Besides these complications, distorted
anatomical relationships due to ascites, organomegaly,
tumour bulk, obesity, peritoneal seeding and previous
surgery limit the procedure. Moreover, these procedures
had to be repeated a number of times to achieve
optimal results which increased the risk of iatrogenic
complications.
Thoracoscopic splanchnicectomy is a percutaneous
procedure performed under direct vision. The
advantages include that the procedure can be
performed bilateral in the same prone position, higher
precision video assisted identification and division of
all the roots of the splanchnic nerves, from T5 through
T12 can be performed, no need for selective double-
lung ventilation to create the working space and use of
CO2 insufflation usually allows to perform a two trocar
technique. It also avoids the side effects associated
with the local diffusion of neurolytic solutions. The
limitations include difficulty in pleural adhesions and
the likelihood that pain relief reduces with increased
period of survival in cancer patients.
Whether unilateral procedure is sufficient [3] or
neurotomies would depend on the side of pain
radiation, whether denervation of the nerve roots or
just the splanchnic nerve is sufficient[4] are questions to
be answered in the future, but certainly the procedure
is a valuable attempt to provide palliation in patients.
This procedure has been reported with either few or
Figure 2: Nerve being cut with cautery
38
 Prasad, et al.: Thoracoscopic splanchnicectomy

no complications. Kordiak et al. (2005)[5] in a study of
31 patients reported no complications of thoracoscopic
splanchnicectomy surgery in any of the study patients
within the observation time period and stated its use
as current palliative analgesic therapy. The patients
referred for palliative surgery have on an average
6 months survival time, and subjecting these for
procedures that can become an important source of
morbidity is not justified .
2. Desai MJ, Kim A, Fall PC, Wang D. Optimizing Quality of Life Through
Palliative Care. J Am Osteopath Assoc 2007;107:9-14.
3. Maher JW, Johlin FC, Pearson D. Thoracoscopic splanchnicectomy for
chronic pancreatitis pain. Surgery 1996;120:603-10.
4. Ihse I, Zoucas E, Gyllstedt E, Lillo-Gil R, Andrén-Sandberg A. Bilateral
Thoracoscopic Splanchnicectomy: Effects on Pancreatic Pain and
Function. Ann Surg 1999;230:785-90.
5. Kordiak J, Brocki M, Rysz J, Stolarek R, Santorek-Strumitto EJ, Gruda
R, et al. Thoracoscopic splanchnicectomy in chronic epigastric visceral
pain therapy. Arch Med Sci 2005;1:171-4.

REFERENCES
1. Pietrabissa A, Vistoli F, Carobbi A, Boggi U, Bisà M, Mosca F.
Thoracoscopic Splanchnicectomy for Pain Relief in Unresectable
Pancreatic Cancer. Arch Surg 2000;135:332-5.
Cite this article as: Prasad A, Choudhry P, Kaul S, Srivastava G, Ali M.
Thoracoscopic splanchnicectomy as a palliative procedure for pain relief in
carcinoma pancreas. J Min Access Surg 2009;5:37-9.
Date of submission: 24/09/08, Date of acceptance: 11/12/08
Source of Support: Nil, Conflict of Interest: None declared.

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Date: 31st July 2009 T E Udwadia

39 Journal of Minimal Access Surgery | April-June 2009 | Volume 5 | Issue 2