Total laparoscopic pancreaticoduodenectomy with left posterior superior mesenteric artery first-approach and plexus-preserving circumferential lymphadenectomy: step-by-step technique with a surgical case report (with video)

Abstract

Introduction Total laparoscopic pancreaticoduodenectomy (tLPD) for cancer of the Vater remains a challenging procedure. Recently, several meta-analyses showed the superior aspects of “superior mesenteric artery (SMA)-first approach,” “systematic mesopancreas dissection,” and “circumferential lymphadenectomy around SMA” in increasing R0 resection rate and reducing postoperative complications including pancreatic fistula and bleeding as well as improving overall survival particularly. Case presentation Our patient is a 70-year-old female with a no special medical history, recruited because of jaundice. She was referred for pancreaticoduodenectomy because of a 10-mm-sized mass in distal bile duct referred to as Vater’s tumor. We used 5 trocars, and the patient was placed in a Trendelenburg position. The transverse colon was lifted, the first loop of the jejunum was pulled to the left, and lymph node groups 14th and 15th were removed en bloc and then exposed the SMA from the anterior to the left posterior side from the caudal side to the origin. The first jejunal vessels and the posterior inferior pancreaticoduodenal artery were ligated as well as the extensive mobility of the duodenum and head of the pancreas from the left side. The systematic mesopancreas dissection from the right site of the SMA will be easily and conveniently done afterwards. Histopathological examination of ypT2N1 indicated that 1 of the 22 lymph nodes was positive, which was 1 of 7 LN no. 14. Pathological results showed a Vater adenocarcinoma with all margins being negative. Conclusions This technique was safe and effective to perform precise level 2 mesopancreas dissection and complete lymphadenectomy around SMA without dissection of pl-SMA in laparoscopic field.

Application of the superior mesenteric artery-first approach in laparoscopic pancreatoduodenectomy: A literature review

“…Six articles examined the left SMA-first approach in LPD ( Fig. 7 a,b) [ 8 , 9 , [34] , [35] , [36] , [37] ]. Shen et al [ 35 ] demonstrated the reformation and improvement of a modified no-touch isolation technique emphasizing exploration of the distal section of the SMV and the SMA's left side prior to determining resectability.…”

“…This reduces the likelihood of tumor cell metastasis by ensuring that all procedures adhere to oncologic no-touch rules. Khiem et al [ 36 ] revealed a successful LPD via the left posterior approach involving SMA plexus preservation, while Cho et al [ 34 ] reported on this approach in detail. Liao et al [ 37 ] described a detailed surgical strategy to determine resectability by first preferentially exposing the SMA's left side, which also ensures the surgical effect and shortens the operative time, particularly for the resected segment.…”

A comparative study of the “superior mesenteric artery first” approach versus the conventional approach in short-term and long-term outcomes in patients with pancreatic ductal adenocarcinoma undergoing laparoscopic pancreaticoduodenectomy

“…The artery-first approach was first proposed by Pessaux [ 22 ] and has since been widely used in OPD, where its advantages have been recognized [ 8 ]. Laparoscopy has a flexible viewing angle from the caudal to the cephalic side as well as a unique dorsal perspective which facilitates the anatomy and exposure of the SMA, thus the SMA-first approach has also begun to be used in LPD [ 9 – 12 , 23 , 24 ]. The advantages of the LPD artery-first approach are as follows.…”

Pancreaticoduodenectomy with superior mesenteric artery first-approach combined total meso-pancreas excision for periampullary malignancies: A high-volume single-center experience with short-term outcomes

“…In the laparotomic approach, an upper abdominal incision was performed to explore the peritoneum to exclude metastases. Meanwhile, in the laparoscopic approach, we use 5 trocars, which procedure was described in our technical article [ 21 ]. We use three approaches to first explore the SMA root:…”