Chunhua Xi, Wentao Gao, Min Tu, Haifeng Li, Cheng Lu, Kuirong Jiang, Junli Wu, Feng Guo, Jianmin Chen, Jishu Wei, Zipeng Lu, Cuncai Dai, Yi Miao
Background: We describe a technique modification with emphasize a left lateral dissection of superior mesenteric artery (SMA) and uncinate process (UP) as a novel approach for laparoscopic pancreaticoduodenectomy (LPD). Local recurrence are quite high for pancreatic cancer and mostly are around celiac and SMA trunk. Here we suggest two anatomical triangles, which are difficult to dissect and easy for recurrence. If we take the root of SMA as radiation center, cranial triangle is surrounded by SMA root, PV, hepatic artery and aorta, caudal triangle or sectorial area is surround by SMA trunk, SMV trunk until its division, and aorta. We are proposing a new strategy aiming at improving R0 resection with focusing on both triangles.
Methods: During LPD, the camera was transferred to left paraumbilical trocar, ventral part of hepatoduodenal ligament or ventral part of cranial triangle, are dissected from left view. Then in infra colic region, the Treitz ligament is incised, the SMA root was reached left posteriorly above left renal vein. By rotating mesentery root upward from left, the distal part of uncinate process (UP) are rotated to left side, so its connections with SMA and SMV jejunal branch are clearly exposed from left view. Dissection continued along SMA axis from its root until its crossing over duodenum and whole length of UP, after IPDA and IPDV are ligated and transected, the distal part of UP can be completely freed from SMA/SMV, and the caudal triangle is mostly cleared. Then the camera was transferred to right paraumbilical trocar, in right posterior view, the dorsal part of cranial triangle, are also cleared from behind to upward until the whole mesopancreas are freed. Resection was complete after transecting pancreas neck.
Results: Forty patients underwent the novel surgical procedure between April 2016 and December 2017 during laparoscopic PD. SMA root and distal UP was dissected via left approach in all patients.
Conclusions: The location of cancer in pancreatic head can be divided into 3 categories, with different infiltration and metastasis area, and should require different focus for dissection. Lateral posterior approach will provide a good exposure of major vessels, the approach here we proposed will provide a complete dissection of both anatomical triangle along SMA-CA axis with good visualization.
