Laparoscopic pancreatoduodenectomy (LPD) is a complex procedure. Critical steps are achieving a negative retroperitoneal margin and re-establishing pancreatoenteric continuity minimizing postoperative pancreatic leak risk [1–4]. Aiming at increasing the rate of R0 resection during pancreatoduodenectomy, many experienced teams have recommended the superior mesenteric artery (SMA)-first approach, consisting in early identification of the SMA at its origin, with further resection guided by SMA anatomic course [5–9]. We describe our technique of LPD with SMA-first approach and pancreatogastrostomy assisted by mini-laparotomy.
The video concerns a 77-year-old man undergoing our variant of LPD for a 2.5-cm pancreatic head mass. After kocherization, the SMA is identified above the left renocaval confluence and dissected-free from the surrounding tissue. Dissection of the posterior pancreatic aspect exposes the confluence between splenic vein, superior mesenteric vein (SMV), and portal vein. Following duodenal section, the common hepatic artery is dissected and the gastroduodenal artery sectioned at the origin. The first jejunal loop is divided, skeletonized, and passed behind the superior mesenteric vessel. Following pancreatic transection, the uncinate process is dissected from the SMV and the SMA is cleared from retroportal tissue rejoining the previously dissected plain. Laparoscopic choledocojejunostomy is followed by a mini-laparotomy-assisted pancreatogastrostomy, performed as previously described , and a terminolateral gastrojejeunostomy.
Twelve patients underwent our variant of LPD (July 2013–May 2015). Female/male ratio was 3:1, median age 65 years (range 57–79), median operation duration 590 min (580–690), intraoperative blood loss 150 cl (100–250). R0 resection rate was 100 %, and the median number of resected lymph nodes was 24 (22–28). Postoperative complications were grade II in two patients and IIIa in one . Median postoperative length of stay was 16 days (14–21).
LPD with SMA-first approach with pancreatogastrostomy assisted by a mini-laparotomy well combines the benefits of laparoscopy with low risk of postoperative complications and high rate of curative resection.
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Gagner M, Pomp A (1994) Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc 8:408–410
Kendrick ML, Cusati D (2010) Total laparoscopic pancreaticoduodenectomy: feasibility and outcome in an early experience. Arch Surg. doi:10.1001/archsurg.2009.243.145:19-23
Asbun HJ, Stauffer JA (2012) Laparoscopic vs open pancreaticoduodenectomy: overall outcomes and severity of complications using the Accordion Severity Grading System. J Am Coll Surg. doi:10.1007/s00464-011-1618-0
Croome KP, Farnell MB, Que FG, Reid-Lombardo KM, Truty MJ, Nagorney DM, Kendrick ML (2014) Total laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: Oncologic advantages over open approaches? Ann Surg. doi:10.1007/s11605-014-2644-8
Pessaux P, Varma D, Arnaud JP (2006) Pancreaticoduodenectomy: superior mesenteric artery first approach. J Gastrointest Surg 10:607–611
Weitz J, Rahbari N, Koch M, Büchler MW (2010) The “artery first” approach for resection of pancreatic head cancer. J Am Coll Surg 210:1–4. doi:10.1016/j.jamcollsurg.2009.10.019
Shrikhande SV, Barreto SG, Bodhankar YD, Suradkar K, Shetty G, Hawaldar R, Goel M, Shukla PJ (2011) Superior mesenteric artery first combined with uncinate process approach versus uncinate process first approach in pancreatoduodenectomy: a comparative study evaluating perioperative outcomes. Langenbecks Arch Surg. doi:10.1007/s00423-011-0824-5
Cho A, Yamamoto H, Kainuma O (2014) Tips of laparoscopic pancreaticoduodenectomy: superior mesenteric artery first approach (with video). J Hepatobiliary Pancreat Sci. doi:10.1002/jhbp.54
Ogiso S, Conrad C, Araki K, Nomi T, Anil Z, Gayet B (2013) Posterior approach for laparoscopic pancreaticoduodenectomy to prevent replaced hepatic artery injury. Ann Surg Oncol. doi:10.1245/s10434-013-3058-7
Addeo P, Rosso E, Fuchshuber P, Oussoultzoglou E, De Blasi V, Simone G, Belletier C, Dufour P, Bachellier P (2013) Double purse-string telescoped pancreaticogastrostomy: an expedient, safe, and easy technique. J Am Coll Surg. doi:10.1016/j.jamcollsurg.2012.11.010
Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213
Drs. Giuseppe Zimmitti, Alberto Manzoni, Pietro Addeo, Marco Garatti, Alberto Zaniboni, Philippe Bachellier and Edoardo Rosso have no conflicts of interest or financial ties to disclose.
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Zimmitti, G., Manzoni, A., Addeo, P. et al. Laparoscopic pancreatoduodenectomy with superior mesenteric artery-first approach and pancreatogastrostomy assisted by mini-laparotomy. Surg Endosc 30, 1670–1671 (2016). https://doi.org/10.1007/s00464-015-4359-7
- SMA-first approach