Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Venous Tangential Resection: Focus on Periadventitial Dissection of the Superior Mesenteric Artery for Obtaining Negative Margin and a Safe Vascular Resection

Abstract

Background

Due to its technical complexity, laparoscopic (L-) radical antegrade modular pancreatosplenectomy (RAMPS) for left-sided pancreatic ductal adenocarcinoma (PDAC) has been described in a few series.1,2,3,4 In addition, splenomesenteric junction tumor involvement is considered a formal contraindication to L-RAMPS.

Methods

The video shows posterior L-RAMPS with a left approach to the superior mesenteric artery (SMA) for a left-sided PDAC with suspected involvement of the splenomesenteric junction.

Results

The patient was a 61-year-old woman affected by a cT3N0M0 pancreatic body PDAC. Following dissection of the superior mesenteric vein (SMV), proper/common hepatic artery, and gastroduodenal artery, the pancreatic neck is encircled and the celiac trunk (CT) skeletonized. The treitz ligament is opened, and the SMA is identified and dissected on its left anterior margin. Pancreatic mobilization en bloc with the Gerota fascia and left adrenal gland is followed by splenic artery transection and suprapancreatic lymphadenectomy completion. The mesopancreas is dissected from the right margin of the SMA and CT and the pancreas is transected. The portal vein and SMV are cross-clamped and a venous tangential resection/closure is performed. Cryostate histological examination of the venous and pancreatic stumps showed absence of tumor cells. Final pathology revealed a pT2N0(0+/42)R0G2 PDAC of the pancreatic body.

Conclusion

During L-RAMPS, periadvential SMA dissection through the left-anterior approach, specular to the right posterior SMA approach described for laparoscopic pancreatoduodenectomy,5^,6 has a primary role in maximizing the vascular surgical margin and, allowing for complete mobilization of the specimen before vein resection, may make a splenomesenteric junction tangential resection/closure easier and safer in case of tumor involvement of the splenomesenteric venous axis.