Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Summary

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Abstract

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.

The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Introduction

Radical antegrade modular pancreatosplenectomy (RAMPS) is an exquisite procedure for malignant tumors located in the pancreatic body or tail, first described by Strasberg in 2003. This operation strategy was designed based on the blood and lymph node drainage of the pancreas, in order to achieve tumor-free dissection planes and radical resection of regional lymph nodes¹. RAMPS is becoming increasingly valued by surgeons as it could be conducive to obtain tumor-free margins and relatively favorable survival results^2,3,4. With advancements in minimally i....

Protocol

The present protocol follows the guidelines of the Ethics of the Second Affiliated Hospital of Guangzhou University of Chinese Medicine. Informed consent was obtained from the patient for this article and the video.

1. Patient Selection

1. Ensure patients have PDAC in the pancreas neck, body, and tail as confirmed by contrast enhanced computed tomography (CT). This procedure is indicated in the following cases: resectable pancreatic cancer and borderline resectable pancreatic cancer after neoadjuvant treatment. The possibility of radical resection increases when the tumor regresses markedly following effective neoa....

Results

A 50-year-old man with upper abdomen discomfort and chronic malnutrition had a 3.2 cm x 2.5 cm tumor in the pancreatic neck identified. He had previously been healthy and had a normal BMI (19.9 kg/m²).

No distant metastasis, major vessels (besides the splenic artery and vein), or lymph node infiltration were detected on the preoperative imaging evaluation. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed to confirm the pathological diagnosis of PDAC. The p.......

Discussion

Despite the 5 year survival rates of PDAC, this is still unsatisfactory for patients who have the chance for radical resection; surgery has been the only curative therapeutic method till now²². Resectability status is mostly assessed by the conditions of the regional critical vessels, including the SMA, CeA, CHA, and SMV^24,25. Although preoperative radiography can provide adequate information about vascular conditions, surgical exploration.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
3D Laparoscope	STORZ	TC200,TC302
Echelon Flex Powered Plus Articulating Endoscopic Linear Cutter and Endopath Echelon Endoscopic Linear Cutter Reloads with Gripping Surface Technology	Ethicon Endo-Surgery	ECR60G/GST60G
HARMONIC ACE Ultrasonic Surgical Devices	Ethicon Endo-Surgery	HAR36
Ligating Clips	Teleflex Medical	5,44,22,05,44,23,05,44,000
Ultrasonic Surgical & Electrosurgical Generator	Ethicon Endo-Surgery	GEN11CN