Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma

Summary

Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) is currently considered technically safe and feasible. However, due to technical challenges and a lack of supporting evidence for widespread clinical applications, only a limited number of institutions are currently conducting L-RAMPS. This article aims to provide detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy.

Abstract

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic capsule to infiltrate surrounding tissues. In conventional distal pancreatosplenectomy (DPS), tumor cells are prone to spread along the direction of blood and lymphatic reflux due to surgical compression. Additionally, inflammation makes it challenging to achieve R0 resection, leading to a lower patient survival rate. To address these limitations, radical antegrade modular pancreatosplenectomy (RAMPS) was developed, emphasizing deeper excision, including the left anterior renal fascia, the left anterior renal adipose sac, and even the left adrenal gland, to improve the R0 resection rate. With the advancement of minimally invasive surgical techniques, laparoscopic RAMPS (L-RAMPS) is being considered technically safe and feasible in oncology. However, due to technical difficulties and a lack of supporting evidence for clinical application, only a few institutions are currently conducting L-RAMPS. In this context, this article presents detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy (L-pRAMPS), offering promise for future clinical applications.

Introduction

Conventional distal pancreatosplenectomy (DPS) has traditionally been the standard surgical procedure for distal pancreatic carcinoma^1,2. Distal pancreatic carcinoma is a highly invasive tumor that easily infiltrates into retroperitoneal tissues. Simultaneously, pancreatic cancer is often accompanied by chronic pancreatitis, making the boundary between the pancreas and adjacent tissues unclear. Consequently, during conventional DPS, there is a risk of tumor cells spreading along the direction of blood circulation and lymphatic return. In addition to the inherent inflammation associated with pancreatic cancer, achieving R0 resection is challenging, leading to a relatively low postoperative survival rate for patients³.

With the advancement of surgical techniques and a deeper understanding of the pancreatic lymphatic system, the high positive rate of the surgical margin and incomplete lymph node dissection in conventional DPS have garnered more attention. In response, radical antegrade modular pancreatosplenectomy (RAMPS) has emerged to address these challenges^3,4. RAMPS involves the complete removal of tissues around the body and tail of the pancreas, including the tumor, to ensure a negative incisional margin and thorough dissection of lymph nodes in N1 nodes, the superior mesenteric artery (SMA), and the anterior and left of the celiac trunk^3,4.

In 2003, Strasberg first reported RAMPS³. With the development of minimally invasive surgical techniques, there have been sporadic reports of laparoscopic RAMPS (L-RAMPS) in recent years. L-RAMPS is preliminarily considered technically safe and feasible in oncology^5,6,7,8,9. However, due to technical difficulties and a lack of supporting evidence for clinical application, only a few institutions are currently conducting L-RAMPS. In light of this situation, this article presents the techniques of laparoscopic posterior radical antegrade modular pancreatosplenectomy (L-pRAMPS) in detail, holding great promise for future clinical application.

Protocol

The surgical procedure was approved by the institutional review board at The First Affiliated Hospital of Jinan University. The patient, a 58-year-old female, was admitted with a chief complaint of "abdominal pain for 2 months." A computed tomography (CT) scan conducted at an external hospital revealed a space-occupying lesion in the distal pancreas, raising concerns about the possibility of pancreatic carcinoma. Before the surgery, the patient provided written informed consent. The surgical tools and equipment used for this procedure are listed in the Table of Materials.

1. Preoperative preparation

1. Prior to the surgery, conduct preoperative blood tests, including a complete blood count, liver and renal function tests, coagulation function test, and serum tumor biomarkers detection^10,11.
   NOTE: The blood sample was drawn by the nurse and sent to the laboratory, where various blood tests were performed, and the results were reported. Serum tumor biomarkers detection revealed elevated levels of carcinoembryonic antigen (48.34 ng/mL) and carbohydrate antigen 125 (131.1 U/mL)^10,11.
2. Perform preoperative electrocardiogram, abdominal magnetic resonance imaging (MRI), chest CT, and other related examinations^10,11.
   NOTE: In this study, the patient underwent abdominal MRI in the Medical Imaging Department. The results of abdominal MRI indicated that the size of the pancreatic body and tail mass is approximately 3.5 cm × 3.0 cm × 3.0 cm, suggesting an epithelial-derived malignant tumor (Figure 1).

2. Surgical technique

1. After tracheal intubation and general anesthesia (following institutionally approved protocols)¹², place the patient in a supine position with their legs apart. Perform routine disinfection with povidone iodine solution.
   NOTE: The chief surgeon is located on the right side of the patient, the assistant is on the left side, and the endoscope holder is positioned between the patient's legs.
2. Make a longitudinal incision of approximately 1 cm through the umbilicus, insert a pneumoperitoneum needle, inject carbon dioxide gas to maintain an abdominal pressure of 12 mmHg, and place a 10 mm trocar and a 30-degree laparoscope.
3. Explore the abdominal cavity to determine if there is any tumor metastasis. Under direct vision, place a 5 mm trocar in the left middle abdomen and right upper abdomen, respectively, and a 10 mm trocar in the left upper abdomen and right middle abdomen, respectively (Figure 2).
4. Use non-invasive forceps to lift and pull the stomach toward the cephalic side, and cut the gastrocolic and gastrosplenic ligaments at the upper edge of the transverse colon using an ultrasonic-harmonic scalpel (Figure 3).
5. Separate the stomach and spleen by ligating and severing the left gastroepiploic vessels, short gastric vessels, posterior gastric vessels, and left subphrenic vessels near the gastric wall. Enter the lesser omental sac and expose the pancreas. Explore the condition of the pancreatic tumor (Figure 2).
6. Separate and expose the common hepatic artery, and remove the lymph nodes adjacent to the common hepatic artery. Suspend the common hepatic artery, separate and expose the celiac trunk and the left gastric artery, and dissect the surrounding lymph nodes (Figure 4).
7. Incise the retroperitoneum from the pancreatic neck to the pancreatic tail at the lower margin of the pancreas, and remove the surrounding lymph nodes. Continue to incise the anterior layer of the left Gerota fascia at the lower margin of the pancreas to reveal the left renal vein. Peel the anterior layer of Gerota fascia from the surface of the left kidney along the left renal vein (Figure 5).
8. Lift the distal pancreas toward the cephalic side to expose the superior mesenteric artery (SMA) and abdominal aorta, and dissect the surrounding lymph nodes at the same time (Figure 5). Separate and expose the superior mesenteric vein (SMV) at the lower margin of the pancreatic neck, and separate the retropancreatic tunnel along the surface of the SMV and portal vein.
9. Sever the pancreas at the neck with a linear stapling device (Figure 6 and Figure 7). Dissect and expose the splenic vein, ligate and sever the root of the splenic vein (Figure 7). Dissect and expose the splenic artery, and remove the surrounding lymph nodes. Then, ligate and cut off the root of the splenic artery (Figure 4).
10. Lift the pancreas and the anterior layer of the Gerota fascia toward the cephalic side to expose the left adrenal vessel and sever it (Figure 5). Continue to peel off the anterior layer of the Gerota fascia and the left adrenal gland upwards (Figure 5 and Figure 8).
11. Above the pancreas, cut off the posterior peritoneum from right to left along the stomach wall. Clear the connective tissues between the abdominal aorta and the left kidney along the left crus of diaphragm. Sever the Gerota fascia tissues at the upper margin of the left adrenal gland (Figure 8).
12. Release the spleen by severing the ligaments and adhesions around the spleen, and ultimately remove the distal pancreas, the anterior layer of the Gerota fascia, the left adrenal gland, and the spleen as a whole (Figure 8). Place the excised specimen into a specimen bag.
13. Irrigate the abdominal cavity with sterile distilled water. Carefully examine the surgical field for active bleeding, pancreatic leakage, and gastrointestinal collateral injury. Place a drainage tube beside the incisal margin of the pancreas.
14. Extend the umbilical incision to about 5 cm in length, cut the abdominal wall layer by layer, and take out the specimen. Send the specimen for intraoperative rapid frozen pathological examination to see whether there is cancer at the incisal margin of the pancreas (Figure 9).
15. Check the number of surgical instruments and gauzes, and remove the trocars under direct vision. Finish the operation after suturing the abdominal wall incisions using 5-0 polypropylene suture.

3. Postoperative procedures

1. Send the patient back to the ward safely after resuscitation.
2. Administer intravenous antibiotics and somatostatin after the surgery.
3. Start a fluid diet on the first day after surgery.
4. Send the abdominal drainage fluid to the laboratory every day to check the amylase concentration.
5. Remove the abdominal drainage tube on the fourth day after surgery.

Results

The surgery proceeded smoothly, and the intraoperative rapid frozen pathological examination indicated the absence of cancer at the incisal margin of the pancreas. Throughout the surgery, the patient's vital signs remained stable, and the anesthesia was effective. The operation duration was 150 min, with an intraoperative blood loss of 80 mL. Anal exhaust occurred 32 h postoperatively. There were no complications such as abdominal hemorrhage, pancreatic leakage, abdominal infection, or incision infection. The postoperati...

Discussion

DPS has been widely used as the standard radical surgery for distal pancreatic carcinoma^1,2. However, due to the highly invasive nature of pancreatic cancer, it is easy for the tumor to grow to the edge of the pancreas and even break through the surface of the pancreas. Meanwhile, accompanying chronic pancreatitis makes the boundary between the pancreas and the surrounding tissues unclear. Therefore, it is difficult to achieve R0 resection during conventional sur...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
10-mm trocar	Xiamen Surgaid Medical Device Co., LTD	NGCS 100-1-10	Sterile, ethylene oxide sterilized, disposable
12-mm trocar	Xiamen Surgaid Medical Device Co., LTD	NGCS 100-1-12	Sterile, ethylene oxide sterilized, disposable
5-mm trocar	Xiamen Surgaid Medical Device Co., LTD	NGCS 100-1-5	Sterile, ethylene oxide sterilized, disposable
Hem-o-lok	America Teleflex Medical Technology Co., LTD	544240	Sterile, ethylene oxide sterilized, disposable
Linear stapling device	America Ethicon Medical Technology Co., LTD	PSEE60A	Sterile, ethylene oxide sterilized, disposable
Pneumoperitoneum needle	Xiamen Surgaid Medical Device Co., LTD	NGCS 100-1	Sterile, ethylene oxide sterilized, disposable
Suction and irrigation tube	Tonglu Hengfeng Medical Device Co., LTD	HF6518.035	Sterile,dry heat sterilized, reusable
Ultrasounic-harmonic scalpel	Chongqing Maikewei Medical Technology Co., LTD	QUHS36S	Sterile, ethylene oxide sterilized, disposable