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

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.

Clinical case. Number one, history. No major comorbidity.

Number two, chief complaint. Confirmed pancreatic cancer for more than two months. Number three, C-A-1-9-9 value is 4666.38 unit per milliliter.

CEA value is normal. Number four, CT scan. The range of pancreatic neck-body cancer is 3.2 times 2.5 centimeters with the splenic artery and vein were invaded.

Number five, pathology. Fine-needle aspiration was done to confirm the diagnosis of adenocarcinoma. After four cycles of neoadjuvant chemotherapy.

Number one, past CT.The tumor maximum diameter was reduced from 3.2 centimeter to 2.5 centimeter. Clinical improvement in performance status, pain, early satiety, weight, nutritional status. Number three, C-A-1-9-9 reduced from 4, 666 to 1, 350 unit per millimeter, more than 50%decrease.

Surgical technique. Place anesthetized patient on the operation table in a supine position. Ensure legs are spreading apart.

Make sure the first surgeon is on the right side of the patient. The first assistant is on the left side and the second assistant with the laparoscope is between the patient's legs. This procedure employs a five-port technique as shown in figure one.

Perform routine diagnostic laparoscope from the start, to exams liver and the peritoneal surfaces for extra pancreatic metastasis. Open the lesser sac using an ultrasound knife by dividing gastrocolic ligament approximately two centimeters distal from the gastroepiploic artery and vein. Dissect and resect the short gastric vessels for facilitating splenectomy.

Suspend the stomach above from the surface of the pancreas. Divide and pass through the gap between the posterior surface of pancreatic neck and the junction part of SMV, PV, and splenic vein. Then carefully clear this area in preparation for pancreatic transaction.

Elevate the transverse colon and its mesentery Perform the Kocher Maneuver to expose the interior surface of the left renal vein. The surgeon adds a gap between IVC and pancreatic head. Explore the lymph node station number 16.

Place the entire small bowel on the right side to provide access to the dorsal side of SMA. Identify the SMA above the left renal vein. Then, dissect it along its peri-adipose tissue plane on the interior left margin and separate it from the pancreas.

Perform the resection range to the left and the posterior plane behind the adrenal gland and onto to the surface to the left kidney. Expose left renal vein. Expose left renal artery.

Ligate it and cutoff left at renal vein. Return to the upper colon region. Isolate and excise splenocolic and perisplenic ligaments.

Anatomize the common hepatic artery and gastroduodenal artery. Dissect the gastroduodenal lymph nodes, and then identify the correct hepatic artery. Move the GDA to the right side using a rubber band for the exposure of interior surface of portal vein.

Divide and pass through the tunnel between the posterior surface of pancreatic neck. Transect the pancreas peritoneum using a mechanical stapler device. Have passed to frozen pathology during the operation.

Ligate and cut off splenic vein. To skeletonize the common hepatic artery, left gastric artery, splenic artery and the celiac axis, dissect at a clear en bloc superior pancreatic lymph nodes. Resect fat and a fibrous tissues from the caudal to the cephalic site of SMA and the celiac axis.

Remove the lymph nodes from the Heidelberg Triangle, which is bounded by the portal vein, celiac axis and SMA. During this procedure, isolate and divide a range of splenic artery. Our account of the larger dorsal and caudal spaces create it.

Ligate and cut off splenic artery exposed and ligate left gastric artery. Expose the left renal vein to determine the dorsal dissection plane. Expose left phrenic artery.

Finally, using an antegrade method, dissect the distal pancreas and spleen, as well as the surrounding soft tissues. Pack the specimen. Representative results.

The total time for the procedure was 240 minutes with a blood loss of 15 millimeter. The postoperative pancreatic fistula was grade A.No peritoneal fluid was found on postoperative CT examination on P-O-D 7. The drains were removed on day number eight, after operation.

The patient's recovery was uncomplicated, and he was discharged on the 13 day after the surgery.Pathology. Moderately poorly differentiated at adenocarcinoma of the pancreatic ductal adenocarcinoma Margins negative. 15 lymph nodes without malignancy.

The tumor was staged as T2, N0 and M0.Conclusion. Laparoscopic radical antegrade modular pancreatosplenectomy via dorsal-caudal artery approach is a technically challenging, but safe and a reproducible procedure for pancreatic neck-body cancer. It must be performed only at high volume centers by surgeons with extensive experience.