Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma
December 29th, 2023
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.
Using non-invasive forceps, lift and pull the stomach towards the cephalic side and with an ultrasonic harmonic scalpel, cut the gastrocolic and gastro splenic ligaments at the upper edge of the transverse colon. To separate the stomach and spleen, ligate and sever the left gastroepiploic vessels, short gastric vessels, posterior gastric vessels, and left subphrenic vessels near the gastric wall. Then enter the lesser or mental sac, and explore the condition of the pancreatic tumor.
Next, separate and expose the common hepatic artery, followed by the celiac trunk and the left gastric artery, and dissect the lymph nodes surrounding both these arteries. Incise the retroperitoneum from the pancreatic neck to the pancreatic tail at the lower margin of the pancreas, and remove the surrounding lymph nodes. Then continue to incise the anterior layer of the left gerota fascia 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. To expose the superior mesenteric artery and abdominal aorta, lift the distal pancreas toward the cephalic side, and simultaneously dissect the surrounding lymph nodes. Separate the superior mesenteric vein at the lower margin of the pancreatic neck, followed by the retro pancreatic tunnel along the surface of the FMV and portal vein.
Using a linear stapling device, sever the pancreas at the neck. After dissecting and exposing the splenic vein, ligate and sever its root. Dissect the splenic artery to remove the surrounding lymph nodes and ligate and cut off the artery root.
After lifting the pancreas and the anterior layer of the gerota fascia, sever the left adrenal vessel and peel off the anterior layer of the gerota fascia and the left adrenal gland upwards. Cut off the posterior peritoneum from right to left above the pancreas, and clear the connective tissues between the abdominal aorta and the left kidney along the left cross of diaphragm. Then sever the gerota fascia tissues at the upper margin of the left adrenal gland.
Next, sever the ligaments and adhesions around the spleen to release it and excise a distal pancreas, the anterior layer of the gerota fascia, the left adrenal gland, and the spleen as a whole. To carefully examine the surgical field, irrigate the abdominal cavity with sterile distilled water, and place a drainage tube beside the incisal margin of the pancreas. Finally, extend the umbilical incision length to about five centimeters.
Cut the abdominal wall layer by layer and take out the specimen. The postoperative CT scan indicates successful tumor removal without significant recurrence or metastasis.
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Overview
Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) is a surgical technique that is currently considered technically safe and feasible. This article provides detailed techniques for performing L-RAMPS, addressing the technical challenges and limited clinical applications.
Key Study Components
Area of Science
- Surgery
- Oncology
- Minimally invasive techniques
Background
- L-RAMPS is a novel surgical approach for pancreatic and splenic diseases.
- Technical challenges have limited its adoption in clinical practice.
- There is a need for detailed procedural guidance to enhance its feasibility.
- Current evidence supporting L-RAMPS is limited.
Purpose of Study
- To provide a comprehensive overview of the L-RAMPS technique.
- To outline the steps involved in the procedure.
- To address the technical challenges faced during surgery.
Methods Used
- Utilization of non-invasive forceps to manipulate the stomach.
- Use of an ultrasonic harmonic scalpel for cutting ligaments.
- Ligation and severing of various vessels to separate the stomach and spleen.
- Dissection of lymph nodes surrounding major arteries.
Main Results
- Successful separation of the stomach and spleen was achieved.
- Access to the lesser sac and exploration of pancreatic tumors were performed.
- Dissection of lymph nodes around the common hepatic artery and celiac trunk was completed.
- Technical feasibility of L-RAMPS was demonstrated.
Conclusions
- L-RAMPS is a technically feasible approach for pancreatic surgery.
- Detailed procedural techniques can enhance its adoption.
- Further studies are needed to establish its clinical efficacy.
