Surgical Tips of Right Posterior Superior Mesenteric Artery Approach for Pancreatoduodenectomy

Summary

This protocol details the right posterior superior mesenteric artery approach during pancreatoduodenectomy. By dissecting the peripancreatic plexus from a caudal direction before dissecting the superior mesenteric vein groove, this technique enhances anatomical clarity, resulting in minimizing intraoperative bleeding. Standardizing this approach ensures surgical reproducibility and facilitates safe vascular resections.

Abstract

Pancreatoduodenectomy (PD) is a complex operation, particularly when tumors involve major vessels, including the portal vein and superior mesenteric vein (SMV) or major arteries. To achieve radical surgery, venous resection is often required, and with advancements in neoadjuvant therapy, aggressive surgical approaches, including arterial divestment and resection, are becoming more common. Ideally, a standardized technique should be applied for resectable tumors. In our institution, the right posterior superior mesenteric artery (SMA) approach is routinely performed. This study presents the details of the right posterior SMA approach.

The protocol outlines the patient selection criteria, surgical positioning, and step-by-step technical procedures. The right posterior SMA approach begins with exposing the SMV, followed by dissection of the peripancreatic plexus (PLph II) posteriorly from a caudal direction. After anterior dissection of the SMV groove and PLphI, the specimen is removed. This technique enables a clear anatomical boundary, facilitating better visualization and safer resection. Standardizing this approach might enhance oncological outcomes, improve surgical reproducibility, and reduce intraoperative bleeding.

Introduction

Pancreatic ductal adenocarcinoma (PDAC) frequently invades major vessels, particularly the superior mesenteric-portal vein (SMPV), due to the anatomical proximity of the pancreatic head to these structures¹. Therefore, safely dissecting the tumor from surrounding tissues, including major vessels, is a critical step in achieving curative resection. To facilitate safe dissection and evaluate resectability, various approaches have been proposed to access the superior mesenteric artery (SMA) before pancreatic head resection. These are collectively referred to as "artery-first approaches"².

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Protocol

The protocol follows the guidelines of the Human Research Ethics Committee of Umeå University Hospital (Institutional Review Board: 2021-02787). In this session, the retropancreatic plexus of the pancreatic head I and II (PLphI, II), and the nerve plexus around the SMA (PLsma) are defined by the General Rules for the Study of Pancreatic Cancer by the Japan Pancreas Society⁴.

1. Patient selection

1. Include patients eligible for curative resection of tumors in the pancreatic head or the periampullary region undergoing pancreatoduodenectomy (PD).

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Results

A 69-year-old male underwent computed tomography (CT) during an episode of pancreatitis, revealing main pancreatic duct (MPD) dilatation measuring 7 mm in the head and 6 mm in the body, along with a small branch-duct IPMN in the head. Based on these findings, a diagnosis of mixed-type intraductal papillary mucinous neoplasm (IPMN) was made. Tumor markers were within normal limits. Endoscopic retrograde cholangiopancreatography (ERCP) with SpyGlass (direct visualization) cholangioscopy identified a fish eye papilla, confi.......

Discussion

The right posterior SMA approach has several advantages in pancreaticoduodenectomy (PD), particularly in cases requiring vascular resection. By dissecting the PLph I and II from a caudal direction and establishing a clear anatomical boundary early in the procedure, this technique enables better visualization and safer resection^6,7. Additionally, identifying and managing the first jejunal vein early in the dissection facilitates a smooth transition to SMV isolatio.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
DaBakey foreceps 30 cm	Aesculap	FB405R
Bipolar scissors	Ethicon	BP340	Main dissection tool
Bipolar scissors' cable	Ethicon	BP940	Cable for the bipolar scissors
OrbEye	Olympus	OME-V200	4K camera, for broadcasting (to conference room) and recording
Peang Heiss gracile 18 cm	Stille	1834
Powerseal	Olympus	PS-0523CJDA	Bipolar heat instrument
Sony monitor 55 inches	Olympus	LMD-XH550ST	Belongs to OrbEye system
Sony recorder	Olympus	HVO-4000ST	Belongs to OrbEye system
Thompson retractor system	Thompson	1900181	Self refractor system