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Follow “the superior mesenteric artery”: laparoscopic approach for total mesopancreas excision during pancreaticoduodenectomy

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Abstract

Background

The prognosis of patients affected by pancreatic adenocarcinoma and periampullary tumors is dismal, mainly due to aggressive tumor biology and low rate of resectability at the diagnosis. Among resectable patients, the quality of surgical resection, with a particular focus on the complete resection of the retropancreatic tissue (the so-called “mesopancreas”) encircling the superior mesenteric artery (SMA), has a cardinal role. With this assumption, many pancreatic surgeons recommend periadventitial dissection of the SMA in order to obtain a total mesopancreas excision (TMpE), maximizing surgical margin and minimizing R1 resection rate.

Objective

To introduce our approaches for periadventitial dissection of the SMA, tailored to patient and tumor characteristics and aiming at obtaining a TMpE, during laparoscopic pancreatoduodenectomy (LPD).

Methods

Three different approaches for the SMA periadventitial dissection during LPD are described: the right, the right–left, and the anterior SMA-first approach. Indications, advantages, and technical aspects of each technique are reported, as well as pathologic results, particularly focusing on resection margin status and removed lymphnodes number, safety, and feasibility.

Results

Overall, R0 rate and number of lymphnodes retrieved were 86% and 26, respectively, without significant differences according to the SMA approach performed. Rate of conversion to laparotomy due to intraoperative bleeding during SMA dissection step was 6% (3/48) among patients who underwent the right SMA approach and nil among remaining patients.

Conclusion

During LPD, a tailored approach for periadventitial dissection of SMA makes TMpE feasible, safe, and oncologic valid, when performed by a team experienced with mininvasive approach and pancreatic surgery.

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Authors and Affiliations

  1. Department of Surgery, Istituto Fondazione Poliambulanza, Bissolati no 57, 25124, Brescia, Italy

    Edouardo Morales, Giuseppe Zimmitti, Claudio Codignola, Alberto Manzoni, Marco Garatti, Valentina Sega & Edoardo Rosso

Authors
  1. Edouardo Morales
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  2. Giuseppe Zimmitti
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  3. Claudio Codignola
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  4. Alberto Manzoni
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  5. Marco Garatti
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  6. Valentina Sega
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  7. Edoardo Rosso
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Correspondence to Edoardo Rosso.

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Disclosures

Edouardo Morales, Giuseppe Zimmitti, Claudio Codignola, Alberto Manzoni, Marco Garatti, Valentina Sega, and Edoardo Rosso have no conflicts of interest or financial ties to disclose.

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Electronic supplementary material

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Supplementary material 1—This video shows the right approach to superior mesenteric artery during laparoscopic pancreaticoduodenectomy. (MP4 128322 kb)

Supplementary material 2—This video shows right-left approach to superior mesenteric artery during laparoscopic pancreaticoduodenectomy. (MP4 212519 kb)

Supplementary material 3—This video shows the anterior approach to superior mesenteric artery during laparoscopic pancreaticoduodenectomy. (MP4 249558 kb)

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Morales, E., Zimmitti, G., Codignola, C. et al. Follow “the superior mesenteric artery”: laparoscopic approach for total mesopancreas excision during pancreaticoduodenectomy. Surg Endosc 33, 4186–4191 (2019). https://doi.org/10.1007/s00464-019-06994-6

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