Surgical Tips of Right Posterior Superior Mesenteric Artery Approach for Pancreatoduodenectomy

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.