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Inframesocolic Artery-First Approach with SMA Divestment to Confirm Resectability in Minimally Invasive Modified

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A novel laparoscopic approach for distal pancreatectomy with celiac axis resection (DP-CAR) allows for early assessment of tumor resectability and superior mesenteric artery (SMA) involvement. This minimally invasive technique preserves the left gastric artery (LGA) and avoids conversion to open surgery.

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Area of Science:

  • Surgical Oncology
  • Gastrointestinal Surgery
  • Minimally Invasive Surgery

Background:

  • Distal pancreatectomy with celiac axis resection (DP-CAR) is an uncommon and technically challenging procedure.
  • Assessing resectability, particularly with potential superior mesenteric artery (SMA) involvement, often occurs after irreversible surgical steps.
  • Minimally invasive approaches (MIS) for DP-CAR are rarely reported.

Purpose of the Study:

  • To describe a laparoscopic distal pancreatectomy with celiac axis resection (DP-CAR) and left gastric artery (LGA) preservation.
  • To highlight a ligament of Treitz artery-first approach for early SMA resectability assessment.
  • To demonstrate the feasibility of MIS DP-CAR in a patient with locally advanced pancreatic cancer.

Main Methods:

  • Laparoscopic distal pancreatectomy with celiac axis resection (DP-CAR) and left gastric artery (LGA) preservation.
  • Preoperative neoadjuvant FOLFIRINOX therapy.
  • Intraoperative assessment of hepatic perfusion using common hepatic artery clamping, indocyanine green (ICG) fluorescence, and ultrasound.
  • Ligament of Treitz artery-first approach for SMA adventitial dissection and resectability confirmation.
  • Intraoperative gastric viability assessment using ICG.

Main Results:

  • Successful laparoscopic DP-CAR with LGA preservation and no conversion to open surgery.
  • Uneventful postoperative course with discharge on postoperative day seven.
  • Pathological confirmation of R0 resection.
  • Eight-month follow-up shows no recurrence and asymptomatic patient.

Conclusions:

  • The ligament of Treitz artery-first approach enables crucial assessment of tumor resectability and SMA involvement before irreversible surgical steps.
  • Laparoscopic DP-CAR with LGA preservation is feasible and safe.
  • This technique facilitates MIS for complex pancreatic cancer cases.