In Situ Anterior Approach to Dissect the Superior Mesenteric Artery in Minimally Invasive Pancreaticoduodenectomy:...

Dissection around the superior mesenteric artery (SMA) is a crucial and one of the most challenging processes in laparoscopic pancreaticoduodenectomy (LPD) owing to the deep anatomic location and the indispensable role of SMA. Multiple approaches to SMA during LPD have been proposed, but most of them require the transection of the jejunum or the neck of pancreas in advance and may cause significant tension on mesenteric vessels that may lead to accidental bleeding.^1-3 Here, we describe an in situ anterior approach to the SMA that aids in the early assessment of tumor resectability without any destructive steps and minimizes bleeding risk.

An 85-year-old man underwent LPD for a distal common bile duct carcinoma, with a percutaneous transhepatic biliary drainage (PTBD) placed 4 weeks prior. Preoperative imaging showed a rare first jejunal vein that runs in front of the SMA and drains into the junction of the SMV and the spleen vein. The in situ anterior approach to the SMA begins with the identification of superior mesenteric vein (SMV) at the inferior border of the pancreas. The right gastroepiploic vein, and right colic vein and gastrocolic trunk are clipped and divided. The SMV is exposed to the level of third portion of the duodenum. Then the left side of the SMV or the "groove" between SMV and SMA is dissected. The colic vein draining into the SMV is clipped and divided. The first jejunal vein that drains into the junction of the SMV and the spleen vein is also clipped and divided. With the surgeon and the assistant grasping the fibrofatty tissue in the "groove" and pulling ventrally in opposite positions, the fibrofatty tissue and neural plexus around the SMA are dissected. In this way the SMA can be skeletonized in a ventral-to-dorsal direction. During the process, the IPDA, the first jejunal artery and their common trunk are identified. The distal end of J1A and the common trunk of IPDA and J1A are securely clipped and divided. The posterior dissection ends when the inferior vena cava or the gauze placed behind the duodenum during the Kocher maneuver is revealed. The dissection could continue cephalad to remove the lymph nodes in the Heidelberg Triangle.⁴ The dorsal pancreatic artery is clipped and divided.

In this case, the operative time was 340 min with an estimated blood loss of 200 ml. The patient recovered uneventfully with no pancreatic fistula and was discharged on postoperative day 8. Histology confirmed poorly-differentiated biliary adenocarcinoma with no involvement of the lymph nodes.

The video illustrates an in situ anterior approach to dissect the superior mesenteric artery in laparoscopic pancreaticoduodenectomy that largely resembles the supracolic anterior artery-first approach in open surgery proposed by Inoue et al.⁵ This approach reduces the risk of vascular injury and bleeding by omitting the significant tension on mesenteric vessels as organs stay in their original positions, and the nondestructive and "reversable" nature makes it easier to achieve an accurate evaluation of tumor resectability early in the surgery.