Mastering Robotic SMA Dissection: How the Correct Anatomical Concept Refines Technical Steps in the Left Posterior...

The left posterior approach to the superior mesenteric artery (SMA) facilitates central vascular ligation and R0 resection during robotic pancreaticoduodenectomy (PD).^1-4 Despite its advantages, embryological intestinal rotation creates a complex anatomy around the SMA.^5,6 This study clarifies the three-dimensional (3D) anatomical considerations and surgical techniques essential for this approach.

The technique begins with a left-sided scope orientation. The transverse mesocolon was cranially retracted using a Nathanson retractor to create a stable, wide operative field. Traction is achieved through the combination of a robotic traction arm and assistant-assisted retraction, allowing one robotic arm to remain available for precise dissection and prompt hemostasis.⁷ A thorough 3D understanding of the discrepancy between the anterior and posterior mesojejunum incision lines is essential.⁶ Ideally, the mesojejunum was transected to create a wide triangular dissection plane.

Between 2021 and 2025, 27 consecutive patients with invasive pancreatic cancer underwent robotic PD using the left posterior approach. The median operative time was 582 min, and the median blood loss was 100 mL. One patient required conversion to gastroduodenal artery bleeding; four underwent planned minilaparotomy for portal vein resection. Notably, no conversion was observed when using the left posterior approach. Clavien-Dindo grade IIIa complications occurred in two patients (7.4%), with no reoperations or mortalities. The rate of R0 resection was 89%.

Mastering the 3D mesojejunal anatomy and maintaining precise resection planes are fundamental to ensuring safety and optimal oncologic outcomes during the left posterior approach in robotic PD.