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Laparoscopic pancreatoduodenectomy with superior mesenteric artery-first approach and pancreatogastrostomy assisted by mini-laparotomy.
Surg Endosc. 2016 Apr; 30(4):1670-1.SE

Abstract

BACKGROUND

Laparoscopic pancreatoduodenectomy (LPD) is a complex procedure. Critical steps are achieving a negative retroperitoneal margin and re-establishing pancreatoenteric continuity minimizing postoperative pancreatic leak risk. Aiming at increasing the rate of R0 resection during pancreatoduodenectomy, many experienced teams have recommended the superior mesenteric artery (SMA)-first approach, consisting in early identification of the SMA at its origin, with further resection guided by SMA anatomic course. We describe our technique of LPD with SMA-first approach and pancreatogastrostomy assisted by mini-laparotomy.

METHODS

The video concerns a 77-year-old man undergoing our variant of LPD for a 2.5-cm pancreatic head mass. After kocherization, the SMA is identified above the left renocaval confluence and dissected-free from the surrounding tissue. Dissection of the posterior pancreatic aspect exposes the confluence between splenic vein, superior mesenteric vein (SMV), and portal vein. Following duodenal section, the common hepatic artery is dissected and the gastroduodenal artery sectioned at the origin. The first jejunal loop is divided, skeletonized, and passed behind the superior mesenteric vessel. Following pancreatic transection, the uncinate process is dissected from the SMV and the SMA is cleared from retroportal tissue rejoining the previously dissected plain. Laparoscopic choledocojejunostomy is followed by a mini-laparotomy-assisted pancreatogastrostomy, performed as previously described, and a terminolateral gastrojejeunostomy.

RESULTS

Twelve patients underwent our variant of LPD (July 2013-May 2015). Female/male ratio was 3:1, median age 65 years (range 57-79), median operation duration 590 min (580-690), intraoperative blood loss 150 cl (100-250). R0 resection rate was 100 %, and the median number of resected lymph nodes was 24 (22-28). Postoperative complications were grade II in two patients and IIIa in one. Median postoperative length of stay was 16 days (14-21).

CONCLUSION

LPD with SMA-first approach with pancreatogastrostomy assisted by a mini-laparotomy well combines the benefits of laparoscopy with low risk of postoperative complications and high rate of curative resection.

Authors+Show Affiliations

Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza of Brescia, Via Bissolati 57, Brescia, Italy. gzimmitti@hotmail.com.Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza of Brescia, Via Bissolati 57, Brescia, Italy.Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza of Brescia, Via Bissolati 57, Brescia, Italy.Department of Oncology, Istituto Ospedaliero Fondazione Poliambulanza of Brescia, Brescia, Italy.Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza of Brescia, Via Bissolati 57, Brescia, Italy.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

26156616

Citation

Zimmitti, Giuseppe, et al. "Laparoscopic Pancreatoduodenectomy With Superior Mesenteric Artery-first Approach and Pancreatogastrostomy Assisted By Mini-laparotomy." Surgical Endoscopy, vol. 30, no. 4, 2016, pp. 1670-1.
Zimmitti G, Manzoni A, Addeo P, et al. Laparoscopic pancreatoduodenectomy with superior mesenteric artery-first approach and pancreatogastrostomy assisted by mini-laparotomy. Surg Endosc. 2016;30(4):1670-1.
Zimmitti, G., Manzoni, A., Addeo, P., Garatti, M., Zaniboni, A., Bachellier, P., & Rosso, E. (2016). Laparoscopic pancreatoduodenectomy with superior mesenteric artery-first approach and pancreatogastrostomy assisted by mini-laparotomy. Surgical Endoscopy, 30(4), 1670-1. https://doi.org/10.1007/s00464-015-4359-7
Zimmitti G, et al. Laparoscopic Pancreatoduodenectomy With Superior Mesenteric Artery-first Approach and Pancreatogastrostomy Assisted By Mini-laparotomy. Surg Endosc. 2016;30(4):1670-1. PubMed PMID: 26156616.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Laparoscopic pancreatoduodenectomy with superior mesenteric artery-first approach and pancreatogastrostomy assisted by mini-laparotomy. AU - Zimmitti,Giuseppe, AU - Manzoni,Alberto, AU - Addeo,Pietro, AU - Garatti,Marco, AU - Zaniboni,Alberto, AU - Bachellier,Philippe, AU - Rosso,Edoardo, Y1 - 2015/07/09/ PY - 2015/06/10/received PY - 2015/06/18/accepted PY - 2015/7/10/entrez PY - 2015/7/15/pubmed PY - 2016/12/15/medline KW - Laparoscopic KW - Mini-laparotomy KW - Pancreato-gastrostomy KW - Pancreatoduodenectomy KW - SMA-first approach SP - 1670 EP - 1 JF - Surgical endoscopy JO - Surg Endosc VL - 30 IS - 4 N2 - BACKGROUND: Laparoscopic pancreatoduodenectomy (LPD) is a complex procedure. Critical steps are achieving a negative retroperitoneal margin and re-establishing pancreatoenteric continuity minimizing postoperative pancreatic leak risk. Aiming at increasing the rate of R0 resection during pancreatoduodenectomy, many experienced teams have recommended the superior mesenteric artery (SMA)-first approach, consisting in early identification of the SMA at its origin, with further resection guided by SMA anatomic course. We describe our technique of LPD with SMA-first approach and pancreatogastrostomy assisted by mini-laparotomy. METHODS: The video concerns a 77-year-old man undergoing our variant of LPD for a 2.5-cm pancreatic head mass. After kocherization, the SMA is identified above the left renocaval confluence and dissected-free from the surrounding tissue. Dissection of the posterior pancreatic aspect exposes the confluence between splenic vein, superior mesenteric vein (SMV), and portal vein. Following duodenal section, the common hepatic artery is dissected and the gastroduodenal artery sectioned at the origin. The first jejunal loop is divided, skeletonized, and passed behind the superior mesenteric vessel. Following pancreatic transection, the uncinate process is dissected from the SMV and the SMA is cleared from retroportal tissue rejoining the previously dissected plain. Laparoscopic choledocojejunostomy is followed by a mini-laparotomy-assisted pancreatogastrostomy, performed as previously described, and a terminolateral gastrojejeunostomy. RESULTS: Twelve patients underwent our variant of LPD (July 2013-May 2015). Female/male ratio was 3:1, median age 65 years (range 57-79), median operation duration 590 min (580-690), intraoperative blood loss 150 cl (100-250). R0 resection rate was 100 %, and the median number of resected lymph nodes was 24 (22-28). Postoperative complications were grade II in two patients and IIIa in one. Median postoperative length of stay was 16 days (14-21). CONCLUSION: LPD with SMA-first approach with pancreatogastrostomy assisted by a mini-laparotomy well combines the benefits of laparoscopy with low risk of postoperative complications and high rate of curative resection. SN - 1432-2218 UR - https://www.unboundmedicine.com/medline/citation/26156616/Laparoscopic_pancreatoduodenectomy_with_superior_mesenteric_artery_first_approach_and_pancreatogastrostomy_assisted_by_mini_laparotomy_ L2 - https://dx.doi.org/10.1007/s00464-015-4359-7 DB - PRIME DP - Unbound Medicine ER -