Name: laparoscopic posterior radical antegrade modular pancreatosplenectomy for distal pancreatic carcinoma
Uploaded: 2023-12-29T14:40:00
Description: Read this Scientific Article Protocol about Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma at JoVE.com

This work was supported by grants from the Basic and Applied Basic Research Project of Guangzhou Basic Research Program (No. 2023A04J1917), the Fundamental Research Funds for the Central Universities (No. 21622312), the Special Foundation for Scientific Research Development of the Affiliated Shunde Hospital of Jinan University (No. 202101004), and Guangdong Basic and Applied Research Foundation (No. 2022A1515012581).

The surgical procedure was approved by the institutional review board at The First Affiliated Hospital of Jinan University. The patient, a 58-year-old female, was admitted with a chief complaint of &#34;abdominal pain for 2 months.&#34; A computed tomography (CT) scan conducted at an external hospital revealed a space-occupying lesion in the distal pancreas, raising concerns about the possibility of pancreatic carcinoma. Before the surgery, the patient provided written informed consent. The surgical tools and equipment u...

<ol>
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DPS has been widely used as the standard radical surgery for distal pancreatic carcinoma1,2. However, due to the highly invasive nature of pancreatic cancer, it is easy for the tumor to grow to the edge of the pancreas and even break through the surface of the pancreas. Meanwhile, accompanying chronic pancreatitis makes the boundary between the pancreas and the surrounding tissues unclear. Therefore, it is difficult to achieve R0 resection during conventional sur...

Conventional distal pancreatosplenectomy (DPS) has traditionally been the standard surgical procedure for distal pancreatic carcinoma1,2. Distal pancreatic carcinoma is a highly invasive tumor that easily infiltrates into retroperitoneal tissues. Simultaneously, pancreatic cancer is often accompanied by chronic pancreatitis, making the boundary between the pancreas and adjacent tissues unclear. Consequently, during conventional DPS, there is a risk of tumor cells spreading along the direction of blood circulation and lymphatic return. In addition to the inherent inflammation associated with pancreatic cancer, achieving R0 resection is challenging, leading to a relatively low postoperative survival rate for patients3.
With the advancement of surgical techniques and a deeper understanding of the pancreatic lymphatic system, the high positive rate of the surgical margin and incomplete lymph node dissection in conventional DPS have garnered more attention. In response, radical antegrade modular pancreatosplenectomy (RAMPS) has emerged to address these challenges3,4. RAMPS involves the complete removal of tissues around the body and tail of the pancreas, including the tumor, to ensure a negative incisional margin and thorough dissection of lymph nodes in N1 nodes, the superior mesenteric artery (SMA), and the anterior and left of the celiac trunk3,4.
In 2003, Strasberg first reported RAMPS3. With the development of minimally invasive surgical techniques, there have been sporadic reports of laparoscopic RAMPS (L-RAMPS) in recent years. L-RAMPS is preliminarily considered technically safe and feasible in oncology5,6,7,8,9. However, due to technical difficulties and a lack of supporting evidence for clinical application, only a few institutions are currently conducting L-RAMPS. In light of this situation, this article presents the techniques of laparoscopic posterior radical antegrade modular pancreatosplenectomy (L-pRAMPS) in detail, holding great promise for future clinical application.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>10-mm trocar</td>
			<td>Xiamen Surgaid Medical Device Co., LTD</td>
			<td>NGCS 100-1-10</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>12-mm trocar</td>
			<td>Xiamen Surgaid Medical Device Co., LTD</td>
			<td>NGCS 100-1-12</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>5-mm trocar</td>
			<td>Xiamen Surgaid Medical Device Co., LTD</td>
			<td>NGCS 100-1-5</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Hem-o-lok</td>
			<td>America Teleflex Medical Technology Co., LTD</td>
			<td>544240</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Linear stapling device</td>
			<td>America Ethicon Medical Technology Co., LTD</td>
			<td>PSEE60A</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Pneumoperitoneum needle</td>
			<td>Xiamen Surgaid Medical Device Co., LTD</td>
			<td>NGCS 100-1</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
		<tr>
			<td>Suction and irrigation tube</td>
			<td>Tonglu Hengfeng Medical Device Co., LTD</td>
			<td>HF6518.035</td>
			<td>Sterile,dry heat sterilized, reusable</td>
		</tr>
		<tr>
			<td>Ultrasounic-harmonic scalpel</td>
			<td>Chongqing Maikewei Medical Technology Co., LTD</td>
			<td>QUHS36S&#160;</td>
			<td>Sterile, ethylene oxide sterilized, disposable</td>
		</tr>
	</tbody>
</table>

laparoscopic posterior radical antegrade modular pancreatosplenectomy for distal pancreatic carcinoma

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic capsule to infiltrate surrounding tissues. In conventional distal pancreatosplenectomy (DPS), tumor cells are prone to spread along the direction of blood and lymphatic reflux due to surgical compression. Additionally, inflammation makes it challenging to achieve R0 resection, leading to a lower patient survival rate. To address these limitations, radical antegrade modular pancreatosplenectomy (RAMPS) was developed, emphasizing deeper excision, including the left anterior renal fascia, the left anterior renal adipose sac, and even the left adrenal gland, to improve the R0 resection rate. With the advancement of minimally invasive surgical techniques, laparoscopic RAMPS (L-RAMPS) is being considered technically safe and feasible in oncology. However, due to technical difficulties and a lack of supporting evidence for clinical application, only a few institutions are currently conducting L-RAMPS. In this context, this article presents detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy (L-pRAMPS), offering promise for future clinical applications.

The surgery proceeded smoothly, and the intraoperative rapid frozen pathological examination indicated the absence of cancer at the incisal margin of the pancreas. Throughout the surgery, the patient&#39;s vital signs remained stable, and the anesthesia was effective. The operation duration was 150 min, with an intraoperative blood loss of 80 mL. Anal exhaust occurred 32 h postoperatively. There were no complications such as abdominal hemorrhage, pancreatic leakage, abdominal infection, or incision infection. The postope...

Read this Scientific Article Protocol about Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma at JoVE.com

Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma

Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) is currently considered technically safe and feasible. However, due to technical challenges and a lack of supporting evidence for widespread clinical applications, only a limited number of institutions are currently conducting L-RAMPS. This article aims to provide detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy.

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic ...

Using non-invasive forceps, lift and pull the stomach towards the cephalic side and with an ultrasonic harmonic scalpel, cut the gastrocolic and gastro splenic ligaments at the upper edge of the transverse colon. To separate the stomach and spleen, ligate and sever the left gastroepiploic vessels, short gastric vessels, posterior gastric vessels, and left subphrenic vessels near the gastric wall. Then enter the lesser or mental sac, and explore the condition of the pancreatic tumor.Next, separate and expose the common hepatic artery, followed by the celiac trunk and the left gastric artery, and dissect the lymph nodes surrounding both these arteries. Incise the retroperitoneum from the pancreatic neck to the pancreatic tail at the lower margin of the pancreas, and remove the surrounding lymph nodes. Then continue to incise the anterior layer of the left gerota fascia to reveal the left renal vein.Peel the anterior layer of gerota fascia from the surface of the left kidney along the left renal vein. To expose the superior mesenteric artery and abdominal aorta, lift the distal pancreas toward the cephalic side, and simultaneously dissect the surrounding lymph nodes. Separate the superior mesenteric vein at the lower margin of the pancreatic neck, followed by the retro pancreatic tunnel along the surface of the FMV and portal vein.Using a linear stapling device, sever the pancreas at the neck. After dissecting and exposing the splenic vein, ligate and sever its root. Dissect the splenic artery to remove the surrounding lymph nodes and ligate and cut off the artery root.After lifting the pancreas and the anterior layer of the gerota fascia, sever the left adrenal vessel and peel off the anterior layer of the gerota fascia and the left adrenal gland upwards. Cut off the posterior peritoneum from right to left above the pancreas, and clear the connective tissues between the abdominal aorta and the left kidney along the left cross of diaphragm. Then sever the gerota fascia tissues at the upper margin of the left adrenal gland.Next, sever the ligaments and adhesions around the spleen to release it and excise a distal pancreas, the anterior layer of the gerota fascia, the left adrenal gland, and the spleen as a whole. To carefully examine the surgical field, irrigate the abdominal cavity with sterile distilled water, and place a drainage tube beside the incisal margin of the pancreas. Finally, extend the umbilical incision length to about five centimeters.Cut the abdominal wall layer by layer and take out the specimen. The postoperative CT scan indicates successful tumor removal without significant recurrence or metastasis.

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