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In This Article

  • Summary
  • Abstract
  • Introduction
  • Protocol
  • Representative Results
  • Discussion
  • Acknowledgements
  • Materials
  • References
  • Reprints and Permissions

Summary

Complete resection of the uncinate process and mesopancreas is one of the most important and difficult processes in laparoscopic pancreatoduodenectomy (LPD). This article presents a method for managing the uncinate process in no-touch LPD using the median-anterior and left-posterior approaches to the superior mesenteric artery (SMA).

Abstract

Laparoscopic pancreatoduodenectomy (LPD) is a demanding abdominal operation that necessitates meticulous surgical skills and teamwork. The management of the pancreatic uncinate process is one of the most important and difficult processes in LPD because of its deep anatomical location and difficult exposure. Complete resection of the uncinate process and mesopancreas has become the cornerstone of LPD. In particular, it is even more difficult to avoid positive surgical margins and incomplete lymph node dissection when the tumor is located in the uncinate process. No-touch LPD, which is an ideal oncological operation process fitting the "tumor-free" principle, has been reported by our group previously. This article introduces the management of the uncinate process in no-touch LPD. Based on the multi-angle arterial approach, in this protocol, the median-anterior and left-posterior approaches to the SMA are used to correctly deal with the important vascular structure, the inferior pancreaticoduodenal artery (IPDA), in order to ensure the safe and complete excision of the uncinate process and mesopancreas. For the achievement of the no-touch isolation technique in LPD, the pancreatic head and the blood supply to the duodenal region must be severed at the very early stage of the operation; after that, the tumor can be isolated intact, resection can be performed in situ, and finally, the tissue can be removed en bloc. This paper aims to show the distinctive ways to manage the uncinate process in no-touch LPD and investigate the viability and safety of this approach. Moreover, the technique may increase the R0 resection rate.

Introduction

The pancreatic uncinate process is the protrusion from the bottom left of the pancreatic head that is situated behind the SMA and superior mesenteric vein (SMV)1. The management of the uncinate process is a challenging area in pancreatic surgery due to its deep anatomy and challenging exposure; therefore, especially for pancreatic cancer located in the uncinate process, surgery is prone to result in a positive surgical margin, incomplete lymph node dissection, and poor prognosis2. Therefore, improved surgical techniques and strategies are urgently required.

Most resection procedures of the pan....

Protocol

This study was approved by the Ethics Committee of the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, and informed written consent was obtained from the patients involved in this study.

1. Preoperative work-up

  1. Perform the high-resolution contrast-enhanced CT12,13 (see Table of Materials) to assess the tumor's extent and search for any abnormal vasculature.
  2. .......

Representative Results

A male patient aged 59 years old with symptoms including upper abdominal pain and jaundice was hospitalized in our department. He had no previous medical history and a relatively moderate normal body mass index (23.94 kg/m2). A contrast-enhanced CT scan was performed, and a tumor with a diameter of approximately 5.5 cm x 4.6 cm x 6.3 cm was found at the head and uncinate process of the pancreas (Figure 10). No evidence of distant metastasis was found, and percutaneous transhepatic cholangica.......

Discussion

With intestinal rotation, the ventral pancreas flips to the dorsal side and unites with the dorsal pancreas throughout the development of the human embryo, and the ventral pancreas also grows into the lower portion of the pancreatic head and the uncinate process1. The pancreatic uncinate process is described as the protrusion from the bottom left of the pancreatic head that is situated behind the SMA and the SMV1.

In the meantime, the mesopancre.......

Acknowledgements

Our article #64904 was supported by the Research project of Traditional Chinese Medicine Bureau of Guangdong Province (ID:20222077).

....

Materials

NameCompanyCatalog NumberComments
3D LaparoscopeSTORZTC200,TC302
Cisatracurium Besylate InjectionHengrui PharmaH20183042
Dual-source dual-energy  CTSOMATOMDefinition FLASH
Echelon Flex Powered Plus Articulating Endoscopic Linear Cutter and Endopath Echelon Endoscopic Linear Cutter Reloads with Gripping Surface TechnologyEthicon Endo-SurgeryECR60G/GST60G
ENDOPATH XCEL TrocarsJohnson & JohnsonCB5LT/CB12LT
HARMONIC ACE Ultrasonic Surgical DevicesEthicon Endo-SurgeryHAR36
Laparoscopic bulldog clampsAesculapFB367R,FB369R
Ligating ClipsTeleflex Medical5,44,22,05,44,23,05,44,000
Nacrotrend anaesthesia monitoring system Monitor Technik,Bad Bramsted
PROLENE Polypropylene Nonabsorbable Suture/5/0Johnson & JohnsonW8556
Propofol Injectable EmulsionAspen Pharma Trading LimitedH20171275
Remifentanil Hydrochloride for injectionHumanwell HealthcareH20030197
Sevoflurane for InhalationHengrui PharmaH20070172
Sufentanil Citrate InjectonHumanwell HealthcareH20054171
TrocarsAOFOFQ-D1/5.5mm 10.5mm
Ultrasonic Surgical & Electrosurgical GeneratorEthicon Endo-SurgeryGEN11CN

References

  1. Léger, L. Pancreatic Surgery. Chugai-Igakusha. , (1984).
  2. O'Sullivan, A. W., Heaton, N., Rela, M. Cancer of the uncinate process of the pancreas: Surgical anatomy and clinicopathological features. Hepatob....

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