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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).
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.
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....
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
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.......
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.......
Our article #64904 was supported by the Research project of Traditional Chinese Medicine Bureau of Guangdong Province (ID:20222077).
....Name | Company | Catalog Number | Comments |
3D Laparoscope | STORZ | TC200,TC302 | |
Cisatracurium Besylate Injection | Hengrui Pharma | H20183042 | |
Dual-source dual-energy CT | SOMATOM | Definition FLASH | |
Echelon Flex Powered Plus Articulating Endoscopic Linear Cutter and Endopath Echelon Endoscopic Linear Cutter Reloads with Gripping Surface Technology | Ethicon Endo-Surgery | ECR60G/GST60G | |
ENDOPATH XCEL Trocars | Johnson & Johnson | CB5LT/CB12LT | |
HARMONIC ACE Ultrasonic Surgical Devices | Ethicon Endo-Surgery | HAR36 | |
Laparoscopic bulldog clamps | Aesculap | FB367R,FB369R | |
Ligating Clips | Teleflex Medical | 5,44,22,05,44,23,05,44,000 | |
Nacrotrend anaesthesia monitoring system | Monitor Technik,Bad Bramsted | ||
PROLENE Polypropylene Nonabsorbable Suture/5/0 | Johnson & Johnson | W8556 | |
Propofol Injectable Emulsion | Aspen Pharma Trading Limited | H20171275 | |
Remifentanil Hydrochloride for injection | Humanwell Healthcare | H20030197 | |
Sevoflurane for Inhalation | Hengrui Pharma | H20070172 | |
Sufentanil Citrate Injecton | Humanwell Healthcare | H20054171 | |
Trocars | AOFO | FQ-D1/5.5mm 10.5mm | |
Ultrasonic Surgical & Electrosurgical Generator | Ethicon Endo-Surgery | GEN11CN |
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