Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy

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 CT^12,13 (see Table of Materials) to assess the tumor's extent and search for any abnormal vasculature.
.......

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.......

Materials

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