This protocol demonstrates the feasibility and safety of performing LPD using the in-situ no-touch isolation technique which might elevate the R0 resection rate. The main advantage of this method is to ensure that all steps follow the oncologic principles of no-touch in order to decrease the risk of metastasis in the tumor cells. Due to the complex resection and reconstruction techniques, this procedure can only be performed by experienced surgical teams in high-volume centers with both open and laparoscopic pancreatic surgical skills.
This method is an oncological ideal operation process. To begin, explore the intraperitoneal organs and peritoneal surfaces, meticulously, for unexpected extra-pancreatic metastases. Resect the greater omentum and open the lesser sac by dividing the gastrocolic ligament.
Then ligate Henle's gastrocolic trunk vein. Explore the gap between the pancreatic neck and SMV at the lower edge of the pancreas. The transverse colon and its mesentery are elevated cephalad.
Then expose the second and third parts of the duodenum after the mesentery section. Expose the inferior vena cava, left renal vein, celiac trunk, aorta, and SMA to reconfirm the resectability, and mobilize the posterior of the pancreatic head. Then perform the dissection along the SMV to clear all the tissues on the right side.
Ensure that there is no ischemia in the transverse colon. Ligate the root of the middle colonic artery to fully expose the SMV. Place the entire small bowel on the left side to facilitate the exposure, and then expose the dissection of the distal duodenum proximal to the ligament of Treitz.
Divide the proximal jejunum with a stapler, and expose the SMA by tracing along the jejunal artery. Place a French 8 catheter for hanging and encircling the dorsal aspect of the SMA and SMV. Pull the catheter to the upper right side to allow SMA dissection on its periadventitial plane on the anterior left margin and its separation from the mesopancreas.
Ligate the first jejunal artery involved by the tumor, and sacrifice. Identify the first jejunal vein and the inferior pancreaticoduodenal veins, or IPDV, which are the branches from the dorsal side of the SMV. Ligate and dissect the IPDV.
Circumferentially dissect the SMA to identify the inferior pancreaticoduodenal artery, or IPDA, which either forms a common trunk with the first jejunal artery or arises directly from the SMA. Then sacrifice the IPDA. At the left posterior approach, dissect the SMA, which is identified at its origin above the LRV, free from the mesopancreas.
Start the SMA approach from the upper colon region. Then, hanging the SMV through a rubber band, use a stapler device to divide the stomach three to five centimeters away from the pylorus. Remove the gallbladder.
Divide the common bile duct and apply the laparoscopic bulldog clamps to occlude the CBD temporarily. Then dissect the hepatoduodenal ligament, ligate, then dissect the right gastric artery and identify the gastroduodenal artery. Doubly ligate or suture the GDA and perform a lymphadenectomy along the CHA, the proper hepatic artery, or PHA, and the portal vein.
Explore the gap between the pancreatic neck and SMV at the lower edge of the pancreas, and transect the neck of the pancreas with an ultrasound knife. Next, do a frozen pathologic examination of the pancreatic stump. Suspend the splenic vein using a rubber band, and dissect the right and dorsal aspects of the SMA within the diamond-shaped window.
Resect the fat and fibrous tissues around SMA and CA from the caudal side to the cephalic side. Ligate and transect the uncinate process artery under the splenic vein, leaving the specimen attached to the splenic vein SMV. Use laparoscopic bulldog clamps to temporarily clamp the splenic vein and the SMV, and transect the involved vein with sufficient margin.
After that, cut off the lymphatics and dissect the duodenum from the retroperitoneum. Measure the length of the venous defect with a soft ruler. If the defect exceeds three centimeters, use an artificial interposition graft.
Perform SMV reconstruction from caudal to cephalic by continuous suture, using 5-0 Prolene sutures. Then perform a single-layer running suturing hepaticojejunostomy with 4-0 absorbable sutures from end to side. Conduct pancreatic anastomosis by duct-to-mucosal end-to-side pancreaticojejunostomy with an internal stent.
Finally, conduct gastrojejunal anastomosis. The representative images show the mass in the uncinate process of the pancreas. Endoscopic ultrasound-guided fine-needle aspiration was performed to acquire the pathology diagnosis of adenocarcinoma.
Eight cycles of modified FOLFIRINOX regimen were performed as neoadjuvant chemotherapy on the patient. After neoadjuvant chemotherapy, the maximum diameter of the tumor reduced from 4.2 centimeters to 3.5 centimeters. When attempting this procedure, the steps that require special care include confirmation of resectability and mobilization of the posterior of the pancreatic head, placement of the French 8 catheter for hanging and encircling the dorsal aspect of the SMA and SMV, ligation of the first jejunal artery involved by the tumor, and identification of IPDA.
