The authors have no acknowledgments.

This study was permitted by the Ethics Committee of the Second Affiliated Hospital of Guangzhou University of Chinese Medicine.
1. Patient selection
<ol>
	<li>Advise the patients suspected of suffering pancreatic ductal adenocarcinoma (PDAC) in the pancreas head to take a contrast-enhanced computed tomography (CT) scan at first. Then select the following patients: borderline resectable cases after neoadjuvant therapy, tumor regresses significantly and has the possibility of radical resection; meanwhile, SMV reconstruction is potentially needed.</li>
	<li>Exclude the following patients: (1) metastatic PDAC; (2) patients with a poor general condition that cannot tolerate major surgery; (3) vascular involvement of SMA, common hepatic artery (CHA), or celiac artery (CA).</li>
</ol>
2. Surgical technique
<ol>
	<li>Operative setting
	<ol>
		<li>Place the anesthetized patient in a completely supine position, with legs spread out.</li>
		<li>During the sterile exposition, ensure that the suprapubic region is exposed adequately for the later specimen removal by a Pfannenstiel incision. Ensure that the operator surgeon stands on the right side, the first assistant is on the left side, and the second&#160;assistant holding the laparoscope is positioned between the patient&#39;s legs. Use the 5-port technique to perform the procedure (Figure 1).</li>
		<li>After the pneumoperitoneum is created, introduce the rigid laparoscope through the sub-umbilical 12 mm trocar, and place the other four trocars along a semi-circle.</li>
	</ol>
	</li>
	<li>Exploration phase
	<ol>
		<li>Explore the intraperitoneal organs and peritoneal surfaces meticulously for unexpected extrapancreatic metastases.</li>
		<li>Resect the greater omentum and open the lesser sac by dividing the gastrocolic ligament.</li>
		<li>Ligate Henle&#39;s gastrocolic trunk vein. Explore the gap between the pancreatic neck and SMV at the lower edge of the pancreas. 
		NOTE: The tunnel between the pancreatic neck and SMV can not be created easily if the anterior wall of SMV is involved.</li>
	</ol>
	</li>
	<li>Dissection phase:
	<ol>
		<li>Subcolonic mesenteric approach: For this approach, follow steps 2.3.2-2.3.5.</li>
		<li>After the transverse colon and its mesentery are elevated cephalad, place the entire small bowel on the left side to facilitate exposure of the pancreaticoduodenal region.</li>
		<li>Expose the second and third parts of the duodenum after the mesentery section.</li>
		<li>In order to reconfirm resectability and mobilize the posterior of the pancreatic head, expose the inferior vena cava (IVC), left renal vein (LRV), celiac trunk, aorta, and SMA (Figure 2).</li>
		<li>Then perform the dissection along the SMV to clear all the tissues on the right side. In order to expose the SMV fully, ligate the root of the middle colonic artery after confirming that there is no ischemia in the transverse colon.</li>
		<li>Left posterior of SMA approach: For this approach, follow steps 2.3.7-2.3.18.</li>
		<li>Place the entire small bowel on the left side to facilitate exposure and the dissection of the distal duodenum proximal to the ligament of Treitz.</li>
		<li>Divide the proximal jejunum with a stapler.</li>
		<li>Expose the SMA by tracing along the jejunal artery.</li>
		<li>Place a Fr8 catheter for hanging for encircling the dorsal aspect of the SMA and SMV.</li>
		<li>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.</li>
		<li>Ligate the first jejunal artery (FJA) involved by the tumor and sacrifice.</li>
		<li>Identify the first jejunal vein (FJV) and the inferior pancreaticoduodenal veins (IPDV), which are the branches from the dorsal side of the SMV.</li>
		<li>Ligate and dissect the IPDV.</li>
		<li>Circumferentially dissect the SMA to identify the inferior pancreaticoduodenal artery (IPDA), which either forms a common trunk with the FJA or arises directly from the SMA (Figure 3).</li>
		<li>Sacrifice the IPDA.</li>
		<li>At the left posterior approach, dissect the SMA, which is identified at its origin above the LRV, free from the mesopancreas.</li>
		<li>In cases that the tumor invades the mesocolon, hang the SMV and SMA through a rubber band followed by coring out of the mesocolon.</li>
		<li>Supracolic median-anterior of SMA approach: For this approach, follow steps 2.3.20-2.3.34.</li>
		<li>Start the SMA approach from the upper colon region.</li>
		<li>Explore the gap between the pancreatic neck and SMV at the lower edge of the pancreas.</li>
		<li>Use a stapler device to divide the stomach 3-5 cm away from the pylorus.</li>
		<li>Remove the gallbladder.</li>
		<li>Divide the common bile duct (CBD) as conventional PD. Take a frozen pathologic examination of the bile duct stump. Apply the laparoscopic bulldog clamps to occlude the CBD temporarily.</li>
		<li>Dissect the hepatoduodenal ligament. Perform a lymphadenectomy along the CHA, the proper hepatic artery (PHA), and the PV.</li>
		<li>Ligate and dissect the right gastric artery.</li>
		<li>Identify the gastroduodenal artery (GDA) at the point where the PHA branches from the CHA.</li>
		<li>Doubly ligate or suture the GDA to minimize the chance of subsequent erosion and bleeding.</li>
		<li>Transect the neck of the pancreas with an ultrasound knife. Take a frozen pathologic examination of the pancreatic stump.</li>
		<li>Suspend the splenic vein (PV) using a rubber band.</li>
		<li>Set up a diamond-shaped window by retracting the transverse mesocolon caudally, the PV cranially, the SMV rightward, and the SMA leftward.</li>
		<li>During the supracolic median-anterior of the SMA approach, dissect the right and dorsal aspects of the SMA within this diamond-shaped window.</li>
		<li>Resect the fat and fibrous tissues around SMA and CA from the caudal side to the cephalic side.</li>
		<li>Ligate and transect the uncinate process artery (UPA) under the PV, leaving the specimen attached to the PV/SMV.</li>
		<li>Combining with median-anterior and left-posterior approaches to the SMA, expose the origin of the IPDA or the common trunk of the IPDA and FJA easily. 
		NOTE: During this procedure, the GDA, UPA, and IPDA have been completely ligated. Furthermore, all the tumor artery inflows are completely occluded till this moment to reduce bleeding.</li>
		<li>Use laparoscopic bulldog clamps to temporarily clamp the PV, the splenic vein, and the SMV. Transect the involved vein with sufficient margin.</li>
		<li>Afterward, cut off the lymphatics and dissect the duodenum from the retroperitoneum.</li>
		<li>Finally, resect the tumor in situ and remove en bloc following the oncologic principles of No-Touch2,6,7.</li>
	</ol>
	</li>
	<li>Reconstruction phase
	<ol>
		<li>Measure the length of the venous defect with a soft ruler. If the defect exceeds 3 cm, consider using an artificial interposition graft.</li>
		<li>Perform SMV reconstruction from caudal to cephalic by continuous suture using 5-0 prolene sutures (Figure 4).</li>
		<li>Reconstruct the digestive tract by Child&#39;s method9.</li>
		<li>An end-to-side, perform single-layer running suturing hepaticojejunostomy with 4-0 absorbable sutures.</li>
		<li>Conduct pancreatic anastomosis by duct-to-mucosal, end-to-side pancreaticojejunostomy within an internal stent9.</li>
		<li>After a side-to-side gastrojejunal anastomosis, place three drainages near the anastomosis.</li>
	</ol>
	</li>
	<li>Bag the specimen and retrieve it through the Pfannenstiel incision.</li>
</ol>

<ol>
	<li>Hirota, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatectomy+using+the+no-touch+isolation+technique+followed+by+extensive+intraoperative+peritoneal+lavage+to+prevent+cancer+cell+dissemination:+a+pilot+study.">Pancreatectomy using the no-touch isolation technique followed by extensive intraoperative peritoneal lavage to prevent cancer cell dissemination: a pilot study.</a> Journal of the Pancreas. 6 (2), 143-151 (2005).</li><li>Gall, T. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reduced+dissemination+of+circulating+tumor+cells+with+no-touch+isolation+surgical+technique+in+patients+with+pancreatic+cancer.">Reduced dissemination of circulating tumor cells with no-touch isolation surgical technique in patients with pancreatic cancer.</a> JAMA Surgery. 149 (5), 482-485 (2014).</li><li>Soeth, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Detection+of+tumor+cell+dissemination+in+pancreatic+ductal+carcinoma+patients+by+CK+20+RT-PCR+indicates+poor+survival.">Detection of tumor cell dissemination in pancreatic ductal carcinoma patients by CK 20 RT-PCR indicates poor survival.</a> Journal of Cancer Research and Clinical Oncology. 131 (10), 669-676 (2005).</li><li>Yap, T. A., Lorente, D., Omlin, A., Olmos, D., de Bono, J. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Circulating+tumor+cells:+a+multifunctional+biomarker.">Circulating tumor cells: a multifunctional biomarker.</a> Clinical Cancer Research. 20 (10), 2553-2568 (2014).</li><li>Fujita, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+right+hemicolectomy+with+radical+lymph+node+dissection+using+the+no-touch+isolation+technique+for+advanced+colon+cancer.">Laparoscopic right hemicolectomy with radical lymph node dissection using the no-touch isolation technique for advanced colon cancer.</a> Surgery Today. 31 (1), 93-96 (2001).</li><li>Hirota, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatoduodenectomy+using+a+no-touch+isolation+technique.">Pancreatoduodenectomy using a no-touch isolation technique.</a> The American Journal of Surgery. 199 (5), 65-68 (2010).</li><li>Kuroki, T., Eguchi, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=No-touch+isolation+techniques+for+pancreatic+cancer.">No-touch isolation techniques for pancreatic cancer.</a> Surgery Today. 47 (1), 8-13 (2017).</li><li>Tan, Z. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+experience+of+laparoscopic+pancreatoduodenectomy+via+orthotopic+resection.">Clinical experience of laparoscopic pancreatoduodenectomy via orthotopic resection.</a> Zhonghua Wai Ke Za Zhi [Chinese Journal of Surgery. 58 (10), 782-786 (2020).</li><li>Osada, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reconstruction+method+after+pancreaticoduodenectomy.+Idea+to+prevent+serious+complications.">Reconstruction method after pancreaticoduodenectomy. Idea to prevent serious complications.</a> Journal of the pancreas. 13 (1), 1-6 (2012).</li><li>Mizrahi, J. D., Surana, R., Valle, J. W., Shroff, R. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatic+cancer.">Pancreatic cancer.</a> Lancet. 395 (10242), 2008-2020 (2020).</li><li>Tempero, M. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatic+adenocarcinoma,+version+2.2021,+NCCN+clinical+practice+guidelines+in+oncology.">Pancreatic adenocarcinoma, version 2.2021, NCCN clinical practice guidelines in oncology.</a> Journal of the National Comprehensive Cancer Network JNCCN. 19 (4), 439-457 (2021).</li><li>Bockhorn, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Borderline+resectable+pancreatic+cancer:+a+consensus+statement+by+the+International+Study+Group+of+Pancreatic+Surgery+(ISGPS).">Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS).</a> Surgery. 155 (6), 977-988 (2014).</li><li>Tee, M. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+pancreatoduodenectomy+does+not+completely+mitigate+increased+perioperative+risks+in+elderly+patients.">Laparoscopic pancreatoduodenectomy does not completely mitigate increased perioperative risks in elderly patients.</a> HPB (Oxford). The Official Journal of the International Hepato Pancreato Biliary Association. 17 (10), 909-918 (2015).</li><li>Palanivelu, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Randomized+clinical+trial+of+laparoscopic+versus+open+pancreatoduodenectomy+for+periampullary+tumours.">Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours.</a> The British Journal of Surgery. 104 (11), 1443-1450 (2017).</li><li>Wang, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+pancreatoduodenectomy+for+pancreatic+or+periampullary+tumours:+A+multicentre,+open-label,+randomised+controlled+trial.">Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours: A multicentre, open-label, randomised controlled trial.</a> The Lancet. Gastroenterology &amp; Hepatology. 6 (6), 438-447 (2021).</li></ol>

The authors have nothing to disclose.

PDAC is one of the most lethal malignant diseases. Despite the fact that the overall 5-year survival rates are still unsatisfactory, surgery remains the only curative therapeutic method till now10. According to the National Comprehensive Cancer Network (NCCN) and International Study Group of Pancreatic Cancer (ISGPS), patients diagnosed with PDAC should be defined as borderline resectable cases while the portal-superior mesenteric vein is suspiciously involved, and in order to improve R0 resection...

Pancreaticoduodenectomy (PD) is a standard surgical procedure for cancer in the pancreaticoduodenal region. The Kocher maneuver is widely used for the efficient exposure of the duodenum and pancreatic head during conventional PD. The mobilization and squeezing of the pancreaticoduodenal area during surgery may cause metastasis of the tumor cells before the ligation of surrounding vessels1. A recent study had shown that the tumor cells had the potential possibility of being squeezed into the portal vein (PV) because of the handling and squeezing of the tumor area by the surgeons, which might further increase the risk of liver metastasis after surgery2.
With the development of biomedical technology, a scientist could detect the spread of solid tumor cells, including pancreatic cancer cells, into the vessels as circulating tumor cells (CTC)3,4.
No-Touch isolation procedures, which have been used in colon cancer, might prevent the dissemination of cancer cells, such as circulating tumor cells, from the primary tumor5. Several studies have reported the use of a no-touch isolation technique for pancreatic head cancer during laparotomy pancreaticoduodenectomy6,7. The concept of this procedure is that the surgeon does not touch the duodenum and pancreatic head region (including the tumor) before ligating and dissecting the vessels (arteries and veins) around the pancreatic head.
No-Touch isolation techniques have been reported in LPD for pancreaticoduodenal region neoplasm8. We herein present a modified in-situ No-Touch isolation LPD with partial resection and reconstruction of SMV for pancreatic cancer after neoadjuvant therapy, which dissects all the inflow arteries first, transects the involved vein with sufficient margin, resects the tumor in-situ, and removes the specimen en-bloc.
The goal and advantages of this method are to ensure that all steps follow the oncologic principles of No-Touch in order to decrease the risk of metastasis of the tumor cells. The rationale behind the development and use of this technique is that the tumor should be mobilized at the final stage, including resecting the tumor in situ and removing the specimen en bloc after tumor inflow arteries and outflow veins are occluded. However, as this procedure requires complex resection and reconstruction techniques when surgeons decide whether to use this method, they need to estimate their own situations such as the learning curve, tumor type, vascular condition, and other factors.

<table><tbody><tr><td>3D Laparoscope</td><td>STORZ</td><td>TC200,TC302</td><td></td></tr><tr><td>Absorbable hemostat</td><td>ETHICON, LLC</td><td>2 in x 4 in</td><td></td></tr><tr><td>Artificial Interposition Graft</td><td>W.L.Gore &amp;amp; Associates, Inc.</td><td>IRTH084040W</td><td></td></tr><tr><td>Drainage tube</td><td>Aiyuan</td><td>424280</td><td></td></tr><tr><td>Echelon Flex Powered Plus Articulating Endoscopic Linear Cutter and Endopath Echelon Endoscopic Linear Cutter Reloads with Gripping Surface Technology</td><td>Ethicon Endo-Surgery</td><td>ECR60G/GST60G</td><td></td></tr><tr><td>Energy Platform</td><td>COVIDIEN ForceTriad Energy Platform</td><td>T2131469EX</td><td></td></tr><tr><td>HARMONIC ACE Ultrasonic Surgical Devices</td><td>Ethicon Endo-Surgery</td><td>HAR36</td><td></td></tr><tr><td>Laparoscopic forceps</td><td>Gimmi</td><td></td><td></td></tr><tr><td>Laparoscopic right angle forceps</td><td>KARL STORZ</td><td></td><td></td></tr><tr><td>Laparoscopic scissors</td><td>AESCULAP</td><td></td><td></td></tr><tr><td>Latex T-shape Catheter</td><td>ZHANJIANG STAR ENTERPRISE CO., LTD.</td><td>24Fr</td><td></td></tr><tr><td>Ligating Clips</td><td>Teleflex Medical</td><td>5,44,22,05,44,23,05,44,000</td><td></td></tr><tr><td>PDSII</td><td>Ethicon, LLC</td><td>W9109</td><td></td></tr><tr><td>PROLENE</td><td>Ethicon, LLC</td><td>W8556</td><td></td></tr><tr><td>Trocar</td><td>Surgaid</td><td>NPCS-100-1-12</td><td></td></tr><tr><td>Ultrasonic Surgical &amp;amp; Electrosurgical Generator</td><td>Ethicon Endo-Surgery</td><td>GEN11CN</td><td></td></tr></tbody></table>

laparoscopic pancreatoduodenectomy for pancreatic cancer using in-situ no-touch isolation technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

A 55-year-old man with upper abdominal pain and marasmus was diagnosed with a 4.2 cm x 3.1 cm tumor in the uncinate process of the pancreas, and the SMV was involved over 180&#176; (Figure 5). The patient was previously healthy and had a relatively normal body mass index (19.47 kg/m2). No distant metastasis was found on the preoperative contrast-enhanced CT scan. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed to acquire the pathology diagnosis of adeno...

Watch this Scientific Journal Video about Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique at JoVE.com

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

laparoscopic-pancreatoduodenectomy-for-pancreatic-cancer-using-situ

Research

JoVE Journal

Medicine

1.9K Views.  The Second Affiliated Hospital of Guangzhou University of Chinese Medicine. No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Video: Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis.
The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index &#62;35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers.
The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy.
The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

Laparoscopic pancreatoduodenctomy (LPD) may offer advantages over open pancreatoduodenectomy, including early postoperative mobilization, less delayed gastric emptying and a shorter hospital stay. However, LPD is technically challenging and not well-standardized, especially regarding the pancreatic anastomosis. We describe a standardized technique for the pancreatic anastomosis during LPD: modified Blumgart pancreaticojejunostomy.

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal ...

Cancer Research

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer: Surgical Planning and Technique

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), relying on collateral flow to the liver through the gastroduodenal artery (GDA). In the current manuscript, the technical conduct of robotic DP-CAR is outlined. The greater curve of the stomach is mobilized with care to avoid sacrificing the gastroepiploic vessels. The stomach and liver are retracted cephalad to facilitate dissection of the porta hepatis. The hepatic artery (HA) is dissected and encircled with a vessel loop. The gastroduodenal artery (GDA) is carefully preserved. The common HA is clamped and triphasic flow in the proper HA via the GDA is confirmed using intra-operative ultrasound. A retropancreatic tunnel is made over the superior mesenteric vein (SMV). The pancreas is divided with an endovascular stapler at the neck. The inferior mesenteric vein (IMV) and splenic vein are ligated. The HA is stapled proximal to the GDA. The entire specimen is retracted laterally with further dissection cephalad to expose the superior mesenteric artery (SMA). The SMA is then traced back to the aorta. The dissection continues cephalad along the aorta with the bipolar energy device used to divide the crural fibers and celiac nerve plexus. The specimen is mobilized from the patient's right to left until the origin of the celiac axis is identified and oriented towards the left. The trunk is circumferentially dissected and stapled. Additional dissection with hook cautery and the bipolar energy device fully mobilizes the pancreatic tail and spleen. The specimen is removed from the left lower quadrant extraction site and one drain is left in the resection bed. A final intra-operative ultrasound of the proper HA confirms pulsatile, triphasic flow in the artery and liver parenchyma. The stomach is inspected for evidence of ischemia. Robotic DP-CAR is safe, feasible and when used in conjunction with multi-modality therapy, offers potential for long-term survival in selected patients.

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection DP-CAR for Pancreatic Cancer: Surgical Planning and Technique

We present our operative approach to robot assisted distal pancreatectomy, splenectomy, and celiac axis resection (DP-CAR), demonstrating that the procedure is safe and feasible with proper planning, patient selection, and surgeon experience.

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), ...

Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several studies have described the safety of RPD in case of a replaced or aberrant right hepatic artery, but detailed video descriptions of the approach are lacking. This case report describes a step-&#173;by-&#173;step technical video in case of a replaced right hepatic artery. A 58-year-old woman presented with an incidental finding of a 1.7 cm pancreatic head mass. RPD was performed using the da Vinci Xi system and involves a robotic-assisted pancreatico- and hepatico-jejunostomy and open gastro-jejunostomy at the specimen extraction site. The operation time was 410 min with 220 mL of blood loss. The patient had an uncomplicated postoperative course and was discharged after 5 days. Pathology revealed a pancreatic head cancer. RPD is a feasible and safe procedure in case of a replaced hepatic artery when performed in selected patients in high-volume centers by experienced surgeons.

Robotic pancreatoduodenctomy (RPD) has been highly standardized in recent years and may be used in selected patients with pancreatic head cancer, including those with a replaced right hepatic artery. This case report describes a standardized and reproducible technique for RPD, which includes the approach of the Dutch LAELAPS-3 training program to an aberrant vasculature.

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several ...

Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic remnants to reduce the severity of postoperative pancreatic fistulas and moreover the overall postoperative morbidity. This reconstruction technique is characterized by an extra-long jejunal loop for the construction of the pancreaticojejunostomy and hepaticojejunostomy. The longer distance between these anastomoses and an additional jejuno-jejunostomy between the afferent and efferent limb of the hepaticojejunostomy separate the fluids and prevent backflow of bile towards the pancreaticojejunostomy. Thus, the secretions cannot activate each other and aggravate an existing anastomotic leakage. We observed a reduced rate of severe postoperative pancreatic fistulas after modified single-loop reconstruction compared to conventional single loop reconstruction. The technique is easy to perform, safe, and less time-consuming than a traditional double-loop reconstruction.

The technique of modified single-loop reconstruction following pancreaticoduodenectomy separates pancreatic secretion from bile, thus reducing the severity of POPF without prolonging the duration of surgery.

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

Robotic lateral pancreaticojejunostomy (RLPJ) may be used in patients with painful, morphine dependent, chronic pancreatitis and a dilated main pancreatic duct. We describe a standardized and reproducible technique for RLPJ, which includes transection of the gastroduodenal artery.

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of the pancreas. The aim of central pancreatectomy is to prevent postoperative life-long endocrine and exocrine insufficiency. The downside of central pancreatectomy is the high rate of postoperative pancreatic fistula, which is the main reason that many surgeons do not routinely use central pancreatectomy in eligible patients. Most studies report open or laparoscopic central pancreatectomy with a pancreatico-gastrostomy anastomosis in adults. This is the first description of a standardized approach to robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy reconstruction in an adolescent (16-year-old boy) with a pseudopapillary tumor in the body of the pancreas. The operation time was 248 min with 20 mL of blood loss. The postoperative course was uneventful except for the short-term medical treatment for a grade B pancreatic fistula. Robotic central pancreatectomy can be safely applied in selected patients in experienced centers.

Robotic central pancreatectomy may be used in selected patients in experienced centers. This protocol presents all steps and the feasibility of a robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy in a 16-year-old adolescent patient.

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of ...

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.
The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who ...

Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy

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.

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 ...

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

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