It is very challenging to avoid positive surgical margins and incomplete lymph node dissection when a tumor is located in the uncinate process. This study introduces the management of the uncinate process in no-touch laparoscopic pancreaticoduodenectomy. The advantages of this strategy are to ensure the safe and complete excision of the uncinate process and mesopancreas based on a multi-angle arterial approach.
This technique possibly will improve the R-zero resection rate. To begin the surgical procedure, examine the peritoneal surfaces and intraperitoneal organs for potential extrapancreatic metastasis. Gain better exposure by removing the greater omentum.
Then sever the gastrocolic ligament to open the lesser sac. Using an ultrasonic knife, dissect the gallbladder triangle. Resect and sever the gallbladder artery and cystic duct.
Then remove the gallbladder and suspend the liver. To expose the hepatoduodenal ligament and hilum. Inspect the gap between the pancreatic neck and the superior mesenteric vein to assess the possibility of surgical resection.
Suspend the transverse colon and its mesentery on the cephalic side to establish adequate exposure. Using the ileocolonic artery as the marker, open the transverse mesocolon, protecting the ileocolonic and middle colonic artery. Expose the second and third segments of the duodenum.
Then, dissect along the right side of the superior mesenteric vein and separate the second and third segments of the duodenum from the transverse mesocolon. Expose the main trunk of the superior mesenteric vein and the proximal dorsal jejunal vein between the superior mesenteric vein and the superior mesenteric artery. Then, dissect the ligated inferior pancreaticoduodenal vein.
To perform the median anterior approach to the superior mesenteric artery, pull the superior mesenteric vein to the right and widen the operation field. Expose the superior mesenteric artery pulsation to determine its trajectory. Expose the right half of the superior mesenteric artery.
Then, dissect outside the arterial sheath of the superior mesenteric artery on the anterior right margin to separate it from the pancreatic mesopancreas. Next, expose the main branches of the inferior pancreaticoduodenal artery or jejunal artery along the right side of the superior mesenteric artery. To perform the left posterior approach.
Place the small bowel on the right side to create space between the fourth segment of the duodenum and the inferior vena cava. Then, dissect the fusion fascia to expose the left renal vein and establish the posterior space for the superior mesenteric artery. Using an ultrasonic scalpel, carefully dissect the ligament of Treitz between the beginning part of the jejunum and the mesentery of the transverse colon.
Then, use a stapler to divide the proximal jejunum. Next, place an FR8 catheter to suspend the dorsal sides of the superior mesenteric artery and the superior mesenteric vein. Pull the catheter to the upper right side to create an adequate exposure space at the left posterior aspect of the superior mesenteric artery.
This facilitates the artery dissection on its periadventitial plane on the anterior left border, and its detachment from the mesopancreas. Trace the superior mesenteric artery to the root along the first jejunal artery. Dissect the superior mesenteric artery on its periadventitial plane on the anterior left margin to separate it from the pancreatic mesopancreas.
Then, circumferentially dissect the superior mesenteric artery. Dissect the ligated inferior pancreaticoduodenal artery. If the first jejunal artery is involved in the tumor, sacrifice it.
Separate the superior mesenteric artery and superior mesenteric vein from the uncinate process and mesopancreas completely. To return to the superior colon region, draw the proximal jejunum from the dorsal of the superior mesenteric artery to the right. Using an ultrasonic knife, reveal the right gastrointestinal vein, the collateral right colonic vein, and the superior mesenteric vein trunk.
Next, expose Henle's gastrocolic trunk vein to disconnect its distal and proximal ends on the right side of the superior mesenteric vein trunk. Then, using a stapler device, divide the stomach three to five centimeters away from the pylorus. Expose the common hepatic artery at the superior margin of the pancreatic neck.
Dissect along the common hepatic artery towards the first hepatic hilum to reveal the proper hepatic artery and the right gastric artery. Then, sever the ligated right gastric artery. Using laparoscopic bulldog clamps, temporarily occlude the separated common bile duct.
Then, dissect the hepatoduodenal ligament. Execute a lymphadenectomy along the common hepatic artery, portal vein, and proper hepatic artery. Finally, dissect the ligated right gastric artery.
Next, locate the gastroduodenal artery at the junction of the proper hepatic artery and the common hepatic artery. Carefully tie the gastroduodenal artery with a 5-0 suture or ligation to reduce the risk of erosion or hemorrhage. Explore the tunnel between the pancreatic neck and the superior mesenteric vein.
Dissect the ligated dorsal pancreatic artery. Place two FR14 catheters to block the pancreatic neck blood supply to reduce bleeding. Using scissors, dissect the parenchyma of the pancreatic neck.
Suture the bleeding point of the resection surface with 5-0 sutures. After ligating and dissecting the left first branch of the superior mesenteric vein, suspend the splenic vein to establish exposure. Dissect the ligated uncinate process artery behind the splenic vein.
Then, identify and retain the alternative right hepatic artery originating from the superior mesenteric artery from the uncinate process artery. Finally, dissect the branches of the ligated portal vein. Using the Kocher maneuver, cut off the lymphatics and dissect the duodenum from the retroperitoneum.
Resect the tumor in situ and remove it en bloc following the oncologic principles of no-touch. Use the Childs method to reconstruct the digestive tract. Perform a single layer running suture hepaticojejunostomy from end to side using 4-0 absorbable sutures.
Then, use an internal stent to perform a duct-to-mucosal, end-to-side pancreaticojejunostomy A contrast-enhanced CT scan performed on a patient showed a tumor at the head and the uncinate process of the pancreas Histopathology results confirmed a pancreatic intraductal papillary mucinous neoplasm with focal moderately differentiated invasive adenocarcinoma. It is important to remember that the blood supply to the pancreatic head and duodenal region must be severed very early in the procedure. After that, the tumor can be isolated intact and resection can be performed in situ.
