Department of Digestive Pathology, Institute Mutualiste Montsouris, Paris Descartes University, Paris, France.
Ann Surg Oncol. 2013 Sep;20(9):3120. doi: 10.1245/s10434-013-3058-7. Epub 2013 Jun 21.
Laparoscopic pancreaticoduodenectomy (PD) has become more popular despite its complexity and tendency for higher morbidity.1 Replaced right hepatic artery (RRHA) and replaced common hepatic artery (RCHA), both originating from the superior mesenteric artery (SMA), are the most significant and relatively common vascular anomalies in patients undergoing PD, occurring in 8.6-21 and 0.4-4.5% of cases, respectively.2,3 An inadvertent injury to theses arteries may result in an intra- or postoperative bleeding, hepatic or bile duct ischemia, and consequent leakage or delayed stricture in the bilioenteric anastomosis.2-4 Therefore, preservation of these aberrant hepatic arteries is essential unless their resection is oncologically indicated.2 We describe a posterior approach that can be advantageous in laparoscopic PD for patients with a RRHA or RCHA.
The posterior approach was used in 81 laparoscopic PDs at the Institute Mutualiste Montsouris between 1994 and 2012.5 In brief, retropancreatic dissection is performed to complete kocherization and expose the posterolateral aspect of the SMA. The origin of the RRHA or RCHA can then be identified and dissected. After division of the pancreatic neck, the portal vein and RRHA or RCHA are separated off the pancreatic neck. In case of the RCHA, the gastroduodenal artery originating from the RCHA is divided during this dissection.
The video shows a secure procedure to preserve a RCHA in laparoscopic PD by early identification and dissection of the aberrant artery via the posterior approach.
The posterior approach can help to prevent inadvertent RRHA or RCHA injury in laparoscopic PD.
尽管腹腔镜胰十二指肠切除术（PD）较为复杂且发病率较高，但它已变得更为流行。1 在接受 PD 的患者中，最显著且相对常见的血管异常为替代右肝动脉（RRHA）和替代肝总动脉（RCHA），它们均发自肠系膜上动脉（SMA），发生率分别为 8.6-21%和 0.4-4.5%。2,3 这些动脉的意外损伤可能导致术中或术后出血、肝或胆管缺血，并导致胆肠吻合口漏或延迟狭窄。2-4 因此，除非这些异常动脉具有明确的肿瘤学切除指征，否则保留这些动脉至关重要。2 我们描述了一种在后腹腔镜 PD 中对 RRHA 或 RCHA 患者有利的后入路方法。
1994 年至 2012 年，在 Mutualiste Montsouris 研究所共进行了 81 例腹腔镜 PD，采用后入路。5 简而言之，行胰后解剖以完成 Kocher 化并显露 SMA 的后外侧。然后可以识别和解剖 RRHA 或 RCHA 的起源。切断胰颈后，门静脉和 RRHA 或 RCHA 与胰颈分离。如果存在 RCHA，则在这一解剖过程中需要切断源自 RCHA 的胃十二指肠动脉。
视频展示了一种通过后入路早期识别和解剖异常动脉，以安全保留 RCHA 的腹腔镜 PD 术式。
在后腹腔镜 PD 中，后入路有助于防止意外损伤 RRHA 或 RCHA。
