Zimmitti Giuseppe, Manzoni Alberto, Addeo Pietro, Garatti Marco, Zaniboni Alberto, Bachellier Philippe, Rosso Edoardo
Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza of Brescia, Via Bissolati 57, Brescia, Italy.
Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
Surg Endosc. 2016 Apr;30(4):1670-1. doi: 10.1007/s00464-015-4359-7. Epub 2015 Jul 9.
Laparoscopic pancreatoduodenectomy (LPD) is a complex procedure. Critical steps are achieving a negative retroperitoneal margin and re-establishing pancreatoenteric continuity minimizing postoperative pancreatic leak risk. Aiming at increasing the rate of R0 resection during pancreatoduodenectomy, many experienced teams have recommended the superior mesenteric artery (SMA)-first approach, consisting in early identification of the SMA at its origin, with further resection guided by SMA anatomic course. We describe our technique of LPD with SMA-first approach and pancreatogastrostomy assisted by mini-laparotomy.
The video concerns a 77-year-old man undergoing our variant of LPD for a 2.5-cm pancreatic head mass. After kocherization, the SMA is identified above the left renocaval confluence and dissected-free from the surrounding tissue. Dissection of the posterior pancreatic aspect exposes the confluence between splenic vein, superior mesenteric vein (SMV), and portal vein. Following duodenal section, the common hepatic artery is dissected and the gastroduodenal artery sectioned at the origin. The first jejunal loop is divided, skeletonized, and passed behind the superior mesenteric vessel. Following pancreatic transection, the uncinate process is dissected from the SMV and the SMA is cleared from retroportal tissue rejoining the previously dissected plain. Laparoscopic choledocojejunostomy is followed by a mini-laparotomy-assisted pancreatogastrostomy, performed as previously described, and a terminolateral gastrojejeunostomy.
Twelve patients underwent our variant of LPD (July 2013-May 2015). Female/male ratio was 3:1, median age 65 years (range 57-79), median operation duration 590 min (580-690), intraoperative blood loss 150 cl (100-250). R0 resection rate was 100 %, and the median number of resected lymph nodes was 24 (22-28). Postoperative complications were grade II in two patients and IIIa in one. Median postoperative length of stay was 16 days (14-21).
LPD with SMA-first approach with pancreatogastrostomy assisted by a mini-laparotomy well combines the benefits of laparoscopy with low risk of postoperative complications and high rate of curative resection.
腹腔镜胰十二指肠切除术（LPD）是一项复杂的手术。关键步骤是获得阴性的腹膜后切缘以及重建胰肠连续性以尽量降低术后胰漏风险。为了提高胰十二指肠切除术中R0切除率，许多经验丰富的团队推荐采用肠系膜上动脉（SMA）优先入路，即早期在其起始部识别SMA，并以SMA的解剖走行为引导进行进一步切除。我们描述了采用SMA优先入路及经迷你剖腹术辅助的胰胃吻合术的LPD技术。
该视频展示了一名77岁男性因胰头肿块接受我们改良的LPD手术。经 Kocher 切口后，在左肾静脉与腔静脉汇合处上方识别SMA，并将其与周围组织游离。胰腺后方的解剖暴露脾静脉、肠系膜上静脉（SMV）和门静脉的汇合处。十二指肠切断后，解剖肝总动脉并在其起始部切断胃十二指肠动脉。切断第一段空肠袢，将其骨骼化并从肠系膜上血管后方穿过。胰腺横断后，将钩突从SMV分离，清除SMA后方门静脉组织，使其与先前解剖的平面相连。先行腹腔镜胆总管空肠吻合术，然后经迷你剖腹术辅助进行胰胃吻合术（按先前描述进行），最后行端侧胃空肠吻合术。
12例患者接受了我们改良的LPD手术（2013年7月至2015年5月）。男女比例为3:1，中位年龄65岁（范围57 - 79岁），中位手术时间590分钟（580 - 690分钟），术中失血150毫升（100 - 250毫升）。R0切除率为100%，切除淋巴结的中位数为24个（22 - 28个）。2例患者术后并发症为Ⅱ级，1例为Ⅲa级。术后中位住院时间为16天（14 - 21天）。
采用SMA优先入路及经迷你剖腹术辅助胰胃吻合术的LPD很好地结合了腹腔镜手术的优点，术后并发症风险低且根治性切除率高。
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