Gao W T, Xi C H, Tu M, Dai X L, Guo F, Chen J M, Wei J S, Lu Z P, Wu J L, Jiang K R, Miao Y
Pancreas Center, the First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China.
Zhonghua Wai Ke Za Zhi. 2017 May 1;55(5):359-363. doi: 10.3760/cma.j.issn.0529-5815.2017.05.010.
To explore the clinical effect of a novel artery first and uncinate process first approach for laparoscopic pancreaticoduodenectomy(LPD), emphasizing the left lateral and posterior dissection of uncinate process (UP) via Treitz ligament approach. From April to November 2016, 18 patients received LPD with a novel approach in Pancreas Center of the First Affiliated Hospital with Nanjing Medical University. All patients were diagnosed as pancreatic head or peri-ampulla tumor, without major vessel invasion nor distant metastasis. For resection, routine caudal view was used in the first step, to dissect the anterior medial border between uncinate process and superior mesenteric vein(SMV). Lymphatic tissues were completely dissected form anterior surface of hepatoduodenal ligament. In the second step, left lateral view with camera from left para-umbilical trocar was used, Treitz ligament was incised, SMA root was exposed. After anticlockwise rotation and retraction of mesentery, the anatomic relationship between SMA trunk, inferior pancreaticoduodenal artery(IPDA), jejunal branch of SMV, and distal part of UP, could be perfectly exposed from left lateral view. SMA was dissected from its root until the position above the uncinate process and duodenum, IPDA was transected, distal part of UP was freed from SMA. In the third step, right lateral view and caudal view were alternatively used; proximal UP mesentery was completely dissected out from SMA root, CA root and posterior surface of hepatoduodenal ligament. Pancreaticoduodenectomy was completed in the forth step after transection of pancreatic neck and common hepatic duct. The SMA root and distal UP were successfully dissected out via Treitz ligament approach in all 18 patients, among them, distal UP was completely excised in 8 patients from left view. Postoperative pathology showed R0 resection rate in 69%. Postoperative complication included intra-abdominal hemorrhage in 1 patient, pancreatic fistula in 7 patients(6 cases with grade A and 1 case with grade B), delayed gastric emptying in 4 patients (2 cases with grade A, 2 cases with grade B). Average postoperative hospital stay was (15.5±6.8)days. The novel artery first and uncinate process first approach through Treitz ligament could help surgeons to completely dissect the full length of meso-pancreas along celiac axis-SMA axis in LPD.
探讨一种新型的先行动脉及先行钩突的腹腔镜胰十二指肠切除术（LPD）的临床效果，强调经Treitz韧带入路对钩突（UP）进行左侧及后方的解剖。2016年4月至11月，南京医科大学第一附属医院胰腺中心18例患者接受了采用该新型术式的LPD。所有患者均诊断为胰头或壶腹周围肿瘤，无大血管侵犯及远处转移。切除时，第一步采用常规尾侧视野，解剖钩突与肠系膜上静脉（SMV）之间的前内侧边界，从肝十二指肠韧带前表面完全清扫淋巴组织。第二步，使用来自左脐旁套管针的摄像头的左侧视野，切开Treitz韧带，暴露肠系膜上动脉（SMA）根部。肠系膜逆时针旋转并牵拉后，从左侧视野可完美暴露SMA主干、胰十二指肠下动脉（IPDA）、SMV的空肠支与UP远端之间的解剖关系。从SMA根部开始解剖SMA直至钩突和十二指肠上方位置，切断IPDA，将UP远端从SMA游离。第三步，交替使用右侧视野和尾侧视野；从SMA根部、肝总动脉根部及肝十二指肠韧带后表面完全清扫近端UP系膜。第四步，横断胰颈和肝总管后完成胰十二指肠切除术。18例患者均通过Treitz韧带入路成功解剖出SMA根部和UP远端，其中8例从左侧视野完全切除UP远端。术后病理显示R0切除率为69%。术后并发症包括1例腹腔内出血，7例胰瘘（6例为A级，1例为B级），4例胃排空延迟（2例为A级，2例为B级）。术后平均住院时间为（15.5±6.8）天。经Treitz韧带的新型先行动脉及先行钩突入路有助于外科医生在LPD中沿腹腔干-SMA轴完全解剖中胰的全长。
