Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
Surg Endosc. 2018 Sep;32(9):4044-4051. doi: 10.1007/s00464-018-6118-z. Epub 2018 Feb 26.
Although the artery-first approach is widely used in open pancreaticoduodenectomy, it is difficult to laparoscopically expose the origin of the inferior pancreaticoduodenal artery (IPDA) from the left side of the superior mesenteric artery (SMA). By contrast, damaging the inferior pancreaticoduodenal veins (IPDVs) is possible when approaching the IPDA from the right side of the SMA. To facilitate the artery-first approach in laparoscopic pancreaticoduodenectomy (LPD), we focused on the proximal-dorsal jejunal vein (PDJV) that branched from the superior mesenteric vein (SMV) dorsal side and drained the IPDVs. This study aimed to clarify the usefulness of the right SMA approach using the PDJV preisolation method.
The PDJV was first isolated, and the IPDVs were divided along the PDJV on the right side of the SMA. Then, the IPDA was divided at the root without first separating the pancreatic head from the portal vein and the SMV. Overall, 21 patients underwent this approach, and the results were retrospectively compared with those of 21 patients who underwent the artery-first approach, which was performed on the left side of the SMA. Anatomical characteristics of the PDJV were evaluated using multidetector computed tomography for the two groups.
Operative times and resection times were significantly lower for the PDJV preisolation group than for the conventional LPD group (489.3 vs. 541.7 min, respectively; p = 0.002). During anatomical evaluation, 41 patients (97.6%) had a PDJV that drained from the SMV dorsally and was in contact with the anterior aspect of the uncinate process. The PDJV was confirmed as the first jejunal vein in 31 patients (73.8%) and as the second jejunal vein in 10 patients (23.8%).
This approach facilitates dissection of the IPDA on the right side of the SMA, thereby reducing operative times.
尽管动脉优先方法在开放胰十二指肠切除术（open pancreaticoduodenectomy）中被广泛应用，但在腹腔镜下从肠系膜上动脉（superior mesenteric artery，SMA）左侧暴露胰十二指肠下动脉（inferior pancreaticoduodenal artery，IPDA）较为困难。相比之下，从 SMA 右侧接近 IPDA 时可能会损伤胰十二指肠下静脉（inferior pancreaticoduodenal veins，IPDVs）。为了便于腹腔镜胰十二指肠切除术（laparoscopic pancreaticoduodenectomy，LPD）中的动脉优先方法，我们专注于发自肠系膜上静脉（superior mesenteric vein，SMV）背侧并引流 IPDVs 的近端背侧空肠静脉（proximal-dorsal jejunal vein，PDJV）。本研究旨在阐明使用 PDJV 预隔离法进行右 SMA 入路的有效性。
首先分离 PDJV，并沿着 SMA 右侧的 PDJV 分离 IPDVs。然后，在不首先将胰头与门静脉和 SMV 分开的情况下，在根部分离 IPDA。共有 21 例患者接受了这种方法，回顾性比较了 21 例接受 SMA 左侧动脉优先方法的患者的结果。对两组患者的 PDJV 解剖结构特征使用多排螺旋 CT 进行了评估。
PDJV 预分离组的手术时间和切除时间明显短于常规 LPD 组（分别为 489.3 分钟和 541.7 分钟；p=0.002）。在解剖学评估中，41 例患者（97.6%）的 PDJV 从 SMV 背侧引流，与钩突的前侧接触。31 例患者（73.8%）的 PDJV 被确认为第一空肠静脉，10 例患者（23.8%）的 PDJV 被确认为第二空肠静脉。
该方法有利于在 SMA 右侧解剖分离 IPDA，从而缩短手术时间。
