Department of Surgery, Istituto Fondazione Poliambulanza, Bissolati no 57, 25124, Brescia, Italy.
Surg Endosc. 2019 Dec;33(12):4186-4191. doi: 10.1007/s00464-019-06994-6. Epub 2019 Jul 22.
The prognosis of patients affected by pancreatic adenocarcinoma and periampullary tumors is dismal, mainly due to aggressive tumor biology and low rate of resectability at the diagnosis. Among resectable patients, the quality of surgical resection, with a particular focus on the complete resection of the retropancreatic tissue (the so-called "mesopancreas") encircling the superior mesenteric artery (SMA), has a cardinal role. With this assumption, many pancreatic surgeons recommend periadventitial dissection of the SMA in order to obtain a total mesopancreas excision (TMpE), maximizing surgical margin and minimizing R1 resection rate.
To introduce our approaches for periadventitial dissection of the SMA, tailored to patient and tumor characteristics and aiming at obtaining a TMpE, during laparoscopic pancreatoduodenectomy (LPD).
Three different approaches for the SMA periadventitial dissection during LPD are described: the right, the right-left, and the anterior SMA-first approach. Indications, advantages, and technical aspects of each technique are reported, as well as pathologic results, particularly focusing on resection margin status and removed lymphnodes number, safety, and feasibility.
Overall, R0 rate and number of lymphnodes retrieved were 86% and 26, respectively, without significant differences according to the SMA approach performed. Rate of conversion to laparotomy due to intraoperative bleeding during SMA dissection step was 6% (3/48) among patients who underwent the right SMA approach and nil among remaining patients.
During LPD, a tailored approach for periadventitial dissection of SMA makes TMpE feasible, safe, and oncologic valid, when performed by a team experienced with mininvasive approach and pancreatic surgery.
胰腺腺癌和壶腹周围肿瘤患者的预后较差，主要是由于肿瘤具有侵袭性生物学特性，且诊断时的可切除率较低。在可切除的患者中，手术切除的质量，特别是围绕肠系膜上动脉（SMA）的胰腺后组织（所谓的“肠系膜”）的完全切除，具有重要作用。基于这一假设，许多胰腺外科医生建议对 SMA 进行 adventitial 解剖，以获得总肠系膜切除（TMpE），最大限度地提高手术切缘并最大限度地降低 R1 切除率。
介绍我们在腹腔镜胰十二指肠切除术（LPD）中针对患者和肿瘤特征进行 SMA adventitial 解剖的方法，旨在获得 TMpE。
描述了 LPD 中 SMA adventitial 解剖的三种不同方法：右侧、右-左和前 SMA 优先方法。报告了每种技术的适应证、优点和技术方面，以及病理结果，特别是重点关注切缘状态和切除的淋巴结数量、安全性和可行性。
总体而言，R0 率和淋巴结检出数分别为 86%和 26，根据所采用的 SMA 方法，无显著差异。在接受右侧 SMA 方法的患者中，由于 SMA 解剖步骤中的术中出血而转为剖腹手术的发生率为 6%（3/48），而其余患者则为零。
在 LPD 中，当由经验丰富的微创方法和胰腺手术团队进行时，针对 SMA adventitial 解剖的个体化方法可使 TMpE 可行、安全且具有肿瘤学有效性。
