Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.
Ann Surg Oncol. 2019 Dec;26(13):4464-4465. doi: 10.1245/s10434-019-07789-8. Epub 2019 Sep 9.
Pancreatic cancer (PC) has serious malignant potential, thus requiring complete resection and adequate regional lymphadenectomy with tumor-free margins.1,2 A standard laparoscopic distal pancreatectomy (LDP) procedure for PC is not yet established due to lack of supportive evidence.36 METHODS: In our hospital, we first administered neoadjuvant chemoradiotherapy for resectable PC. Considering the benefits offered by a laparoscopic magnified caudo-dorsal view, we devised and standardized an LDP procedure for PC, which we employed in five patients with left-sided resectable tumors. First, the retroperitoneum was incised between the proximal jejunum and the inferior mesenteric vein with the transverse colon pushed up ventrally and cranially and with the proximal jejunum moved to the right. Then, the left renal vein (LRV) could be easily identified at this site. The retroperitoneal tissue was dissected along the LRV, and the origin of the superior mesenteric artery (SMA) also was identified just above the LRV easily. The left adrenal gland was removed to secure the dorsal margin, if needed. The retroperitoneal dissection was continued along the major anatomical landmarks, including the LRV, the left renal artery, the left kidney, and the crus of the diaphragm beside the origin of the SMA. Using the same operative field, lymphadenectomy around the SMA was performed before dividing the pancreas. We could safely and easily expose the left aspect of the SMA after dissecting the ligament of Treitz. The dissection around the SMA was performed toward the side of the arterial root that had already been exposed above the LRV. Thus, the most important difficult steps of LDP for PC, such as retroperitoneal dissection and lymphadenectomy around the SMA, were safely performed early in the operation with a good laparoscopic view.
The median operative time was 341 (range 288-354) minutes, and median blood loss was 150 (range 50-150) ml. An intraoperative transfusion was not required for any patient. Severe postoperative complications or mortality were absent. An R0 resection was achieved in all patients.
LDP using the "caudo-dorsal artery first approach" is safe and useful for performing a minimally invasive, curative resection for left-sided PC.
胰腺癌（PC）具有严重的恶性潜能，因此需要完整切除并进行充分的区域淋巴结清扫，以确保切缘无肿瘤。1,2 由于缺乏支持性证据，目前尚未建立标准的腹腔镜胰尾部切除术（LDP）用于 PC。36 方法：我院对可切除 PC 患者首先进行新辅助放化疗。考虑到腹腔镜放大的背侧视图带来的益处，我们设计并标准化了一种用于 PC 的 LDP 手术，在 5 例左侧可切除肿瘤的患者中应用该手术。首先，在横结肠向上和向头侧推挤的情况下，于空肠近端和肠系膜下静脉之间切开后腹膜，将空肠近端移至右侧。然后，在此处可轻易识别左肾静脉（LRV）。沿 LRV 解剖腹膜后组织，也可轻易地在 LRV 上方识别出肠系膜上动脉（SMA）的起源。如果需要，切除左肾上腺以确保背侧切缘。沿主要解剖标志继续进行腹膜后解剖，包括 LRV、左肾动脉、左肾和 SMA 起源处旁的膈肌脚。使用相同的手术视野，在胰腺分离前进行 SMA 周围淋巴结清扫。在解剖Treitz 韧带后，可以安全且轻松地暴露 SMA 的左侧。沿 SMA 进行解剖，朝向已在 LRV 上方暴露的动脉根侧。因此，在手术早期即可使用良好的腹腔镜视野，安全且轻松地完成 LDP 治疗 PC 的最重要的困难步骤，如腹膜后解剖和 SMA 周围淋巴结清扫。
中位手术时间为 341 分钟（范围 288-354 分钟），中位出血量为 150 毫升（范围 50-150 毫升）。所有患者均无需术中输血。无严重术后并发症或死亡。所有患者均达到 R0 切除。
采用“背侧动脉优先法”的 LDP 安全且有助于对左侧 PC 进行微创、根治性切除。
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