Total laparoscopic radical antegrade modular pancreato-splenectomy with left-posterior superior mesenteric artery first-approach for distal pancreatic cancer: step-by-step technique with a surgical case report (with video).

INTRODUCTION

Left-sided pancreatic cancers are uncommon but seem more aggressive than tumors of pancreatic head. Radical antegrade modular pancreato-splenectomy (RAMPS) was proved to have safe and effective advantages while comparing with standard retrograde pancreato-splenectomy (SRPS) in recent systematic literature reviews and meta-analyses. Laparoscopic SMA first-approach RAMPS was recently proceeded with optimistic perioperative outcomes.

CASE PRESENTATION

Our patient is a 67-year-old female with a medical history of diabetes and hypertension, recruited because of upper left quadrant abdominal pain. She was referred for pancreato-splenectomy because of a 3-cm-sized mass in distal pancreas. We use 5 trocars and the patient placed in a Trendelenburg position. The retroperitoneum is opened at the left-posterior side of the meso-pancreato-duodenum along to the inframesocolic space, so that the anterior surface of the aorta (AO), inferior vena cave (IVC), left renal vein (LRV), left adrenal grand (LAG), and kidney are completely exposed. The inferior border of the pancreas had been dissected and separated from the superior mesenteric vein (SMV) below the pancreatic isthmus, removed the lymph nodes (LNs) groups 14v and 17. Then, dissect of LNs groups 7,8,9,11p,12 en bloc at the superior side of the pancreas. Dissection of LNs group 14p, d or SMA LNs after transecting the pancreas. The operation time was 240 min, the estimated blood loss was 200 ml. With no postoperative complications as well as no diarrhea, the patient was discharged on the POD10 uneventfully. Pathological result: pancreatic ductal adenocarcinoma with T2N1 staging and negative margin (R0).

CONCLUSIONS

This technique was safe and effective to perform precise and complete lymphadenectomy and negative posterior resection in total laparoscopic left-posterior SMA first-approach RAMPS for distal pancreatic cancer.