Garnier Jonathan, Javed Ammar A, Sacks Greg D, Marchetti Alessio, Andel Paul C M, Garg Karan, Salinas Camila Hidalgo, Morgan Katherine A, Wolfgang Christopher L, Hewitts D Brock
Division of Hepatobiliary and Pancreatic Surgery, NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA.
Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France.
Ann Surg Oncol. 2025 May;32(5):3578-3581. doi: 10.1245/s10434-025-16943-4. Epub 2025 Feb 7.
En-bloc celiac axis resection (CAR) was first proposed by Lyon H. Appleby in 1952 for gastric cancer and later modified for pancreatic resections with gastric preservation by Nimura et al. in 1976. CAR remains uncommon, performed in fewer than 0.2 cases annually. Advancements in preoperative imaging and anatomy understanding, ischemic complication management, and centralization of care have improved outcomes. This report presents a robotic distal pancreatectomy (DP) with CAR and superior mesenteric artery (SMA) divestment.
A 65-year-old woman presented with back pain. Imaging revealed biopsy-proven pancreatic adenocarcinoma in the pancreatic body, encasing the celiac, splenic, and common hepatic arteries with SMA abutment. Following four cycles of neoadjuvant FOLFIRINOX, follow-up imaging demonstrated stable disease without metastasis. The need for hepatic artery reconstruction was assessed intraoperatively, with alternative strategies detailed in the accompanying video.
The patient underwent a distal pancreatectomy and splenectomy with class Ia CAR. Surgery was conducted in a caudal approach, lasted 420 minutes with minimal blood loss (100 ml). Laparoscopic ultrasound (lapUS) and indocyanine green (ICG) perfusion were used to assess resectability, vascular perfusion, and targeted blood vessels. The postoperative course was uneventful, except for a Grade B chyle leak managed conservatively. No liver or gastric ischemia occurred. Adjuvant chemotherapy was initiated two months postoperatively.
Enhanced visualization, improved dexterity, and adjuncts including lapUS and ICG are potential benefits that are available to surgeons with the robotic platform when performing arterial divestment and CAR via a caudal approach.
整块腹腔干切除术（CAR）于1952年由里昂·H·阿普尔比首次提出用于胃癌治疗，1976年由二村等人对其进行改良，用于保留胃的胰腺切除术。CAR仍然不常见，每年实施病例少于0.2例。术前影像学和解剖学认识的进步、缺血性并发症管理以及医疗的集中化改善了治疗效果。本报告介绍了一例机器人辅助下远端胰腺切除术（DP）联合CAR及肠系膜上动脉（SMA）剥离术。
一名65岁女性因背痛就诊。影像学检查显示经活检证实为胰体部胰腺腺癌，包绕腹腔干、脾动脉和肝总动脉，与SMA相邻。在接受四个周期的新辅助FOLFIRINOX治疗后，随访影像学检查显示病情稳定，无转移。术中评估了肝动脉重建的必要性，并在随附视频中详细介绍了替代策略。
患者接受了Ia类CAR的远端胰腺切除术和脾切除术。手术采用尾侧入路，持续420分钟，失血极少（100毫升）。使用腹腔镜超声（lapUS）和吲哚菁绿（ICG）灌注评估可切除性、血管灌注和目标血管。术后病程顺利，除了保守处理的B级乳糜漏。未发生肝脏或胃缺血。术后两个月开始辅助化疗。
增强的可视化、提高的灵活性以及包括lapUS和ICG在内的辅助手段，是外科医生在通过尾侧入路进行动脉剥离和CAR时，利用机器人平台可获得的潜在益处。
