Katsumata Kaori, Kim Michael P, Maxwell Jessica E, Snyder Rebecca A, Cao Hop S Tran, Tzeng Ching-Wei D, Katz Matthew H G, Ikoma Naruhiko
Department of Surgery, National Hospital Organisation Tokyo Medical Center, Tokyo, Japan.
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Ann Surg Oncol. 2025 Jun 25. doi: 10.1245/s10434-025-17707-w.
Robotic pancreatoduodenectomy (RPD) has been increasingly performed, but maintaining oncological operative standards and safety remains challenging. An aberrant hepatic artery originating from the superior mesenteric artery (SMA), most commonly seen as a replaced right hepatic artery (rRHA), is present in approximately 16% of patients with pancreatoduodenal malignancies. The presence of the rRHA is a known risk factor for technically challenging RPD, and injury to this artery increases the risk of postoperative complications. Therefore, thorough preoperative review of CT images is essential. We demonstrate our approach to RPD with particular attention to oncologic proximal SMA dissection in a patient with an rRHA.
A 77-year-old White woman with cT3N1M0 distal bile duct cancer and an rRHA originating from the SMA underwent RPD. Preoperative CT images showed lymphadenopathy in the posterior hepatic artery station and the presence of the rRHA, necessitating careful intraoperative dissection. The procedure began with identifying and encircling the distal portion of the rRHA. Following pancreatic division, the superior mesenteric vein was retracted to expose the SMA. The rRHA was identified, and a precise periadventitial dissection of the SMA was performed, completing en bloc resection.
The patient was discharged 8 days after surgery. Pathology revealed a 3.7-cm poorly differentiated adenocarcinoma (pT3N2) with 5 of 34 lymph nodes positive. All margins were negative.
Patients undergoing RPD often have an aberrant hepatic artery from the SMA. Preserving this artery while performing adequate en-bloc lymph node dissection is important for optimal outcomes.
机器人胰十二指肠切除术（RPD）的开展越来越多，但维持肿瘤手术标准和安全性仍具有挑战性。起源于肠系膜上动脉（SMA）的异常肝动脉，最常见的是替代右肝动脉（rRHA），在约16%的胰十二指肠恶性肿瘤患者中存在。rRHA的存在是RPD技术上具有挑战性的已知危险因素，该动脉损伤会增加术后并发症的风险。因此，术前对CT图像进行全面评估至关重要。我们展示了在一名有rRHA的患者中进行RPD的方法，特别关注肿瘤学上的近端SMA解剖。
一名77岁白人女性，患有cT3N1M0远端胆管癌，并有一条起源于SMA的rRHA，接受了RPD。术前CT图像显示肝动脉后站有淋巴结肿大以及rRHA的存在，这需要在术中仔细解剖。手术开始时识别并环绕rRHA的远端部分。在胰腺离断后，将肠系膜上静脉牵开以暴露SMA。识别出rRHA，并对SMA进行精确的外膜周围解剖，完成整块切除。
患者术后8天出院。病理显示为一个3.7cm的低分化腺癌（pT3N2），34个淋巴结中有5个阳性。所有切缘均为阴性。
接受RPD的患者常存在来自SMA的异常肝动脉。在进行充分的整块淋巴结清扫时保留该动脉对获得最佳结果很重要。
