Total Laparoscopic Pancreaticoduodenectomy with Left Posterior Superior Mesenteric Artery First-Approach and Plexus-Preserving Circumferential Lymphadenectomy: A Surgical Case Report (With Video)

Abstract

Introduction: Total laparoscopic pancreaticoduodenectomy (tLPD) for cancer of Vater remains a challenging procedure. Recently, several meta-analyses showed the superior aspects of “Superior Mesenteric Artery (SMA)-first approach”, “Systematic mesopanreas dissection” and “Circumferential lymphadenectomy around SMA” in increasing R0-resection rate and reducing postoperative complications including pancreatic fistula and bleeding as well as improving overall survival particularly. Case presentation: Our patient is a 70-year-old female with a no special medical history, recruited because of jaundice. She was referred for pancreaticoduodenectomy because of a 10mm-sized mass in distal bile duct referred to Vater’s tumor. We use 5 trocars and the patient placed in a Trendelenburg position. The transverse colon was lifted, the first loop of the jejunum was pulled to the left, the lymph nodes groups 14th and 15th were removed en bloc and then exposed the SMA from the anterior to the left posterior side from the caudal side to the origin. The first jejunal vessels and the posterior inferior pancreaticoduodenal artery were ligated and extensive mobility of the duodenum and head of the pancreas from the left side. The systematic mesopancreas dissection from the right site of the SMA will be easily and conveniently done afterwards. Histopathological examination of ypT2N1 indicated that 1 of the 22 lymph nodes was positive, that was 1 of 7 LNs No. 14. Pathological results showed a Vater adenocarcinoma with all margins being negative. Conclusions This technique was safe and effective to perform precise level-2 mesopancreas dissection and complete lymphadenectomy around SMA without dissection of pl-SMA in laparoscopic field.