Name: management of the uncinate process in no-touch laparoscopic pancreaticoduodenectomy
Uploaded: 2023-05-05T12:20:00.000+00:00
Duration: 9 min 32 s
Description: Watch this Scientific Journal Video about Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy at JoVE.com

Our article #64904 was supported by the Research project of Traditional Chinese Medicine Bureau of Guangdong Province (ID:20222077).

This study was approved by the Ethics Committee of the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, and informed written consent was obtained from the patients involved in this study.
1. Preoperative work-up
<ol>
	<li>Perform the high-resolution contrast-enhanced CT12,13 (see Table of Materials) to assess the tumor&#39;s extent and search for any abnormal vasculature.</li>
	<li>Determine the inclusion and exclusion criteria for patients.
	<ol>
		<li>Select patients meeting the following criteria: (1) a tumor located in the uncinate process that needs radical resection; (2) resectable cases.</li>
		<li>Exclude the following cases: (1) metastatic tumor; (2) patients with poor cardio-pulmonary function that may not tolerate laparoscopic surgery; (3) a tumor that has invaded the major vessels such as SMA, common hepatic artery (CHA), or celiac artery (CA).</li>
	</ol>
	</li>
</ol>
2. Anesthetization steps
<ol>
	<li>Use 0.3 &#181;g/kg sufentanil, 3 &#181;g/mL propofol, and 0.15 mg/kg cis-atracurium (see Table of Materials) for anesthesia induction.</li>
	<li>Perform endotracheal intubation14 after the muscle relaxant takes effect.</li>
	<li>Puncture and catheterize the radial artery and central vein under the guidance of ultrasound.</li>
	<li>Use target-controlled infusion (TCI) of 1-2 &#181;g/mL propofol, 1-3 ng/mL remifentanil, 1.53 &#181;g/kg/min cis-atracurium, and sevoflurane (see Table of Materials) with an inhaled concentration of 1%-2% to maintain anesthesia, and keep the depth of anesthesia between 37 and 64 on the Nacrotrend Index15. 
	NOTE: The Nacrotrend anesthesia monitoring system (see Table of Materials) is an anesthesia depth monitoring method developed in recent years. It obtains the original EEG, analyzes the changes in frequency and power in the EEG, integrates the factors of phase and harmonics, and expresses the anesthesia depth in the form of a value from 0-99.</li>
	<li>Set the ventilator parameters to volume control ventilation mode, with a tidal volume of 8 mL/kg, an inhalation oxygen saturation of 60%, a gas flow of 2 L/min, and an end-expiratory carbon dioxide range of 35-45 mmHg.</li>
</ol>
3. Installation
<ol>
	<li>Refer to our previously published8 article (Figure 1) for details on the patient position and trocar (see Table of Materials) location.</li>
	<li>Surgeon position: Ensure that the operator surgeon and the first assistant stand on the patient&#39;s right and left sides, respectively. Ensure that the holder of the laparoscope stands between the patient&#39;s legs.</li>
</ol>
4. Surgery techniques
<ol>
	<li>Inspect the peritoneal surfaces and intraperitoneal organs for any potential extrapancreatic metastases. Remove the greater omentum for better exposure, and open the lesser sac by severing the gastrocolic ligament.</li>
	<li>Dissect the gallbladder triangle with an ultrasonic knife, then resect and sever the gallbladder artery and cystic duct, and finally, remove the gallbladder, and suspend the liver to expose the hepatoduodenal ligament and hilum (Figure 2).</li>
	<li>Explore the gap between the pancreatic neck and the SMV in order to assess the surgical resectability. 
	NOTE: The preferred gap is the space between the posterior neck of the pancreas and the SMV, which is difficult to open and expose if the tumor has invaded the SMV.</li>
	<li>Suspend the transverse colon and its mesentery on the cephalic side to establish effective exposure.</li>
	<li>Using the ileocolonic artery as the marker, open the transverse mesocolon. Protect the ileocolon artery and middle colonic artery.</li>
	<li>Expose the second and third segments of the duodenum, dissect along the right side of the SMV, and separate the second and third segments of the duodenum from the transverse mesocolon.</li>
	<li>Expose the main trunk of SMV and the proximal-dorsal jejunal vein (PDJV) between the SMV and SMA (Figure 3), and then ligate and dissect the inferior pancreaticoduodenal vein (IPDV). 
	NOTE: Be careful not to apply too much pressure, as this might cause the IPDV to hemorrhage.</li>
	<li>Perform the median-anterior approach to the SMA following steps 4.8.1-4.8.4.
	<ol>
		<li>Start the median-anterior approach to the SMA from the inferior colon region.</li>
		<li>Pull the SMV just to the right, widen the operation field, and expose the SMA pulsation to determine its trajectory.</li>
		<li>Expose the right half of the SMA, and dissect outside the arterial sheath of the SMA on the anterior-right margin in order to separate the SMA from the pancreatic mesopancreas. 
		NOTE: The middle colonic artery (MCA), which runs along the side of the vascular arch of the margin of the transverse mesocolon, can be directly linked to the trunk of the SMA in cases where it is difficult to identify the SMA, such as when it is difficult to assess arterial visual pulsation in obese patients. The best place to locate and identify the trunk of the SMA is where the MCA begins in the inferior colonic region. If required, color ultrasound assistance could be used.</li>
		<li>Through the median-anterior approach to the SMA approach, expose the main branches of the IPDA or jejunal artery (JA) along the right side of the SMA, and then conduct a further follow-up to confirm them (Figure 4). 
		NOTE: The authors&#39; experience is that IPDA and JA can be effectively identified by the subsequent left-posterior approach to the SMA.</li>
	</ol>
	</li>
	<li>Perform the left-posterior approach to the SMA following steps 4.9.1-4.9.9.
	<ol>
		<li>Place the entire small bowel to the right side to facilitate space exposure between the fourth segment of the duodenum and the inferior vena cava.</li>
		<li>Dissect the fusion fascia, and expose the left renal vein (LRV) to establish the posterior space of the SMA.</li>
		<li>Use an ultrasonic scalpel to dissect the ligament of Treitz between the beginning part of the jejunum and the mesentery of the transverse colon.</li>
		<li>Use a stapler to divide the proximal jejunum.</li>
		<li>Place an Fr8 catheter for suspending the dorsal sides of the SMA and SMV.</li>
		<li>To facilitate SMA dissection on its periadventitial plane on the anterior-left border and its detachment from the mesopancreas, pull the catheter to the upper right side. Establish an effective exposure space at the left-posterior aspect of the SMA (Figure 5).</li>
		<li>Trace up the SMA to the root along the first jejunal artery (FJA).</li>
		<li>Dissect the SMA on its periadventitial plane on the anterior-left margin in order to separate it from the pancreatic mesopancreas. Circumferentially dissect the SMA.</li>
		<li>Ligate and dissect the IPDA (Figure 6). Sacrifice the FJA if it is involved in the tumor.</li>
	</ol>
	</li>
	<li>Using the median-anterior and left-posterior SMA approaches, separate the SMA and SMV from the uncinate process and mesopancreas completely (Figure 7).</li>
	<li>Return to the superior region of the colon following steps 4.11.1-4.11.16.
	<ol>
		<li>Draw the proximal jejunum from the dorsal of the SMA to the right.</li>
		<li>Reveal the right gastrointestinal vein, the collateral right colonic vein, and the SMV trunk using an ultrasonic knife (see Table of Materials).</li>
		<li>Expose Henle&#39;s gastrocolic trunk vein to disconnect its distal and proximal ends on the right side of the SMV trunk. 
		NOTE:Find Henle&#39;s gastrocolic trunk vein along the right reticular vein on the right side of the SMV.</li>
		<li>Divide the stomach 3-5 cm away from the pylorus using a stapler device (see Table of Materials).</li>
		<li>Expose the CHA at the superior margin of the pancreatic neck.</li>
		<li>Dissect along the CHA toward the first hepatic hilar to reveal the proper hepatic artery (PHA) and the right gastric artery (RGA). Ligate and sever the RGA.</li>
		<li>Use laparoscopic bulldog clamps (see Table of Materials) to temporarily occlude the common bile duct (CBD) after separating the CBD.</li>
		<li>Dissect the hepatoduodenal ligament. Execute a lymphadenectomy along the CHA, PV, and PHA.</li>
		<li>Ligate and dissect the right gastric artery.</li>
		<li>Locate the gastroduodenal artery (GDA) at the junction of the PHA with the CHA, and meticulously ligate or suture (5-0, see Table of Materials) the GDA to reduce the possibility of an ensuing erosion or hemorrhage.</li>
		<li>Explore the tunnel between the pancreatic neck and the SMV. Ligate and dissect the dorsal pancreatic artery (DPA).</li>
		<li>Place two Fr14 catheters to block the pancreatic neck blood supply in order to reduce bleeding (Figure 8).</li>
		<li>Dissect the parenchyma of the pancreatic neck using scissors. Suture (5-0, see Table of Materials) the bleeding point of the resection surface. 
		NOTE: Examine a fast-frozen pathological specimen of the pancreatic stump to prove the negative margin.</li>
		<li>Suspend the splenic vein (SV) to establish exposure after the left first branch of the SMV has been ligated and dissected (Figure 9).</li>
		<li>Ligate and dissect the uncinate process artery behind the SV. Identify and retain the alternative right hepatic artery originating from the SMA from the uncinate process artery. 
		NOTE: At this point, all the blood supplies to the tumor are completely occluded.</li>
		<li>Ligate and dissect the branches of the PV.</li>
	</ol>
	</li>
	<li>Using the Kocher maneuver, cut off the lymphatics, and dissect the duodenum from the retroperitoneum. Resect the tumor in situ, and remove it en bloc following the oncologic principles of no-touch16,17.</li>
	<li>Use Child&#39;s method for the reconstruction of the digestive tract8,18.</li>
	<li>Perform a single-layer running suture hepaticojejunostomy from end to side using 4-0 absorbable sutures. Utilize an internal stent to perform a duct-to-mucosal, end-to-side pancreaticojejunostomy.</li>
</ol>
5. Postoperative management
<ol>
	<li>If the gastric tube drainage is &#60;200 mL, remove the tube on the next day.</li>
	<li>Start appropriate physical exercise if the vital signs are stable and the patient is generally in good condition.</li>
	<li>Assess the amylase level of the drainage liquid on postoperative day 3, and review the abdominal CT on postoperative day 7. Remove the drainage tubes if there is no evidence of biochemical leakage, lymphatic fistula, or hemorrhage.</li>
</ol>

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The authors have nothing to disclose.

With intestinal rotation, the ventral pancreas flips to the dorsal side and unites with the dorsal pancreas throughout the development of the human embryo, and the ventral pancreas also grows into the lower portion of the pancreatic head and the uncinate process1. The pancreatic uncinate process is described as the protrusion from the bottom left of the pancreatic head that is situated behind the SMA and the SMV1. 
In the meantime, the mesopancreas rotates around the SMA into a spiral along with intestinal rotation20. As the IPDA and IPDV arise from the posterior area of the SMA and SMV, their lengths are also relatively shorter due to the rotation of the mesenteric vascular axis. These vessels may be inadvertently injured and lead to massive bleeding when dissecting the pancreatic uncinate process and mesopancreas from the SMA. Due to this issue, the management of the pancreatic uncinate process is one of the most important and difficult processes in LPD. Importantly, the complete resection of the uncinate process and mesopancreas has become a cornerstone of LPD. 
This study provides a unique strategy for the management of the uncinate process in no-touch LPD, which might potentially develop into a reproducible, standardized, and effective oncological procedure for the safe and complete excision of the uncinate process and mesopancreas. The median-anterior and left-posterior approaches to the SMA are used to ligate and dissect the IPDA, IPDV, and uncinate process artery in situ. The blood supply to the pancreatic head and duodenal region must be severed at the very early stage of the operation so that the tumor can be isolated intact, and then SMA and SMV can be separated from the uncinate process and mesopancreas completely, and the specimen can be resected en bloc using the Kocher maneuver.
The pancreatic uncinate process is situated behind the SMA1. Preoperative high-resolution contrast-enhanced CT should be performed to classify the anatomical features of the interaction between them into one of two types: type I, when the uncinate process is located at the right side of the SMA (this type is common in ampullary tumors and some cases of pancreatic head tumor); and type II, when the uncinate process extends to the left side of the SMA (this type is more commonly seen when the tumor is located in the uncinate process of pancreas)21. It is relatively easy to dissociate the uncinate process and mesopancreas from the SMA in type I. However, the SMA, the SMV, and their branches are presented on the ventral side of the uncinate process and tumor in type II. This kind of uncinate process excision is challenging and calls for a multi-angle combined arterial approach and advanced surgical skills. In these situations, dissecting the 14th group of lymph nodes is challenging. Using the median-anterior and left-posterior approaches to the SMA is beneficial and necessary. 
The goal and benefit of this method are the demonstration of the feasibility and safety of the management of the uncinate process in no-touch LPD. This complex procedure is recommended to be performed in relatively high-volume centers by experienced surgical teams. The learning curve is inevitably steep as this operation strategy requires effective cooperation among the surgical teams, comprehensive anatomical knowledge of the epigastrium, and a flexible response capability against unexpected variations. Furthermore, a limited number of cases are suitable for this procedure, and randomized clinical trials are difficult to design and implement; as a result, high-level evidence regarding the short-term and long-term outcomes of this strategy is difficult to establish.

The pancreatic uncinate process is the protrusion from the bottom left of the pancreatic head that is situated behind the SMA and superior mesenteric vein (SMV)1. The management of the uncinate process is a challenging area in pancreatic surgery due to its deep anatomy and challenging exposure; therefore, especially for pancreatic cancer located in the uncinate process, surgery is prone to result in a positive surgical margin, incomplete lymph node dissection, and poor prognosis2. Therefore, improved surgical techniques and strategies are urgently required.
Most resection procedures of the pancreatic head and uncinate process are performed along the right side of the SMV and SMA3. Although this approach largely works for ampullary tumors, it has drawbacks for pancreatic head cancer, particularly for large tumors in the uncinate process2. During the procedure, it is frequently required to spin and pull the SMV and SMA in order to expose them. The IPDA cannot be dissected clearly with such approaches, which usually results in bleeding or insufficient cleaning of the area. In this work, the authors describe an approach that can support the early control of the IPDA, which results in better bleeding control, less blood loss, and better dissection of the uncinate process.
Meanwhile, conventional laparotomy or laparoscopy pancreatoduodenectomy requires a Kocher maneuver for the wide mobilization of the duodenum and pancreatic head4. However, with this maneuver, the tumor cells have the potential capacity to metastasize via the portal vein (PV), as the surgeon might squeeze the tumor while holding it during surgery4,5,6. The no-touch isolation technique is one of the popular concepts in pancreatoduodenectomy. Although it has not been proven by large clinical trials whether this surgical intervention could enhance the cancer-related prognosis of pancreatic cancer patients, the study of Hirota et al.7 reported the significance of no-touch technology in preventing cancer cell metastasis by using molecular markers (CEA mRNA) to detect cancer cells in the portal vein blood. In their study, the no-touch technique group had a lower spread rate of portal vein cancer cells and a higher 3 year survival rate than the conventional technique group. No-touch LPD has been reported by the team of the current authors previously as an ideal oncological operation process fitting the &#34;tumor-free&#34; principle8,9.
This article presents the management of the uncinate process in no-touch LPD. The median-anterior and left-posterior approaches to the SMA were performed to deal precisely with the IPDA. To achieve the no-touch isolation technique in LPD, the blood supply to the duodenum and pancreatic heads must be cut off at the very early stage of the operation, after which the tumor can be isolated intact, resected in situ, and finally, removed en bloc.
The purpose and advantages of this strategy are to ensure the safe and complete excision of the uncinate process and mesopancreas based on a multi-angle arterial approach10. This article aims to explore the efficacy and safety of this technique for the management of the uncinate process in no-touch LPD, which might improve the R0 resection rate11.

<table><tbody><tr><td>3D Laparoscope</td><td>STORZ</td><td>TC200,TC302</td><td></td></tr><tr><td>Cisatracurium Besylate Injection</td><td>Hengrui Pharma</td><td>H20183042</td><td></td></tr><tr><td>Dual-source dual-energy&amp;nbsp; CT</td><td>SOMATOM</td><td>Definition FLASH</td><td></td></tr><tr><td>Echelon Flex Powered Plus Articulating Endoscopic Linear Cutter and Endopath Echelon Endoscopic Linear Cutter Reloads with Gripping Surface Technology</td><td>Ethicon Endo-Surgery</td><td>ECR60G/GST60G</td><td></td></tr><tr><td>ENDOPATH XCEL Trocars</td><td>Johnson &amp;amp; Johnson</td><td>CB5LT/CB12LT</td><td></td></tr><tr><td>HARMONIC ACE Ultrasonic Surgical Devices</td><td>Ethicon Endo-Surgery</td><td>HAR36</td><td></td></tr><tr><td>Laparoscopic bulldog clamps</td><td>Aesculap</td><td>FB367R,FB369R</td><td></td></tr><tr><td>Ligating Clips</td><td>Teleflex Medical</td><td>5,44,22,05,44,23,05,44,000</td><td></td></tr><tr><td>Nacrotrend anaesthesia monitoring system&amp;nbsp;</td><td>Monitor Technik,Bad Bramsted</td><td></td><td></td></tr><tr><td>PROLENE Polypropylene Nonabsorbable Suture/5/0</td><td>Johnson &amp;amp; Johnson</td><td>W8556</td><td></td></tr><tr><td>Propofol Injectable Emulsion</td><td>Aspen Pharma Trading Limited</td><td>H20171275</td><td></td></tr><tr><td>Remifentanil Hydrochloride for injection</td><td>Humanwell Healthcare</td><td>H20030197</td><td></td></tr><tr><td>Sevoflurane for Inhalation</td><td>Hengrui Pharma</td><td>H20070172</td><td></td></tr><tr><td>Sufentanil Citrate Injecton</td><td>Humanwell Healthcare</td><td>H20054171</td><td></td></tr><tr><td>Trocars</td><td>AOFO</td><td>FQ-D1/5.5mm 10.5mm</td><td></td></tr><tr><td>Ultrasonic Surgical &amp;amp; Electrosurgical Generator</td><td>Ethicon Endo-Surgery</td><td>GEN11CN</td><td></td></tr></tbody></table>

management of the uncinate process in no-touch laparoscopic pancreaticoduodenectomy

Laparoscopic pancreatoduodenectomy (LPD) is a demanding abdominal operation that necessitates meticulous surgical skills and teamwork. The management of the pancreatic uncinate process is one of the most important and difficult processes in LPD because of its deep anatomical location and difficult exposure. Complete resection of the uncinate process and mesopancreas has become the cornerstone of LPD. In particular, it is even more difficult to avoid positive surgical margins and incomplete lymph node dissection when the tumor is located in the uncinate process. No-touch LPD, which is an ideal oncological operation process fitting the "tumor-free" principle, has been reported by our group previously. This article introduces the management of the uncinate process in no-touch LPD. Based on the multi-angle arterial approach, in this protocol, the median-anterior and left-posterior approaches to the SMA are used to correctly deal with the important vascular structure, the inferior pancreaticoduodenal artery (IPDA), in order to ensure the safe and complete excision of the uncinate process and mesopancreas. For the achievement of the no-touch isolation technique in LPD, the pancreatic head and the blood supply to the duodenal region must be severed at the very early stage of the operation; after that, the tumor can be isolated intact, resection can be performed in situ, and finally, the tissue can be removed en bloc. This paper aims to show the distinctive ways to manage the uncinate process in no-touch LPD and investigate the viability and safety of this approach. Moreover, the technique may increase the R0 resection rate.

A male patient aged 59 years old with symptoms including upper abdominal pain and jaundice was hospitalized in our department. He had no previous medical history and a relatively moderate normal body mass index (23.94 kg/m2). A contrast-enhanced CT scan was performed, and a tumor with a diameter of approximately 5.5 cm x 4.6 cm x 6.3 cm was found at the head and uncinate process of the pancreas (Figure 10). No evidence of distant metastasis was found, and percutaneous transhepatic cholangical drainage19 was performed before the operation. The total bilirubin declined from 201.4 &#181;mol/mL to 36.0 &#181;mol/mL.
Representative results are shown in Table 1. The operation lasted 314 min, and the total blood loss was 80 mL. The pancreatic fistula was not found, as the amylase level of the abdominal drainage fluid was normal throughout the postoperative period, and the drainage tubes were removed before postoperative day 8. No other significant morbidity occurred, and this patient was discharged on the 11th postoperative day. Histopathology confirmed a pancreatic intraductal papillary mucinous neoplasm with focal moderately differentiated invasive adenocarcinoma (Figure 11). The surgical margins were microscopically negative (R0), and none of the 18 lymph nodes were involved.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/64904/64904fig01.jpg" /> 
Figure 1: Distribution of the trocars. The five-port method was used. The patient was laid down in a supine position with his legs spread out. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64904/64904fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/64904/64904fig02.jpg" /> 
Figure 2: Removal of the gallbladder and suspending the liver to expose the hepatoduodenal ligament and hilum. Abbreviation:&#160;HL = hepatoduodenal ligament. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64904/64904fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/64904/64904fig03.jpg" /> 
Figure 3:&#160;The PDJV between the SMV and the SMA is exposed in the inferior colonic region. Abbreviations:&#160;PDJV = proximal-dorsal jejunal vein; SMV = superior mesenteric vein; SMA = superior mesenteric artery. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64904/64904fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/64904/64904fig04.jpg" /> 
Figure 4: Exposure of the main branches of the IPDA and JA along the right side of the SMA through the median-anterior approach to the SMA. Abbreviations:&#160;IPDA = inferior pancreaticoduodenal artery; JA = jejunal artery; SMV = superior mesenteric vein; SMA = superior mesenteric artery. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64904/64904fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/64904/64904fig05.jpg" /> 
Figure 5: Method of hanging the SMA and SMV. (A) and (B) represent the method of hanging the SMA and SMV to establish a sufficient view of the left-posterior surface of the SMA. Abbreviations: IPDA = inferior pancreaticoduodenal artery; SMA = superior mesenteric artery; SMV = superior mesenteric vein. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64904/64904fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/64904/64904fig06.jpg" /> 
Figure 6: Dissection along the SMA circumferentially exposing the IPDA, which originates directly from the SMA. Abbreviations:&#160;IPDA = inferior pancreaticoduodenal artery; JA = jejunal artery; SMA = superior mesenteric artery. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64904/64904fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/64904/64904fig07.jpg" /> 
Figure 7:&#160;Separating the SMA and SMV from the uncinate process and mesopancreas. Using the median-anterior and left-posterior approaches to the SMA, the SMA and SMV are completely separated from the uncinate process and mesopancreas. Abbreviations: SMA = superior mesenteric artery; SMV = superior mesenteric vein. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64904/64904fig07large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/64904/64904fig08.jpg" /> 
Figure 8: Placing two Fr14 catheters to block the pancreatic neck blood supply and reduce bleeding. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64904/64904fig08large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 9" class="xfigimg" src="/files/ftp_upload/64904/64904fig09.jpg" /> 
Figure 9: Suspending the SV to establish the exposure. Abbreviations:&#160;SV = splenic vein; SMA = superior mesenteric artery; SMV = superior mesenteric vein. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64904/64904fig09large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 10" class="xfigimg" src="/files/ftp_upload/64904/64904fig10.jpg" /> 
Figure 10: Image showing the tumor in the head and uncinate process of the pancreas. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64904/64904fig10large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 11" class="xfigimg" src="/files/ftp_upload/64904/64904fig11.jpg" /> 
Figure 11: Histopathological study. Histopathology confirmed a pancreatic intraductal papillary mucinous neoplasm with focal moderately differentiated invasive adenocarcinoma. (A) Postoperative paraffin specimens in which the size of the stomach is 7 cm x 5 cm x 2.5 cm, the length of the small intestine is about 22 cm, the size of the pancreas is 6 cm x 4 cm x 3 cm, and there is a gray mass in the head of the pancreas, which is about 6 cm x 3 cm x 1.5 cm in size. (B) Atypical glands, suggesting a focally infiltrating adenocarcinoma. (C,D) An intraductal papillary mucinous tumor. Magnifications: B, 200x; C, 400x; D, 300x. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64904/64904fig11large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Variable</td>
			<td>Outcome</td>
		</tr>
		<tr>
			<td>Intraoperative</td>
			<td></td>
		</tr>
		<tr>
			<td>operative time, min</td>
			<td>314</td>
		</tr>
		<tr>
			<td>Intraoperative blood loss, mL</td>
			<td>80</td>
		</tr>
		<tr>
			<td>Postoperative</td>
			<td></td>
		</tr>
		<tr>
			<td>Postoperative pancreatic fistula</td>
			<td>Not found</td>
		</tr>
		<tr>
			<td>Drain removal, postoperative day</td>
			<td>8</td>
		</tr>
		<tr>
			<td>Postoperative hospital stay, days</td>
			<td>11</td>
		</tr>
		<tr>
			<td>Pathological diagnosis</td>
			<td>Pancreatic intraductal papillary mucinous neoplasm with focal moderately differentiated invasive adenocarcinoma</td>
		</tr>
	</tbody>
</table>
Table 1: Representative results of the surgery.

Watch this Scientific Journal Video about Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy at JoVE.com

Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy

Complete resection of the uncinate process and mesopancreas is one of the most important and difficult processes in laparoscopic pancreatoduodenectomy (LPD). This article presents a method for managing the uncinate process in no-touch LPD using the median-anterior and left-posterior approaches to the superior mesenteric artery (SMA).

Laparoscopic pancreatoduodenectomy (LPD) is a demanding abdominal operation that necessitates meticulous surgical skills and teamwork. The management of ...

management-uncinate-process-no-touch-laparoscopic

Nanyang Technological University

Research

JoVE Journal

Medicine

767 Views.  The Second Affiliated Hospital of Guangzhou University of Chinese Medicine. Het is een grote uitdaging om positieve chirurgische marges en onvolledige lymfeklierdissectie te vermijden wanneer een tumor zich in het uncinaatproces bevindt. Deze studie introduceert de behandeling van het uncinaatproces bij no-touch laparoscopische pancreaticoduodenectomie. De voordelen van deze strategie zijn om de veilige en volledige excisie van het uncinaatproces en mesopancreas te garanderen op basis van een arteriële benadering met meerdere hoeken.Deze techniek zal mogelijk...

Video: Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis.
The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index &#62;35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers.
The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy.
The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

Laparoscopic pancreatoduodenctomy (LPD) may offer advantages over open pancreatoduodenectomy, including early postoperative mobilization, less delayed gastric emptying and a shorter hospital stay. However, LPD is technically challenging and not well-standardized, especially regarding the pancreatic anastomosis. We describe a standardized technique for the pancreatic anastomosis during LPD: modified Blumgart pancreaticojejunostomy.

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal ...

Cancer Research

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer: Surgical Planning and Technique

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), relying on collateral flow to the liver through the gastroduodenal artery (GDA). In the current manuscript, the technical conduct of robotic DP-CAR is outlined. The greater curve of the stomach is mobilized with care to avoid sacrificing the gastroepiploic vessels. The stomach and liver are retracted cephalad to facilitate dissection of the porta hepatis. The hepatic artery (HA) is dissected and encircled with a vessel loop. The gastroduodenal artery (GDA) is carefully preserved. The common HA is clamped and triphasic flow in the proper HA via the GDA is confirmed using intra-operative ultrasound. A retropancreatic tunnel is made over the superior mesenteric vein (SMV). The pancreas is divided with an endovascular stapler at the neck. The inferior mesenteric vein (IMV) and splenic vein are ligated. The HA is stapled proximal to the GDA. The entire specimen is retracted laterally with further dissection cephalad to expose the superior mesenteric artery (SMA). The SMA is then traced back to the aorta. The dissection continues cephalad along the aorta with the bipolar energy device used to divide the crural fibers and celiac nerve plexus. The specimen is mobilized from the patient's right to left until the origin of the celiac axis is identified and oriented towards the left. The trunk is circumferentially dissected and stapled. Additional dissection with hook cautery and the bipolar energy device fully mobilizes the pancreatic tail and spleen. The specimen is removed from the left lower quadrant extraction site and one drain is left in the resection bed. A final intra-operative ultrasound of the proper HA confirms pulsatile, triphasic flow in the artery and liver parenchyma. The stomach is inspected for evidence of ischemia. Robotic DP-CAR is safe, feasible and when used in conjunction with multi-modality therapy, offers potential for long-term survival in selected patients.

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection DP-CAR for Pancreatic Cancer: Surgical Planning and Technique

We present our operative approach to robot assisted distal pancreatectomy, splenectomy, and celiac axis resection (DP-CAR), demonstrating that the procedure is safe and feasible with proper planning, patient selection, and surgeon experience.

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), ...

Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several studies have described the safety of RPD in case of a replaced or aberrant right hepatic artery, but detailed video descriptions of the approach are lacking. This case report describes a step-&#173;by-&#173;step technical video in case of a replaced right hepatic artery. A 58-year-old woman presented with an incidental finding of a 1.7 cm pancreatic head mass. RPD was performed using the da Vinci Xi system and involves a robotic-assisted pancreatico- and hepatico-jejunostomy and open gastro-jejunostomy at the specimen extraction site. The operation time was 410 min with 220 mL of blood loss. The patient had an uncomplicated postoperative course and was discharged after 5 days. Pathology revealed a pancreatic head cancer. RPD is a feasible and safe procedure in case of a replaced hepatic artery when performed in selected patients in high-volume centers by experienced surgeons.

Robotic pancreatoduodenctomy (RPD) has been highly standardized in recent years and may be used in selected patients with pancreatic head cancer, including those with a replaced right hepatic artery. This case report describes a standardized and reproducible technique for RPD, which includes the approach of the Dutch LAELAPS-3 training program to an aberrant vasculature.

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several ...

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body. With technological development, the robotic surgical system has shown its advantage in minimally invasive surgery and been increasingly applied in central pancreatectomy. However, reconstruction of the continuity of pancreas with end-to-end anastomosis after robotic central pancreatectomy has not been applied. In this study, we report surgical techniques for robotic central pancreatectomy with end-to-end anastomosis. The pancreas is reconstructed by duct-to-duct anastomosis of the pancreatic duct with a pancreatic stent inserted in the two stumps of pancreatic duct, and by end-to-end anastomosis of the pancreatic parenchyma. Compared with traditional central pancreatectomy with pancreaticoenteric anastomosis, this approach decreases the operative injury to the patient, and also conserves the integrity and continuity of the digestive duct and pancreatic duct. The robotic surgical system integrated with multiple instruments with flexible and precise movement is particularly suitable for the dissection and reconstruction of the pancreatic duct. We found that robotic central pancreatectomy with end-to-end anastomosis is safe and feasible, and we need more experience to evaluate its best indications and long-term outcomes.

The robotic central pancreatectomy with end-to-end anastomosis is feasible and safe for tumor in the pancreatic neck and proximal portion of pancreatic body. The operative techniques of this operation are presented.

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of the pancreas. The aim of central pancreatectomy is to prevent postoperative life-long endocrine and exocrine insufficiency. The downside of central pancreatectomy is the high rate of postoperative pancreatic fistula, which is the main reason that many surgeons do not routinely use central pancreatectomy in eligible patients. Most studies report open or laparoscopic central pancreatectomy with a pancreatico-gastrostomy anastomosis in adults. This is the first description of a standardized approach to robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy reconstruction in an adolescent (16-year-old boy) with a pseudopapillary tumor in the body of the pancreas. The operation time was 248 min with 20 mL of blood loss. The postoperative course was uneventful except for the short-term medical treatment for a grade B pancreatic fistula. Robotic central pancreatectomy can be safely applied in selected patients in experienced centers.

Robotic central pancreatectomy may be used in selected patients in experienced centers. This protocol presents all steps and the feasibility of a robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy in a 16-year-old adolescent patient.

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of ...

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct.
This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms.
LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.

This article provides a whole technical process of laparoscopic duodenum-preserving pancreatic head resection via an inferior infracolic approach. This is a surgical approach for benign tumors without intraoperative fluorescence image guidance.

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic ...

Application of Mid-Pancreatectomy with End-to-End Anastomosis in Pancreatic Benign Tumors

Mid-pancreatectomy combined with end-to-end anastomosis is a surgical procedure used to treat benign pancreatic tumors. It involves removing the tumor from the middle section of the pancreas and connecting the proximal and distal ends through an anastomosis. The traditional surgical approach for resecting the middle segment of the pancreas involves closing the proximal pancreas and creating a Roux-en-Y anastomosis with the jejunum. However, this approach carries a double risk of pancreatic stump fistula and pancreatico enteric anastomotic leak postoperatively. In this paper, a new procedure is described where stent tubes were placed into the proximal and distal sides of the pancreatic ducts after ensuring sufficient freedom from the proximal distal pancreas. The pancreatic parenchyma was then sutured continuously under direct vision to achieve pancreatic end-to-end anastomosis. This procedure helps preserve pancreatic function, reducing the risk of postoperative pancreatic insufficiency. However, due to the complexity and risks involved, thorough evaluation and preparation are necessary before surgery. We carefully assess the patient's history, serology, and imaging results to determine the feasibility and effectiveness of the procedure. During surgery, we consider the use of a suitable pancreatic duct stent to ensure the flow of pancreatic juice into the intestine through physiological pathways. Our goal is to remove the tumor while preserving as much normal pancreatic tissue as possible for the anastomosis. After the operation, it is crucial to monitor the patient's pancreatic function, paying close attention to blood glucose levels, drainage fluid volume, and amylase value of the pancreatic anastomosis. During the postoperative follow-up visit, the patient's pancreatic function was assessed, and there was no significant change in quality of life compared to before the surgery. This indicates that mid-pancreatectomy combined with end-to-end anastomosis is a safe and effective procedure for treating pancreatic benign neoplasms.

The present protocol describes the application of mid-pancreatectomy combined with end-to-end anastomosis in the surgical treatment of pancreatic benign tumors, which presents a feasible solution for managing such tumors while concurrently preserving pancreatic function.

Mid-pancreatectomy combined with end-to-end anastomosis is a surgical procedure used to treat benign pancreatic tumors. It involves removing the tumor ...

Laparoscopic Retroperitoneal Treatment of Necrotizing Pancreatitis Complications

Retroperitoneal Laparoscopic Debridement and Drainage for Pancreatic Abscess

In patients with severe necrotizing pancreatitis, pancreatic necrosis and secondary infection of surrounding tissues can quickly spread to the whole retroperitoneal space. Treatment of pancreatic abscess complicating necrotizing pancreatitis is difficult and has a high mortality rate. The well-accepted treatment strategy is early debridement of necrotic tissues, drainage, and postoperative continuous retroperitoneal lavage. However, traditional open surgery has several disadvantages, such as severe trauma, interference with abdominal organs, a high rate of postoperative infection and adhesion, and hardness with repeated debridement. The retroperitoneal laparoscopic approach has the advantages of minimal invasion, a better drainage route, convenient repeated debridement, and avoidance of the spread of retroperitoneal infection to the abdominal cavity. In addition, retroperitoneal drainage leads to fewer drainage tube problems, including miscounting, displacement, or siphon. The debridement and drainage of pancreatic abscess tissue via the retroperitoneal laparoscopic approach plays an increasingly irreplaceable role in improving patient prognosis and saving healthcare resources and costs. The main procedures described here include laying the patient on the right side, raising the lumbar bridge and then arranging the trocar; establishing the pneumoperitoneum and cleaning the pararenal fat tissues; opening the lateral pyramidal fascia and the perirenal fascia outside the peritoneal reflections; opening the anterior renal fascia and entering the anterior pararenal space from the rear; clearing the necrotic tissue and accumulating fluid; and placing drainage tubes and performing postoperative continuous retroperitoneal lavage.

Author Spotlight: Advancements in Retroperitoneal Approach for Necrotizing Pancreatitis

To improve the drainage of patients with necrotizing pancreatitis complicated with peripancreatic abscess and reduce the mortality of patients with necrotizing pancreatitis, we adopted a retroperitoneal approach for peripancreatic abscess debridement and drainage by laparoscopy.

In patients with severe necrotizing pancreatitis, pancreatic necrosis and secondary infection of surrounding tissues can quickly spread to the whole ...

Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy

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