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G. Murimwa and P. M. Polanco
maneuver is recommended, which is particularly useful if portal vein or SMV
resection and repair is anticipated (Fig.26.3).
2. Dissection of the hepatic artery node, CHA, PHA, and GDA, and the “clamp-
ing test”
The dissection of the anterior hepatic artery node (station 8A) allows for easier identication and dissection of the CHA.Once the CHA is identied, we
extend dissection toward the PHA, carefully preserving the right gastric artery if
possible. The GDA is then dissected at the superior border of the pancreas. These
vessels are encircled with vessel loops for gentle traction. At this point, we perform a “clamping test” on the CHA to conrm adequate retrograde ow from the
SMA, pancreatoduodenal arch, and GDA toward the PHA. Pulsatile triphasic
duplex/Doppler signal conrmation of the PHA and liver arterial blood supply is
recommended via intraoperative ultrasound. If adequate liver arterial ow is
conrmed, we proceed with the DP-CAR (Fig.26.4a, b).
3. Dissection of the pancreas neck, retropancreatic tunnel creation, and pancreas
division
The inferior border of the pancreas is dissected. The anterior aspect of the
SMV is identied and dissected cranially under the pancreas neck. Once a retropancreatic tunnel is completed, we proceed with the division of the pancreas
neck with a linear laparoscopic or robotic stapler load. The stapler size (color)
will vary based on pancreas parenchyma thickness. If thick tissue is found, we
recommend staplers ranging from 2.5 to 4mm (green, purple, or black loads). If
there is concern for distance to the tumor or margin involvement, ultrasound can
be used. If there is limited space between the GDA and the tumor margin to t in
a linear stapler, the pancreas is divided with scissors and then oversewn with 4-0
barbed sutures in continuous fashion (Fig.26.5a–c).
4. Dissection of the left gastric artery and vein (LGA, LGV), splenic vein, CA, and
diaphragm crus
Division of the pancreas neck facilitates the exposure and dissection of the
LGV (also known as coronary vein) and splenoportal conuence. This is performed with hook monopolar dissection and vessel sealer dissection. If the splenoportal conuence is not compromised by tumor, early division of the LGV
(with a vessel sealer) and splenic vein (with a linear vascular stapler) allows
Fig. 26.3 Division of
gastrocolic ligament and
mobilization of the greater
curvature of the stomach
26 Minimally Invasive Distal Pancreatectomy withCeliac Artery Resection
451
ba
Fig. 26.4 (a) Dissection of the hepatic artery node, common hepatic artery (CHA), proper hepatic
artery (PHA), and gastroduodenal artery (GDA). (b) Clamping of common hepatic artery (CHA)
with robotic ultrasound conrming adequate pulsatile arterial blood supply (with triphasic doppler
signal) to the liver by reverse ow from gastroduodenal artery
a
b
c
Fig. 26.5 (a) Pancreas neck and superior mesenteric vein (SMV) dissection with creation of retropancreatic tunnel. (b) Division of pancreas neck with linear gastrointestinal stapler. (c) Divided
pancreas neck. SMV superior mesenteric vein
better exposure of the arterial anatomy, including the LGA, splenic artery, and
cranial aspect of the CA.After the LGA is circumferentially dissected, a vessel
loop is placed around it for traction. This allows exposure and dissection of the
diaphragmatic crus. Division of the median arcuate ligament is recommended to
expose the anterior and proximal aspect of the CA and aorta (Fig.26.6a, b).
5. Division of the CHA and LGA and dissection of the SMA and aorta
The CHA and LGA are now divided with linear vascular staplers. The left
lateral aspect of the SMV and the root of the mesentery is dissected to expose the
anterior aspect of the SMA.The SMA is dissected cranially. All the periadventitial lymphatic and nerve tissue is dissected and divided until the anterior wall of
452
ab
Fig. 26.6 (a) Dissection and division of left gastric artery (LGA). (b) Division of median arcuate
ligament and diaphragm crus
Fig. 26.7 Division of
common hepatic artery
(CHA). Dissected
gastroduodenal artery
(GDA) and proper hepatic
artery (PHA) shown
G. Murimwa and P. M. Polanco
the aorta is exposed. Dissection is continued cranially with monopolar dissection
and vessel sealer until the emergence of the CA is identied. Lateral muscle
bers of the diaphragm crus need to be divided for adequate exposure of the
celiac trunk. During this step, lymph node stations 7, 9, 14, 16, and 18 are dissected toward surgical specimens (Fig.26.7).
6. Dissection and division of the CA and completion of radical antegrade modular
pancreatosplenectomy (RAMPS) medial-to-lateral or lateral-to-medial RAMPS
with a nal dissection and division of the CA
At this point of the procedure, we often contemplate two options.
(a) If dissection of the anterior aspect of the aorta and CA appears feasible, we
continue the dissection until circumferential dissection is obtained. The dissection of the body of the pancreas with complete dissection of periaortic
lymphatic and neural tissue with anterior traction is necessary to clearly
identify and dissect the CA.The CA is divided with a vascular linear stapler.
The surgery is completed via principles of conventional anterior RAMPS,
with resection of anterior renal fascia or posterior RAMPS if the adrenal
gland is involved. Nodal stations 10 and 11 are dissected during this portion
of the procedure (Fig.26.8a–c).
(b) If exposure or dissection of the anterior aspect of the SMA, aorta, or CA is
challenging due to an extension of mass brotic post-radiation tissue or
excess retroperitoneal fat and lymphatic tissue, we recommend turning the
a
b
26 Minimally Invasive Distal Pancreatectomy withCeliac Artery Resection
453
c
Fig. 26.8 (a) Dissection of superior mesenteric artery (SMA), aorta and circumferential dissection and division of celiac axis (CA). (b) Completion of anterior radical antegrade modular pancreatosplenectomy (RAMPS) with dissection of Gerota’s fascia. (c) Dissection of splenocolic
attachments and spleen mobilization
attention to the distal pancreas and spleen. Dissection of the distal pancreas
and spleen is performed by mobilizing the splenic exure of colon and
lateral attachments of the spleen. The splenic hilum is circumferentially dissected and divided with vascular linear stapling. Separating the spleen from
the pancreas permits easier manipulation and anterior traction of the pancreas while performing a lateral-to-medial RAMPS.This allows easier identication of the left crus, dissection of the anterolateral aspect of the aorta,
and an easier dissection of the CA.Once the CA is circumferentially dissected, it is divided with a vascular stapler.
(c) If the portal vein, SMV, or portal conuence has any involvement with
tumor, dissection of this area should be carried out last after the CA is
divided. In these scenarios, partial resection and repair, a vein patch, or
resection and primary anastomosis are needed (Fig. 26.9a, b). While all
these could be performed robotically in very qualied hands, the decision to
continue robotically or convert to open relies on the surgeon’s judgment and
experience.
7. Placement of specimens in a bag, revision of hemostasis, drain placement,
retrieval of specimens, and closure
After placement of the specimens in an endoscopic bag, we perform thorough hemo-
stasis revision of all blood vessel stumps. We routinely create a falciform ap to place
around the PHA, GDA, and the CA stump to protect these vessels from potential pancreatic leaks. A round Blake drain is left in the resection bed connected to closed bulb suction. The specimens are removed through an extended incision of our 15-mm utility port
454
ab
Fig. 26.9 (a) Proximal and distal control of portal vein (PV) and superior mesenteric vein (SMV)
with laparoscopic “bulldog” clamps and resection PV wall due to tumor involvement. (b) Robotic
repair of portal vein with running 5-0 prolene suture
Fig. 26.10 Retrieval of
specimen with an
endoscopic bag
G. Murimwa and P. M. Polanco
(Fig.26.10). Alternatively, a small Pfannenstiel incision is created to remove the specimens. Incisions and trocar sites are closed in a standard fashion.
Perioperative Care
While we selectively admit patients to the intensive care unit, such admission is
recommended if major blood loss or any critical occurrence is encountered during
the operation or if liver and gastric ischemia are present. Standard management
under enhanced recovery after surgery (ERAS) protocols is recommended. Diet
progression starts on postoperative day 1 with a liquid diet. Bloodwork during the
early postoperative days should include a liver panel. We routinely check amylase
levels in drain uid on day 1 and 3 and advocate for early drain removal if there is
no evidence of a leak. If a chyle leak is suspected due to a “milky” appearance in the
drain output, triglyceride levels are tested to conrm the leak. Medium-chain triglyceride diet is recommended if this complication occurs. If the patient develops
delayed gastric emptying, nasogastric decompression could be needed. If this issue
doesn’t resolve within a week, the patient may require transient total parenteral
nutrition or post-pyloric enteric feeding.
26 Minimally Invasive Distal Pancreatectomy withCeliac Artery Resection
455
Conclusion
DP-CAR is an aggressive and challenging surgical intervention with a higher risk of
morbidity and mortality than standard pancreatic operations. Yet minimally invasive
DP-CAR, when performed at high-volume and experienced centers, is safe and feasible and could provide improved long-term survival for a selected group of pancreatic cancer patients in combination with multimodality therapy.
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Chapter 27
Enucleation
LucaMilone, MeiZhenCao, AndrewGumbs, andRomuloGenato
Introduction
Pancreatic Surgery, https://doi.org/10.1007/978-3-031-78409-5_27
Preoperative Considerations
L. Milone et al.
Fig. 27.1 Magnetic