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48 Modied Distal Pancreatectomy withCeliac Axis En-bloc Resection
371
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9. Konishi M, Kinoshita T, Nakagori T, etal. Distal pancreatectomy
with resection of the celiac axis and reconstruction of the hepatic
artery for carcinoma of the body and tail of the pancreas. J HepatoBiliary- Pancreat Surg. 2000;7:183–7.
10. Kondo S, Katoh H, Hirano S, etal. Results of radical distal pancreatectomy with en bloc resection of the celiac artery for locally
advanced cancer of the pancreatic body. Langenbeck’s Arch Surg.
2003;388:101–6.
11. Okada K, Kawai M, Tani M, etal. Preservation of the left gastric
artery on the basis of anatomical features in patients undergoing
distal pancreatectomy with celiac axis en-bloc resection (DP-CAR).
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the left gastric artery in patients with pancreatic body cancer. World
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Robotic Distal Pancreatectomy
MarcoVitoMarino, MarcoRamera,
andAlessandroEsposito
49
Abstract
Since its rst description in 1994 by Cuschieri (J R Coll
Surg Edinb 39:178–84, 1994), laparoscopic left pancreatectomy has been increasingly performed by hepatopancreato- biliary surgeons worldwide. Despite reported
benets of less blood loss, faster recovery and shorter
hospital stay over the classic open procedure (de Rooij
etal. Ann Surg 269(1):2–9, 2019; Bjornsson etal. Br J
Surg 2020), the rst International Survey on Minimally
Invasive Pancreatic Resection reported the minimally
invasive distal pancreatectomy median lifetime case volume was quite low even for expert pancreatic surgeons
(van Hilst etal. HPB (Oxford) 19:190–204, 2017). The
technical expertise required for tissue manipulation, vascular dissection and control of bleeding while ensuring
adequate oncological outcome remains a signicant hindrance to widespread adoption. The lack of specic training program, the poor ergonomics denitively limited the
widespread of the laparoscopic distal pancreatectomy.
The da Vinci robotic system (Intuitive Surgical,
Sunnyvale, CA, USA) with its microsuturing and microdissection capabilities associated to an enhanced visualization may potentially provide several advantages over
the laparoscopic approach. Early reports show encouraging results over the laparoscopic distal pancreatectomy in
terms of reduced blood loss (Chen et al. Surg Endosc
M. V. Marino (*)
General Surgery Department, Azienda Ospedaliera Ospedali
Riuniti Villa Soa-Cervello, Palermo, Italy
General Surgery Department, Istituto Villa Salus, Siracusa, Italy
M. Ramera
General Surgery Department, Fondazione Poliambulanza,
Brescia, Italy
A. Esposito
General and Pancreatic Surgery Department, University Hospital
of Verona, Verona, Italy
29:3507–18, 2015), increased splenic preservation rate
(Hong etal. Surg Endosc 34:2465–2473, 2020), reduced
conversion to open with comparable short term oncological efcacy (Marino etal. Dig Surg 37:229–239, 2020).
There is a lack to technical standardization of approach
and patient selection via novel difculty scoring needs to
be validated in larger cohorts. The prevention of clinically signicant pancreatic stula continues to be a challenge and long term oncological outcomes for malignancy
remains unclear. Limitations of cost and learning curve
especially with the adoption of more complex procedures
will need to be overcome for wider application of the
robotic approach.
49.1 Surgical Technique
49.1.1 Instruments andTools
For robotic-assisted distal pancreatectomy we personally use
the following instrumentations which should be available in
the operating room before starting the operation. Four robotic
ports and one 12 mm laparoscopic ports are employed,
sometimes a 5mm laparoscopic port is used when the exposure of the operative eld is challenging.
A 30° robotic camera is preferred instead of the 0° scope
for the opportunity to switch from up to down during the dissection around the pancreas, a Tip-Up Fenestrated Grasper is
preferred as retractor instrument for the longer length of the
tips, a Monopolar Curved Scissors and a Fenestrated Bipolar
Forceps as energy device, nally the Harmonic ACE®Curved
Shears (Ethicon Endo-Surgery, Inc., Cincinnati, OH, USA)
as advanced energy device. In case of obese patients, we
employ the Vessel Sealer Extend that has a higher hemostatic
effect than Harmonic ACE®, conversely the latter has in our
opinion a better dissecting capability which are crucial in
case of smooth and meticulous dissection.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_49
373
374
M. V. Marino et al.
Medium-large and large robotic Hem-o-lok® clips and
Horizon™ small-wide titanium clips (Teleex Medical Ltd.,
RTP Durham, NC, USA) should be available as well as a
45mm Laparoscopic stapler (Purple or Black load) for the
pancreatic transection. We do not recommend the utilization
of a robotic stapler for the pancreatic transection due to the
lack of tactile feedback and the difculties in modulating the
closure of the jaws. Monolament sutures of 3–0 Prolene®
and a 25cm cotton tape complete the armamentarium. Two
atraumatic laparoscopic instruments are available.
49.1.2 Operating Room Conguration
The patient under general anesthesia is located in supine
position, with legs apart and arms tucked to the body. The
robotic cart is docked over the right ank of the patient,
while the surgeon console is located at the inferior left corner
of the operating theater. The bed assistant is located between
the patient’s legs, while the scrub nurse stands at the lower
left side of the patient.
The pneumoperitoneum is established by using a Veress
needle. The bed is tilted in reverse-Trendelenburg position
(15–20°) and right lateral decubitus (10°). A total of ve trocars are inserted. The four 8mm robotic ports are placed in a
straight line at the umbilical line as following:
– in the right ank for arm number 1 (R1),
– in the right pararectal area for arm number 2 (R2),
– in the periumbilical area for arm number 3 (R3),
– in the left ank for arm number 4 (R4) (Fig.49.1).
A 12mm laparoscopic port connected to the AirSeal® system is placed between R3 and R4in the left pararectal area.
A Tip-Up Fenestrated Grasper, a Monopolar Curved Scissors
and a Fenestrated Bipolar Forceps are used as initial instruments for arm number 1, 2 and 4 respectively.
49.1.3 Distal Splenopancreatectomy
The operation starts by inspecting the abdominal cavity, an
intraoperative ultrasound is performed with the aims to
exclude liver metastasis and to assess the tumor location. The
gastrocolic ligament is then opened preserving the gastroepiploic arcade by the Monopolar Scissors while the stomach is
retracted cephalad by the arm number 1. The posterior wall
of the stomach is xed to the anterior abdominal wall by a
running suture of 3–0V-loc™ thus freeing the arm number 1
which is used for the tissue retraction. The spleno-gastric
ligament is transected, and the short gastric vessels are completely cut by the Harmonic ACE®.
The splenic exure is routinely taken down through a
supramesocolic approach or by mobilizing the left colon
from its lateral attachments. The pancreatic gland is entirely
exposed, and its inferior margin is progressively dissected
free from the transverse mesocolon.
The splenic vein is visualized and dissected towards the
conuence with the superior mesenteric vein, nally it is
encircled by a vessel-loop. Similarly, the superior margin of
the pancreas is incised and the splenic artery is dissected at
its origin and encircled by a vessel-loop. A retropancreatic
tunnel is started and the pancreas is suspended by a cottontape which is handled by the arm number 1. The splenic
artery and next the splenic vein are clipped by the Hem-olok® and divided (Fig. 49.2).
The distal pancreas is transected at the level of the neck
with a laparoscopic stapler (Endo GIA™ Medtronic,
Minneapolis, MN, USA) purple (3–4mm) or black (4–5mm)
load or alternatively with the Harmonic ACE® depending on
the thickness of pancreatic gland (Fig. 49.3). Prior to division, 2 stay sutures of 3–0 Prolene® are placed, one proximally and one distally the transection point, at the inferior
Fig. 49.1 Trocart layout
Fig. 49.2 Splenic artery control
49 Robotic Distal Pancreatectomy
Fig. 49.3 Pancreatic transection
border of the pancreas for retraction. The distal pancreas is
dissected from the retroperitoneum.
The phrenocolienal ligament is cut and the spleen is freed
from its lateral attachments.
49.1.4 Spleen-Preserving Distal Pancreatectomy
Once the gastrocolic ligament is opened the left gastroepiploic and the short gastric vessels are preserved. The inferior
and the superior margins of the pancreas are dissected and
The splenic artery and veins are both isolated and encircled
by two vessel-loops. The level of pancreatic transection is
assessed by an IOUS and tunnelized by a cotton tape.
If a Kimura technique was attempted, the distal pancreas
is dissected and mobilized in a medial to lateral fashion the
splenic vessels are skeletonized from the isthmus toward
the hilum of the spleen, ligating and dividing all pancreatic
branches trough Harmonic ACE® scalpel or small titanium
clips.
If a Warshaw technique was performed the splenic vessels
(artery rst) are controlled and divided between Hem-olok® clips or sectioned through a white stapler load application. In particular the artery is isolated clipped proximally at
its origin and distally at the level of splenic hilum preserving
the origin of the left gastroepiploic artery. The splenic vein
was controlled at the splenic hilum preserving the left gastroepiploic vein.
No brin glue was placed on the pancreatic stump. An
intraoperative frozen section of the pancreatic remnant was
sent for pathological examination to conrm negative margins when appropriate. A single suction drain is placed
close to the pancreatic remnant. The specimen, inserted in
endoscopic bag, is retrieved through a Pfannenstiel incision
or through the incision of the 12-mm trocar in case of
spleen preservation and for non-bulky lesions.
375
49.2 Results
A total of 45 patients (25 males, 20 females) underwent
robotic distal pancreatectomy since October 2016 up to now.
In Thirty-ve cases a distal pancreatectomy with splenectomy was carried out, while in ten cases a spleen-preserving
approach was pursued.
The mean age was 58.5years. The BMI was 27.4. Ten out
of 45 (22.2%) had a previous abdominal surgery and the majority (30 out of 45) suffered by a malignant pancreatic pathology.
The leading indication for surgery was pancreatic ductal adenocarcinoma (22) followed by chronic pancreatitis [1] and neuroendocrine tumors [2]. The mean operative time was 225min
(range 150–655min), the spleen preserving procedures were
associated to a longer operative time (255 vs 190min). The
overall estimated blood loss was 115ml (5–300ml). In case of
benign conditions, a spleen preserving procedures was completed in 100% of cases. Only 2 patients were converted to
open due to the difculties in bleeding control and concerns
regarding the oncologic adequacy. Eleven patients experimented post-operative complications, seven were classied as
minor, while four were major (8.9%). Only three patients
developed a postoperative pancreatic stula (2 grade B and 1
grade C according ISGPS classication [3]). Two patients were
reoperated the rst for a peripancreatic uid collection associated to a grade C pancreatic stula, the second for a colon perforation. The mean length of hospital stay was 9days (range
6–21 days). The 90-day mortality rate was one due to postoperative pulmonary embolism. An R0 resection rate was
achieved in 100% of cases. The mean nodal harvested was 19.5
nodes (range 7–25 nodes). The recurrence rate at a mean follow-up of 16 months was 15%. The disease-free survival at
3-year was 57.8% while the overall-free survival was 70.2%.
49.3 Discussion
The robotic pancreatic surgery is progressively gaining
momentum as it is applied both for pancreatoduodenectomy
or enucleation [4, 5].
Spleen preserving distal pancreatectomy (SPDP) is an
important organ preservation technique for pancreatic body/
tail non-malignant tumors that offers several hematological
and immunological benets, as proven in several studies [6,
7]. Two techniques are commonly applied for this purpose
and differ in the preservation or not of the splenic vessels [8].
With the advent of the minimally invasive approach and in
particular of the robotic platform, there was great interest in
evaluating the contribution that this technology could bring
in the preservation of the spleen.
376
M. V. Marino et al.
Three recent meta-analyses [9, 10] have evaluated the
spleen preservation rate between RDP and LDP with controversial results. All of these studies actually report that
spleen preservation rates were less than 50%. In almost all
of the series included in these meta-analyses, the parameter
“spleen preservation rate” actually refers to the ratio
between the number of operations in which the spleen has
been preserved and the total number of minimally invasive
procedures performed for any pathology. Other retrospective studies have carefully evaluated this issue. A Korean
single-center and single-surgeon analysis conducted on
more than 200 patients undergoing MIDP has the laparoscopic and robotic approach (about one fth of cases) [11].
Although the nature of the study is retrospective, the
authors report the number of cases where there was an
intent to preserve the spleen. RDP was associated with a
higher preservation success rate (96.8% vs 82.5%;
P=0.02). another study carefully considered this question.
From the retrospective analysis of all patients undergoing
SPDP for low-grade benign or malignant tumors at the
Shanghai hospital, a propensity score matching was
obtained compared RDP and ODP [12]. The RDP cohort
showed a signicantly higher spleen preservation rate
(63.5% vs 26.5%, P<0.001), less estimated blood loss and,
interestingly, shorter operative time. In logistic regression
analysis, the open approach, together with increasing age,
tumor size, and blood loss, such as the pathological type of
inammatory neoplasm, were independent predictors of
spleen preservation failure.
It is possible that the surgeon’s and/or patient’s preference
for a particular approach has still limited the design of randomized prospective trails.
Another widely debated point is the adequacy of the
robotic approach for malignant tumors, especially
PDAC. Three systematic reviews and meta-analyses suggested comparable oncological outcomes in terms of resection margin, 30-day mortality, disease-free survival, and
overall survival between MIDP and ODP [13–15]. Once
again, the currently available data could suffer from retrospective selection bias. Results from 2 ongoing randomized
controlled trials, the European multicenter DIPLOMA trial
(ISRCTN44897265), and the Chinese multicenter “Study
of Laparoscopic Versus Open Distal Pancreatectomy in
Patients with Pancreatic Cancer at the Body and Tail”
(NCT03792932), should increase the level of evidence
available on this topic.
References
1. Marino MV, Mirabella A, Gomez Ruiz M, et al. Roboticassisted versus laparoscopic distal pancreatectomy: the results
of a case-matched analysis from a tertiary care center. Dig Surg.
2020;37(3):229–39.
2. Chen S, Zhan Q, Chen JZ, etal. Robotic approach improves spleenpreserving rate and shortens postoperative hospital stay of laparoscopic distal pancreatectomy: a matched cohort study. Surg Endosc.
2015;29(12):3507–18.
3. Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update
of the International Study Group (ISGPS) denition and grading of postoperative pancreatic stula: 11 Years After. Surgery.
2017;161(3):584–91.
4. Liu R, Wakabayashi G, Palanivelu C, etal. International consensus
statement on robotic pancreatic surgery. Hepatobiliary Surg Nutr.
2019;8(4):345–60.
5. Marino MV, Podda M, Gomez Ruiz M, Fernandez CC, Guarrasi
D, Gomez FM. Robotic-assisted versus open pancreaticoduodenectomy: the results of a case-matched comparison. J Robot Surg.
2020;14(3):493–502.
6. Benoist S, Dugue L, Sauvanet A, etal. Is there a role of preservation of the spleen in distal pancreatectomy? J Am Coll Surg.
1999;188(3):255–60.
7. Shoup M, Brennan MF, McWhite K, et al. The value of splenic
preservation with distal pancreatectomy. Arch Surg. 2002;137(2):
164–8.
8. Esposito A, Casetti L, De Pastena M, et al. Robotic spleenpreserving distal pancreatectomy: the Verona experience. Updat
Surg. 2020;
9. Hu YH, Qin YF, Yu DD, et al. Meta-analysis of short-term outcomes
comparing robot-assisted and laparoscopic distal pancreatectomy. J
Comp Eff Res. 2020;9(3):201–18.
10. Kamarajah SK, Sutandi N, Robinson SR, et al. Robotic versus
conventional laparoscopic distal pancreatic resection: a systematic
review and meta-analysis. HPB (Oxford). 2019;21(9):1107–18.
11. Hong S, Song KB, Madkhali AA, et al. Robotic versus laparoscopic distal pancreatectomy for left-sided pancreatic tumors: a
single surgeon’s experience of 228 consecutive cases. Surg Endosc.
2020;34(6):2465–73.
12. Weng Y, Jin J, Huo Z, et al. Robotic-assisted versus open distal
pancreatectomy for benign and low-grade malignant pancreatic
tumors: a propensity score-matched study. Surg Endosc. 2020;
13. van Hilst J, Korrel M, de Rooij T, et al. Oncologic outcomes of
minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis.
Eur J Surg Oncol. 2019;45(5):719–27.
14. Riviere D, Gurusamy KS, Kooby DA, et al. Laparoscopic versus open distal pancreatectomy for pancreatic cancer. Cochrane
Database Syst Rev. 2016;4(CD011391)
15. Nakamura M, Nakashima H.Laparoscopic distal pancreatectomy
and pancreatoduodenectomy: is it worthwhile? A meta-analysis
of laparoscopic pancreatectomy. J Hepatobiliary Pancreat Sci.
2013;20(4):421–8.
Total Pancreatectomy
AleksandarKaramarkovic, JovanJuloski, andVladicaCuk
50
Abstract
Total pancreatectomy (TP) plays an important role in the
treatment of some pancreatic disorders for several reasons: (I) TP is the only surgery for a radical resection of
pancreatic cancer with extensive tumors for which complete removals cannot be achieved by means of pancreatoduodenectomy (PD) or distal pancreatectomy (DP). (II)
TP is helpful to the dissection of surrounding lymph
nodes and nerves, and may improve the long-term prognosis of pancreatic cancer. (III) Pancreatic cancer involving multi segments extensively, as well as main-duct
IPMN and multifocal branch-duct IPMN involving the
entire pancreas, require TP. (IV) Anastomotic leak, postoperative pancreatic stula (POPF), and postoperative
pancreatic hemorrhage (PPH) as the consequence of
POPF can be prevented by performing TP.
In order to achieve better local control for borderline
resectable pancreatic cancer (BRPC) and locally advanced
pancreatic cancer (LAPC), especially after neoadjuvant
treatment, we recommend adding TRIANGLE operation
to TP as a key procedure.
50.1 Introduction
The rst successful TP for pancreatic adenocarcinoma was
performed by Rockey [1] in 1943. After advances made in
the surgical techniques and glycemic monitoring as well as
the development of synthetic insulin and pancreatic enzymes,
the medical management after TP has improved. Some studies have demonstrated acceptable QOLs after TP for neo-
A. Karamarkovic (*) · J. Juloski · V. Cuk
Department of HPB Surgery, Surgical Clinic “Nikola Spasic”,
University Clinical Center Zvezdara, Belgrade, Serbia
Faculty of Medicine University of Belgrade, Belgrade, Serbia
e-mail: alekara@sbb.rs
plastic disease [2–4]. With growing experience, technical
improvement and perioperative care advancement, we now
have mortality less than 3% and morbidity rates around 40%
in high-volume centers [5, 6].
50.2 Indications
Indications for TP can be classied into four “T” groups [7, 8]:
1. Tumors of advanced stage or specic localization
2. Technical problems due to soft pancreatic tissue or small
pancreatic duct
3. Troubles due to perioperative surgical complications
4. Therapy refractory pain due to chronic pancreatitis
The most frequent indication for TP is advanced or multifocal pancreatic tumors [8]. Recurrent pancreatic carcinoma,
IPMN and extensive neuroendocrine tumors are also tumor
related indications for total pancreatectomy [9–11]. TP for
cases of main-duct IPMN and mixed-type IPMN is conducted either as a primary en block resection, when IPMN
extends throughout the entire pancreas, or as a sequential
operation, when frozen section analysis reveals IPMN on the
resection margin after partial resection [12]. Management of
multifocal branch-duct IPMN is a bit more challenging, and
still a matter of controversies, regarding indication, correct
timing, and extent of surgical interventions [12]. Based on
the “Fukuoka” criteria, the risk of malignancy in these
lesions have been described [13]. According to these guidelines, resection of lesion greater than 3cm in diameter should
be resected. Smaller ones should be resected, but only if
“high risk” stigmata are present (mural nodules, positive
cytology, symptoms, or a synchronously dilated main duct).
Still remaining concerns are, among all IPMN smaller than
3cm, that are resected, about 25% were shown to be malignant [13]. Standard approach for all suspected malignant
branch-duct IPMN is adequate resection with lymphadenectomy, similar to the approach in main-duct IPMN [12].
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_50
377
378
In the case of chronic pancreatitis without dilation of pancreatic duct in patients resistant to medical treatment, TP has
been proposed [14]. The procedure is also proposed for
patients with hereditary pancreatitis who are at elevated risk
for pancreatic cancer development [15].
Technical problems due to soft pancreatic tissue represent
not so uncommon indication for TP. In cases when reconstructions of the common hepatic (CHA) and superior mesenteric arteries (SMA) are undertaken, TP is generally
performed and recommended [16, 17]. The complete resection of pancreas reduces the rate of morbidity and mortality
by eliminating completely the incidence of POPF and its
potentially fatal effect on the arterial anastomosis [15].
Following “partial” pancreatic resection, complications
such as POPF complicated by acute bleeding, sepsis, can
occur. In these cases, TP is indicated as a salvage procedure [7].
In patients undergoing pancreatectomy for PDAC, TP
provides chances of R0 resection in isolated neck marginpositive patients and was associated with a survival benet.
TP is recommended for patients having cancer spread from
the head to the left part of the pancreas [15, 18].
The denition of BRPC and LAPC is based on the relationship of tumor and its nearby main blood vessels [19].
Previous classication made by AHPBA/SSO/SSAT was
further claried by the National Comprehensive Cancer
Network (NCCN), and International Study Group of
Pancreatic Surgery (ISGPS) also [20, 21].
While neoadjuvant therapy is necessary in LAPC to
achieve a chance of conversion surgery afterwards, its use
in BRPC and especially resectable pancreatic cancer is currently still under debate. Surgical resection of BRPC is still
controversial; i.e., Whether or not to resect the tumor
largely depends on preoperative imaging diagnosis, which
unfortunately cannot always provide real resectability [22]
or distinguish tumor invasion from brosis caused by
inammation [23].
Despite the wide application of MDT in the treatment of
pancreatic cancer [24], there is still a dilemma where the
patient may lose the opportunity of surgery for a resectable
tumor or the surgeon may end up by excising an unresectable
tumor for which R0 resection cannot be achieved. For example, especially those patients who are considered unresectable
because of CA, CHA or SMA encasement (no more than half
in circumference) can get R0 resection with surgeon’s effort.
For the treatment of BRPC, neoadjuvant therapy is highly
recommended in guidelines especially in Europe and US
[25]. Some treatment reported has greatly improved the resection rate and prognosis of BRPC and LAPC [26, 27].
The TRIANGLE operation (Fig.50.1) was proposed by
Heidelberg group in 2017 [28] as novel approach for the
patients with LAPC after the neoadjuvant therapy. The rationale of this procedure is the observation that after neoadju-
A. Karamarkovic et al.
Fig. 50.1 TRIANGLE total pancreatectomy with en block porto-
mesenteric vein resection. Intraoperative view after complete dissection
of the TRIANGLE region including circumferential skeletonization of
the CA/CHA, SMA (red tape) and PV/SMV (blue tape) resection and
reconstruction with ringed PTFE allograft interposition
vant therapy conventional imaging fails to differentiate
between actual tumor encasement or abutment and only
brotic residual tissue mainly to the arterial structures [28].
However, some patients, whose tumor fails to down-stage
but develops after neoadjuvant therapy, lose the opportunity
to undergo radical resection of the tumor. For those patients
with artery encasement, upfront surgery with extensive dissection of the TRIANGLE region including celiac axis (CA),
CHA, SMA portal vein (PV) and superior mesenteric vein
(SMV), as well as complete skeletonization of these vessels,
may allow R0 resection and decrease the local recurrence. In
fact, those patients in the study of Zhai etal., do not appear
local recurrence after surgery [29]. Some studies described
that the TRIANGLE operation for BRPC was safe and efcient [29, 30]. TRIANGLE operation should be added to TP
as a key procedure, which will help to increase the number of
lymph nodes examined, reduce complications rate and have
better radical treatment efcacy for BRPC [29].
50 Total Pancreatectomy
379
50.3 Surgical Procedure
TP can be performed in two different situations, namely:
1. TP as a second step after PD.
This is the situation, which takes place after PD due to
technical reasons, early septic and bleeding complications or
neoplastic inltration of the pancreatic resectional margin
found at frozen section. In such cases, left pancreatectomy is
performed after PD.
2. TP as an “at once” procedure.
In this case, an en-bloc resection is performed of the
entire pancreas, part of the stomach, duodenum, jejunum,
common bile duct, gallbladder, and spleen.
Resectability was evaluated according to NCCN guidelines (version 3. 2017.) [31].
1. Kocher’s Maneuver to Lift the Head of the Pancreas and
the Duodenum.
After the exposure of left renal vein and the abdominal
aorta leftwards, expose the root of SMA (Artery First
approach). The origin of SMA isolated from a right posterior
approach [32] just above the aorta and left renal vein; after
that, infrapancreatic portion of SMA taped using Mesenteric
approach, proposed by Nakao [33] (Fig.50.2). The concept
of this Artery First strategy, is to evaluate any potential tumor
adherence to the SMA or replacing RHA origin at the beginning of the operation and either stop resection or plan an
arterial resection if required and indicated.
2. Skeletonizing the Hepatoduodenal Ligament.
The elements of the hepatic pedicle are skeletonized,
according to technique for PD.
3. Mobilization of the Spleen and the Body and Tail Portion
of Pancreas.
The body and tail of the pancreas are mobilized from left
to right, in order to dissect and isolate the spleno-pancreatic
complex from distal to proximal till meet the pancreatic isthmus and head.
4. Clearance of TRIANGLE.
Technique comprises dissection of all soft tissue along the
CA, SMA, SMV, and PV in association with a radical tumor
removal. During the resection process, if must be proven that
the specic periarterial tissue does not include viable tumor by
frozen section; afterwards a radical artery-sparing approach
can be conducted [34]. Complete skeletonization of the
regional vasculature is required. Arterial circumferential skeletonization is obligatory, which include complete clearance of
the sheath of the proper vasculature, on the adventitial level.
This results in an anatomic TRIANGLE bordered by the
CA/CHA, SMA and PV/SMV revealed by the dissection and
nally resection indicating the comprehensive removal of all
soft tissue contained within these borders- usually brotic,
neural, and lymphatic tissue (Fig.50.3).
The resection and reconstruction of SMV or PV could be
done when either of them was invaded by tumor, vein reconstruction including direct anastomosis or articial vascular
graft (Fig.50.3). TRIANGLE TP exerts great impact on the
radical resection the negative rate of surgical margin and
long-time survival of patients of pancreatic cancer [28, 29].
The coronary vein is usually divided during the procedure
when TP is performed and a re-insertion is not possible in
most patients due to the extent of resection. Therefore, stomach perfusion has to be critically evaluated at the end of the
operation and a distal or even subtotal stomach resection
may be required to avoid congestion-related ischemia [35].
Fig. 50.2 Pancreatectomy with complete circumferential vascular
clearance and total mesopancreas excision (mesenteric approach)
5. Detachment of the Cephalic duodenopancreatic complex,
Dividing the Gastric Antrum, Transecting Jejunum.
Once the left splenopancreatic complex has been entirely
mobilized and the retropancreatic vessels have been freed,
380
ab
A. Karamarkovic et al.
Fig. 50.3 Radical total pancreatectomy with vascular resection:
Clearance of TRIANGLE with en block porto-mesenteric venous trunk
resection (proximal and distal stumps of PV/SMV are clamped with
vascular clamps—marked with blue arrowhead, while SMA is clamped
the procedure completed with detachment of the cephalic
duodenopancreatic complex, as in extended PD.
with vascular bulldog in order to reduce intestinal congestion) (a); dissection of all soft tissue (TRIANGLE) between CA/CHA and SMA
(red tapes) as well as the reconstructed PV/SMV with PTFE ringed
allograft interposition (blue tape) (b)
In contrast to vein resection, artery resection is more
debatable for its increased morbidity and mortality and
mostly considered as an individual decision in selected
6. Bilio-digestive Reconstruction.
patients [34, 38]. Furthermore, during recent years, the techniques of replacement applied for the hepatic artery or the
Include jejunal loop to perform transmesocolic biliodigestive anastomosis and, subsequently, transmesocolic gastrojejunal anastomosis.
superior mesenteric artery have been improved and procedures such as SA use (Fig. 50.4) have been described for
restoration of hepatic or small-intestine perfusion [16].
According to our policy, we have performed arterial
resection, only if replacing right hepatic artery (RRHA) ori-
50.4 Vascular Resection
gin from the SMA, was inltrated by the tumor (Fig.50.5).
Regarding specic complications and outcomes, the post-
TRIANGLE TP can be combined with arterial resection
and reconstruction, while venous resection is frequently
required in this situation. The most recent meta-analysis
described that patients with pancreatectomy plus venous
resection seemed to attain a larger tumor size, positive
lymph nodes and R1 resection rates and higher 30-day mortality [36]. Controversially to the reported impaired survival after venous resection, a recent propensity
score-matched analysis showed similar survival among the
patients with venous resection and pancreatectomy alone
groups [37].
operative complications and the length of hospital stay and
non-R0 rate were not signicantly different compared to
those without artery resection. Another recent study, covering nearly 40years of experience conrmed the safety and
efcacy of arterial resection for patients with LAPC, additionally suggesting preoperative neoadjuvant therapy with
artery resection as a useful concept for LAPC [39].
A single-center cohort study reported that pancreatectomy with artery resection can obtain better one-, three-, and
ve-year survival rates compared to palliation for patients
with LAPC [40].
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50 Total Pancreatectomy
381
Fig. 50.4 TRIANGLE total pancreatectomy with combined vascular
resections (PTFE graft interposition with SA transposition in reconstruction): Venous resection of PV/SMV trunk and arterial RRHA from
SMA resection (SA prepared for transposition and RRHA reconstruc-
tion) (a); PTFE ringed allograft interposition used for PV/SMV reconstruction while SA transpositioned and anastomosed for the RRHA
reconstruction (SA-RRHA end to end anastomosis marked with blue
arrowhead) (b)
50.5 Comment
Use of TP is supported for the treatment of PDAC in
appropriately selected patients because the long-term survival rates of patients who underwent TP for pancreatic
cancer were comparable to those for patients who underwent PD [41]. The similar 3- and 5-year survival rates in
patients who underwent TP vs. those who underwent PD
suggested that the glycemic issues were not major determinants of death in the long term [42]. TRIANGLE operation is a possible method to achieve the radical resection
of BRPC in patients who have not received neoadjuvant
Fig. 50.5 TRIANGLE total pancreatectomy with arterial resection:
Clearance of TRIANGLE space with concomitant resection of RRHA
arising from SMA: direct “side to end” SMA-RRHA arterial reconstruction (anastomotic line marked with blue arrowheads). PV portal
vein, SMV superior mesenteric vein, IVC inferior vena cava, LRL left
renal vein, AO aorta, SMA superior mesenteric artery, CA celiac axis,
CHA common hepatic artery, SA splenic artery, LGA left gastric artery,
GDA gastroduodenal artery, RRHA replacing right hepatic artery from
SMA; CBD common bile duct
therapy or in LAPC patients after neoadjuvant treatment.
With TRIANGLE TP, artery sparing resection can be
achieved and the postoperative risk of POPF and PPH can
be reduced. However, more studies are needed to further
assess the reliability, feasibility and long-term effect of
this operation [29].
Acknowledgements The authors have no conicts of interest to
disclose.