An anatomical review of various superior mesenteric artery-first approaches during pancreatoduodenectomy for pancreatic
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REVIEW ARTICLE
An anatomical review of various superior mesenteric artery‑first approaches during pancreatoduodenectomy for pancreatic cancer Junji Yamamoto1 · Hiroki Kudo1 · Yusuke Kyoden1 · Yoshinori Ajiro1 · Masaya Hiyoshi1 · Takayuki Okuno1 · Hiroshi Kawasaki1 · Masaru Nemoto1 · Fuyo Yoshimi1 Received: 22 July 2020 / Accepted: 8 September 2020 © Springer Nature Singapore Pte Ltd. 2020
Abstract When pancreatic head cancer invades the superior mesenteric artery (SMA), attempts at curative resection are aborted. Preoperative imaging diagnostics to determine the surgical curability have yet to surpass the intraoperative information acquired via inspection, palpation, and trial dissection. Pancreatoduodenectomy (PD) is a standard measure for treating periampullary cancers. In conventional PD, SMA invasion is usually identified by dissecting the retroportal lamina, which connects the uncinate process and SMA nerve plexus after dividing the neck of the pancreas. During PD for pancreatic head cancer, this retroperitoneal margin frequently vitiates surgical curability. SMA-first approaches during PD are methods where the SMA is dissected first by severing the posterior pancreatic capsule to assess the SMA involvement of pancreatic cancer early in the operation. The first report of such an approach prompted subsequent reports of various maneuvers that are now known collectively as “artery-first” approaches. We herein review those approaches by classifying them according to (1) the side of the mesocolon from where the SMA approach occurs (supracolic or infracolic) and (2) the direction of access (right or left and anterior or posterior). The steps of the reported PD procedures are numbered according to a timeline and summarized using anatomical division of the SMA. Keywords Pancreatoduodenectomy · Operative procedure · Pancreatic cancer · Artery-first approach
Introduction Pancreatoduodenectomy (PD) has become a standard measure for treating periampullary cancers because of its ability to significantly reduce postoperative mortality to less than 3%. Improved mortality is also attributable to an enhanced understanding of the surgical anatomy and tumor status during preoperative imaging assessments, improved operative expertise, and more-effective management of postoperative complications [1]. However, pancreatic head cancers, especially those arising from the uncinate process, often surround the superior mesenteric artery (SMA), and real invasion of the SMA contraindicates curative resection. With regard to determining the surgical curability, preoperative imaging diagnostics * Junji Yamamoto j‑[email protected] 1
Department of Gastrointestinal Surgery, Ibaraki Prefectural Central Hospital, Koibuchi 6528, Kasama, Ibaraki 309‑1793, Japan
have yet to surpass the information acquired intraoperatively via inspection, palpation, and trial dissection. In conventional PD, SMA invasion is usually determined while dissecting the retroportal lamina [2, 3] containing the nerve plexus and lymph–areolar connective tissue t
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