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. 2018 Sep;32(9):4044-4051.
doi: 10.1007/s00464-018-6118-z. Epub 2018 Feb 26.

Approaching the superior mesenteric artery from the right side using the proximal-dorsal jejunal vein preisolation method during laparoscopic pancreaticoduodenectomy

Yuichi Nagakawa  1 , Yuichi Hosokawa  2 , Yatsuka Sahara  2 , Chie Takishita  2 , Yosuke Hijikata  2 , Hiroaki Osakabe  2 , Tetsushi Nakajima  2 , Tomoki Shirota  2 , Kenji Katsumata  2 , Masafumi Nakamura  3 , Akihiko Tsuchida  2
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Approaching the superior mesenteric artery from the right side using the proximal-dorsal jejunal vein preisolation method during laparoscopic pancreaticoduodenectomy

Yuichi Nagakawa et al. Surg Endosc. 2018 Sep.

Abstract

Background: Although the artery-first approach is widely used in open pancreaticoduodenectomy, it is difficult to laparoscopically expose the origin of the inferior pancreaticoduodenal artery (IPDA) from the left side of the superior mesenteric artery (SMA). By contrast, damaging the inferior pancreaticoduodenal veins (IPDVs) is possible when approaching the IPDA from the right side of the SMA. To facilitate the artery-first approach in laparoscopic pancreaticoduodenectomy (LPD), we focused on the proximal-dorsal jejunal vein (PDJV) that branched from the superior mesenteric vein (SMV) dorsal side and drained the IPDVs. This study aimed to clarify the usefulness of the right SMA approach using the PDJV preisolation method.

Methods: The PDJV was first isolated, and the IPDVs were divided along the PDJV on the right side of the SMA. Then, the IPDA was divided at the root without first separating the pancreatic head from the portal vein and the SMV. Overall, 21 patients underwent this approach, and the results were retrospectively compared with those of 21 patients who underwent the artery-first approach, which was performed on the left side of the SMA. Anatomical characteristics of the PDJV were evaluated using multidetector computed tomography for the two groups.

Results: Operative times and resection times were significantly lower for the PDJV preisolation group than for the conventional LPD group (489.3 vs. 541.7 min, respectively; p = 0.002). During anatomical evaluation, 41 patients (97.6%) had a PDJV that drained from the SMV dorsally and was in contact with the anterior aspect of the uncinate process. The PDJV was confirmed as the first jejunal vein in 31 patients (73.8%) and as the second jejunal vein in 10 patients (23.8%).

Conclusions: This approach facilitates dissection of the IPDA on the right side of the SMA, thereby reducing operative times.

Keywords: Artery-first approach; Inferior pancreaticoduodenal artery; Laparoscopic pancreaticoduodenectomy; Pancreatic tumor; Proximal-dorsal jejunal vein; SMA-first approach.

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