Open and Minimal Approaches to Pancreatic Adenocarcinoma

Abstract

Surgical options and approaches to pancreatic cancer are changing in the current era. Neoadjuvant treatment strategies for pancreatic cancer combined with the increased use of minimal access surgical techniques mean that the modern pancreatic surgeon requires mastering a number of surgical approaches with to optimally manage patients. Whilst traditional open surgery remains the most frequent approach for surgery, the specific steps during surgery may need to be modified in light of the aforementioned neoadjuvant treatments. Robotic and laparoscopic approaches to pancreatic resection are feasible, but these surgical methods remain in their infancy. In this review article, we summarise the current surgical approaches to pancreatic cancer and how these are adapted to the minimal access setting with discussion of the patient outcome data.

Figure 1

The Cattell-Braasch manoeuvre. The right colon, small bowel mesentery root, and duodenum (Kocherization) are mobilised from right to the left quadrant to allow exposure of the retroperitoneal structures and major vasculature. With completion of the Cattel-Braasch manoeuvre, the root of the SMA can be dissected free and SMA isolated from the tumour. (Taken from https://media.springernature.com/original/springer-static/image/art:10.1007/s11605-015-29581/MediaObjects/11605_2015_2958_Fig2_HTML.gif.)

Figure 2

Preoperative CT triple phase may identify the anomalous anatomy shown here where the right hepatic artery originates from the SMA (red sloop) and left hepatic artery from the left gastric artery (blue sloop). The above patient had received neoadjuvant chemoradiation, and therefore, normal anatomical planes are not present and preoperative imaging can assist in safe dissection.

Figure 3

Postoperative CT demonstrating a single layer pancreaticojejunostomy using a dunking technique performed over a pancreatic duct stent.

Figure 4

The posterior artery-first approach for the pancreatic cancer. The pancreatic resection has been completed. The blue sloop is encircling the SMA and the green sloop the portal vein. All the retropancreatic tissues have been divided prior to pancreatic neck division. Gerota's fascia is apparent, and the yellow sloop is displacing the common hepatic artery. This patient had also received neoadjuvant chemoradiation.

Figure 5

Surgical methods for vein reconstruction after vein resection for PDAC. (Taken from Glebova et al., J Vasc Surg 622: 424-443).

Figure 6

A 12 mm port is placed two fingerbreadths below and to the right of the umbilicus, two robotic ports are placed in the right upper quadrant, a port is placed in the right lower quadrant, a port in the left lower quadrant, and a port in the anterior axillary line on the left side of the abdomen.