Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Nov 30;11(23):7112.
doi: 10.3390/jcm11237112.

Surgical Strategies to Dissect around the Superior Mesenteric Artery in Robotic Pancreatoduodenectomy

Kosei Takagi  1 , Yuzo Umeda  1 , Ryuichi Yoshida  1 , Tomokazu Fuji  1 , Kazuya Yasui  1 , Jiro Kimura  1 , Nanako Hata  1 , Kento Mishima  1 , Takahito Yagi  1 , Toshiyoshi Fujiwara  1
Affiliations

Surgical Strategies to Dissect around the Superior Mesenteric Artery in Robotic Pancreatoduodenectomy

Kosei Takagi et al. J Clin Med. .

Abstract

The concept of the superior mesenteric artery (SMA)-first approach has been widely accepted in pancreatoduodenectomy. However, few studies have reported surgical approaches to the SMA in robotic pancreatoduodenectomy (RPD). Herein, we present our surgical strategies to dissect around the SMA in RPD. Among the various approaches, our standard protocol for RPD included the right approach to the SMA, which can result in complete tumor resection in most cases. In patients with malignant diseases requiring lymphadenectomy around the SMA, we developed a novel approach by combining the left and right approaches in RPD. Using this approach, circumferential dissection around the SMA can be achieved through both the left and right sides. This approach can also be helpful in patients with obesity or intra-abdominal adhesions. The present study summarizes the advantages and disadvantages of both the approaches during RPD. To perform RPD safely, surgeons should understand the different surgical approaches and select the best approach or a combination of different approaches, depending on demographic, anatomical, and oncological factors.

Keywords: pancreatic cancer; pancreatoduodenectomy; robotic surgery; superior mesenteric artery; surgical approach.

PubMed Disclaimer

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Surgical approaches to the superior mesenteric artery (SMA) in robotic pancreatoduodenectomy: (a) right and left approaches to the SMA; (b) right approach to the SMA; (c) left approach to the SMA.
Figure 2
Figure 2
The anatomy around the superior mesenteric artery (SMA) during the right approach: (a) right approach is suitable for dissecting the right aspect of the SMA; (b) with the pancreatic head lifted, the axis of the SMA can be rotated clockwise approximately 90°, and the dissection area can be expanded; however, a difficult area for dissection still exists at the right side of the SMA (purple arrow); and (c) an overview of the dissection area around the SMA by the right approach. IPDA, inferior pancreaticoduodenal artery; J1A, first jejunal artery.
Figure 3
Figure 3
The anatomy around the superior mesenteric artery (SMA) during the left and right approaches: (a) the left approach is suitable for dissecting the left aspect of the SMA; and (b) the overview of circumferential dissection around the SMA using a combination of both approaches. IPDA, inferior pancreaticoduodenal artery; J1A, first jejunal artery.
Figure 4
Figure 4
Lymphadenectomy around the superior mesenteric artery (SMA) in robotic pancreatoduodenectomy: (a) the left aspect of the SMA is exposed by the left approach; and (b) the right aspect of the SMA is skeletonized by the right approach. SMA, superior mesenteric artery; SMV, superior mesenteric vein; CHA, common hepatic artery; IVC, inferior vena cava.
See this image and copyright information in PMC

References

    1. Sanjay P., Takaori K., Govil S., Shrikhande S.V., Windsor J.A. ‘Artery-first’ approaches to pancreatoduodenectomy. Br. J. Surg. 2012;99:1027–1035. doi: 10.1002/bjs.8763. - DOI - PubMed
    1. Jiang X., Yu Z., Ma Z., Deng H., Ren W., Shi W., Jiao Z. Superior mesenteric artery first approach can improve the clinical outcomes of pancreaticoduodenectomy: A meta-analysis. Int. J. Surg. 2020;73:14–24. doi: 10.1016/j.ijsu.2019.11.007. - DOI - PubMed
    1. Asbun H.J., Moekotte A.L., Vissers F.L., Kunzler F., Cipriani F., Alseidi A., D’Angelica M.I., Balduzzi A., Bassi C., Björnsson B., et al. The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection. Ann. Surg. 2020;271:1–14. doi: 10.1097/SLA.0000000000003590. - DOI - PubMed
    1. Bhandare M.S., Parray A., Chaudhari V.A., Shrikhande S.V. Minimally invasive surgery for pancreatic cancer-are we there yet?—A narrative review. Chin. Clin. Oncol. 2022;11:3. doi: 10.21037/cco-21-131. - DOI - PubMed
    1. Nagakawa Y., Watanabe Y., Kozono S., Boggi U., Palanivelu C., Liu R., Wang S.E., He J., Nishino H., Ohtsuka T., et al. Surgical approaches to the superior mesenteric artery during minimally invasive pancreaticoduodenectomy: A systematic review. J. Hepatobiliary Pancreat. Sci. 2022;29:114–123. doi: 10.1002/jhbp.905. - DOI - PubMed

LinkOut - more resources