A Novel Classification and Staged Approach for Dissection Along the Celiac and Hepatic Artery During Pancreaticoduodenectomy

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In recent decades, there have been enthusiastic discussions of, and active proposals for, new approaches to dissection around the superior mesenteric artery during pancreaticoduodenectomy (PD). In contrast, dissection along the celiac axis (CA) and hepatic artery (HA) and in the hepatoduodenal ligament has rarely been systematically discussed. In this report, we propose and describe a three-level classification of dissection along the CA-HA system which is applicable to a variety of diseases for which PD is indicated. The extent of dissection is classified into three levels. With the first level (LV-1), neither LN nor plexus dissection is required. The second level (LV-2) includes en bloc resection of LNs along the CA, HA, and in the hepatoduodenal ligament, preserving the nerve plexus around the artery. The third level (LV-3) includes en bloc dissection of LNs and the nerve plexus close to cancer invasion, for example, being accompanied by half circumferential dissection of the nerve plexus around the CA or circumferential dissection of that of HA. LV-1 dissection is indicated for benign lesions, low grade malignancy, pancreatic metastasis, or intraductal papillary mucinous neoplasm. LV-2 is indicated for periampullary malignancies requiring dissection of regional LNs, including ampullary, distal bile duct, duodenal cancers, and pancreatic cancers without evidence of invasion around the CA-HA system. LV-3 is indicated for malignancies with evidence of perineural invasion in the CA-HA system, such as pancreatic cancer at the pancreatic neck or advanced bile duct cancer. In combination with classified superior mesenteric artery dissection, a variety of PD procedures would be systematically classified, understood, and reproduced regardless of nature of disease, surgeon, or approach.