Artery-First Approaches to Distal Pancreatectomy

Abstract

Artery-first approaches to pancreatic resections have been widely practiced in the setting of a pancrearticoduodenectomy or Whipple procedure for pancreatic cancer. The purposes of artery-first approaches are to determine the resectability in the early phase of operation, to perform more oncologic resection by isolation of the tumor from the blood flow and to reduce the intraoperative blood loss. Until recently, however, artery approaches to a distal pancreatectomy (DP) have been scarcely performed due to the difficulty in approaching the origin of the splenic artery before the transection of the pancreas especially in open surgery. In contrast, by laparoscopic approaches, a surgeon can enter the retroperitoneal space behind the pancreatic body taking advantage of the caudo-cranial angle view through a laparoscope and explore the origin of the celiac artery from the aorta and the origin of the splenic artery without dividing the pancreas. The same approaches can be carried out in open surgery also with techniques, so-called “Tiger Den” approach, as follows. First, we divide the ligament of Treitz and mobilize the fourth portion of the duodenum and proximal jejunum. The adipose tissue in the retroperitoneal space is dissected and the inferior vena cava (IVC) is exposed. The mesentery of the transverse colon is also divided along the posterior border of the pancreatic body, the dissection over the IVC is extended to the left and the left renal vein is exposed. By careful dissections over the aorta, a surgeon can identify the origin of superior mesenteric artery (SMA) and that of the celiac artery. Large Kelly forceps can be passed through the retroperitoneal space behind the pancreatic body toward the left side of the left gastric artery. A Penrose drain is passed thorough the retroperitoneal space and the pancreatic body is lifted upward by the Penrose drain as this procedure is called a hanging maneuver of the pancreas. By the hanging maneuver, the origin of the celiac artery is well visualized. The splenic artery is temporally occluded to isolate the specimen from blood inflow. In cases that en bloc resection of the celiac artery is required due to the extension of the tumor, the celiac artery occluded with bulldog clamps, the blood flow of intrahepatic arteries evaluated with Doppler ultrasonography, the celiac artery is to be ligated or clipped after the confirmation of sufficient arterial blood flow to the liver. After the occlusion of the splenic artery or celiac artery for a conventional DP or distal pancreactectomy with celiac artery resection (DP-CAR), respectively, the pancreas is divided at the designated part, typically in front of the superior mesenteric vein (SMV). The splenic vein is divided and the pancreatic body is flapped to the left side. The pancreatic body is dissected together with posterior tissue. The splenic artery, which had been already occluded, is now divided for DP, while the celiac artery and common hepatic artery are divided for DP-CAR. During DP-CAR, the left gastric artery is also divided if the origin of the left gastric artery is involved by the tumor. When needed, the left adrenal gland is resected en bloc and the tail of the pancreas and the spleen are dissected to complete DP or DP-CAR. In conclusion, the Tiger Den approach and the hanging maneuver of the pancreas are useful for artery-first approaches to DP and DP-CAR.