Hanging spleno-mesenteric confluence - approach to minimal invasive pancreatoduodenectomy

Abstract

Presenter: Omero Costa Filho MD, MSc | Hospital Militar de Área de Porto Alegre (HMAPA) Methods: Description of our conventional technique for LPD using hanging maneuver to expose uncinate process with the principles of “artery-first” approach. Results: LPD is performed with the patient placed in a supine, split-leg position and carefully secured to the operative table, and the surgeon on foot between the patient legs, and an assistant at each side. A 12-mm Hasson trocar is placed at about 16 cm from the xyphoid, and a pneumoperitoneum is established. A total of four additional trocars, two 12 mm and two 5 mm, are placed in the abdomen with a semi-circular pattern centered around the head of the pancreas. All the steps to LPD was following our institutional protocol and we focus on uncinate process time. After the surgeon switches position to the right side of the patient, an instrument is used partially open to retract the uncinate process to the right of the patient and dissect freely the splenic mesenteric venous confluence (SMVC). The uncinate process is carefully dissected from the lateral aspect of the superior mesenteric vein (SMV) while small vessels clipped. To best expose, we ligate the gastrocolic trunk (Henle’s trunk) at this time. Then portal vein (PV) and SMV are carefully looped with two penrose drain number 2 to have proximal and distal control, if needed, and to facilitate retraction by the assistant on the left side of the patient. The SMV is retracted medially with penrose. Care must be taken with the first jejunal vein, that was our inferior limit and start point of dissection. The SMA can be found directly under and slightly medial to the SMV. The SMA dissection is carried out using a vessel sealing device. The inferior pancreaticoduodenal artery is usually ligated with clips. During all dissection, release of hanging PV and SMV was done to ensure hepatic inflow. When the dissection found SMVC, we hung the PV with penrose, to expose the mesopancreas and nodes at take off SMA and celiac trunk (CT). A complete, en-bloc resection of the uncinate process is assured, looking to expose SMA and CT emergence from Abdominal Aorta. Conclusion: This is technique description of our actual LPD in approach of uncinate process but can be extend to robotic pancreatic surgery. We continue to track our cases to improve our results with secure issues and oncology outcomes. Until now, with use of initial experience of hanging spleno-mesenteric confluence show a better view of mesopancreas and SMA. Further evaluation with our historical cohort may show beneficial use of our suggestion to such challenge MIS procedure.