Isolated Pancreatoduodenectomy with Portal Vein Resection Using the Nakao Mesenteric Approach

Abstract

The ideal surgical approach for pancreatic head cancer is isolated pancreatoduodenectomy (PD); that is, en bloc resection using non-touch isolation technique. However, this approach is difficult because of the complex peripancreatic vascular anatomy. In 1981, we developed an antithrombogenic bypass catheter for the portal vein (PV) to prevent portal congestion or hepatic ischemia during PV resection and facilitate simultaneous resection of the hepatic artery. In 1992, we developed a mesenteric approach for PD. The mesenteric approach allows dissection from the non-cancer infiltrating side and determination of cancer-free surgical margins and resectability, followed by systematic lymphadenectomy around the superior mesenteric artery. This approach enables early ligation of the inferior pancreatoduodenal artery and excision of the second portion of pancreatic head nerve plexus. Through this development of the mesenteric approach and antithrombogenic catheter-bypass procedure of the PV, establishment of isolated PD was completed in 1992. This is the ideal surgery for pancreatic head cancer from both surgical and oncological viewpoints. The precise surgical techniques of isolated PD, using the Nakao mesenteric approach are herein introduced.