Laparoscopic radical antegrade modular pancreatosplenectomy for pancreatic cancer: technical tips and pitfalls

Abstract

: Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been increasingly performed for pancreatic ductal adenocarcinoma (PDAC) in the body and tail of the pancreas. However, it is technically demanding, and a lack of experience can lead to serious intraoperative and postoperative complications or local recurrence due to residual tumors at the surgical margins. There are three keys to successful L-RAMPS: understanding anatomical variations; obtaining appropriate operative fields; and familiarity with several approaches. Preoperative evaluation should be focused not only on the tumor characteristics but also on the anatomical variations of major vessels. Surgeons should choose the appropriate approach according to the tumor location and anatomical variations for each patient. Retracting the liver and stomach is crucial for obtaining appropriate operative fields around the pancreas. Optimizing the caudal view of laparoscopy is important for safe approaches to the major vessels. Adequate posterior dissection according to the extent of retropancreatic invasion and en bloc regional lymphadenectomy should be performed for oncological benefits. Additionally, proper pancreatic transection with precompression of the pancreas, adequate selection of the cartridge of stapler, and slow firing technique is crucial for the prevention of postoperative pancreatic fistulas. A review of the literature was performed and our standard L-RAMPS technique was described.