The 'TRIANGLE Operation' by Laparoscopy: Radical Pancreaticoduodenectomy with Major Vascular Resection for Borderline Resectable Pancreatic Head Cancer.

Abstract

It has recently been shown that the 'triangle operation'1 may be associated with margin-free resection in selected patients with borderline resectable pancreatic cancer after neoadjuvant chemotherapy. Such a procedure consists of en bloc removal, following the adventitial plane of the whole mesopancreas from the triangular space delimited by the superior mesenteric artery, hepatic artery, and portal vein.2-11 In this video, we show how to safely perform this procedure by laparoscopy. A 70-year-old male with persistent back pain and significant loss of weight underwent a computed tomography that showed a 3cm mass of the uncinate process of the pancreas with involvement of the superior mesenteric artery and venous axis. The biopsy, performed at the time of endoscopic retrograde cholangiopancreatography, showed an adenocarcinoma of the pancreas. Cancer antigen (CA) 19-9 was in the normal range. The patient received eight cycles of neoadjuvant chemotherapy (FOLFIRINOX). The chemotherapy induced a major tumoral radiological response with tumoral shrinkage, however the preoperative computed tomography showed persistent infiltration of the mesopancreas behind the superior mesenteric artery and venous axis. A radical laparoscopic pancreaticoduodenectomy with portal vein resection was performed, including the complete clearing of the superior mesenteric artery and the right side of the celiac trunk, as in the 'triangle operation'. Venous reconstruction was achieved with an end-to-end 5/0 polypropylene running suture with growth factor, while intestinal reconstruction was achieved with an end-to-side hepaticojejunal anastomosis, a double purse-string pancreaticogastrostomy, and side-to-side mechanical linear gastrojejunostomy. The specimen was removed via a short Pfannenstiel incision. Operative time was 7h and 15min, and blood loss was 150. Frozen sections of the superior mesenteric artery margins were negative for tumoral cells. On postoperative day 5, the patient had a hematemesis with bleeding from the pancreaticogastrostomy, which was treated endoscopically. Hospital stay was 16days. Histopathological examination showed a well-differentiated adenocarcinoma of the pancreas [ypT3 N1 (3/36) R0]. The 'triangle operation' for borderline resectable pancreatic head cancer can be achieved safely by laparoscopy in carefully selected patients.1-11 Proven experience in both open and laparoscopic pancreatic surgery is mandatory.