A Sequential “Top-Down” and “Retro Mesenteric Caudo-cranial Superior Mesenteric Artery Approach” for Posteriorly Located Locally Advanced Pancreatic Head Cancers

Purpose: We present a novel surgical strategy with a “Top-Down approach”, followed by “Retro mesenteric caudocranial SMA 1st approach” in posteriorly placed locally advanced pancreatic head cancer with combined SMA/SMV (Superior mesenteric vein) involvement along with invasion of Inferior Vena Cava (IVC) (Case details in Video 1). Methods & Results: The surgical strategy included Cattell Braasch manoeuvre followed by early pancreatic neck transection. In cases with combined SMA and SMV involvement, often SMV resection and anastomosis is required first before dealing with SMA involvement, depending on the extent and location of vascular involvement. The purpose is dual; to minimize the venous clamp duration and to get a good access for SMA dissection and clearance of the triangle area. Then the SMA is approached from retro mesenteric area and caudocranial SMA divestment was performed, as the SMA wall was uninvolved. Finally, the involved anterior wall of IVC was resected en bloc and the IVC defect was reconstructed by peritoneal patch. Unlike the conventional methods, retro mesenteric approach allows dissection from the dorsal and peripheral sides of the SMA, allowing direct access to the jejunal branches and inferior pancreaticoduodenal arteries from the caudal aspect of SMA. It also allows adequate dissection of peripancreatic and para-aortic nodes along with peripancreatic nerve plexus resection and peri-arterial divestment of SMA in locally advanced tumours. This approach also provides optimal access to the retroperitoneum allowing for posterior mesopancreatic dissection. (2-4) Conclusion: The sequential approach addresses the multilevel vascular involvement in sequential manner and allows for a margin negative resection, minimal tumour handling and less blood loss in a difficult scenario. (Videos 1 & 2)