Total Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Left-Posterior Superior Mesenteric Artery First-approach for Distal Pancreatic Cancer (with video)

Abstract Pancreatic ductal adenocarcinoma (PDAC) is one of the most malignant gastrointestinal cancers. Among them, tumors of the pancreatic body and tail, or left-sided PDAC are uncommon, which accounted for about one-third of all the pancreatic neoplasms[1], and supposedly seem more aggressive than tumors of pancreatic head, not only cause by the late presentation, but also due to the difference of molecular characteristics, embryology and histology and therapeutic response[2].Surgery is considered the only curative treatment method in pancreatic cancer, and Radical antegrade modular pancreatosplenectomy (RAMPS), which was firstly published by Strasberg et al., was proved to be superior in safe and effective aspects while comparing with standard retrograde pancreatosplenectomy (SRPS) in recent systematic literature reviews and meta-analyses[3-5]. And according to Guidelines of National Comprehensive Cancer Network (NCCN) as well as Japanese Pancreas Society (JPS), one of major factors that determined the respectability of PDAC was Superior Mesenteric Artery (SMA)’s infiltration[6, 7]. So that, SMA first-approach has been proved with benefits of improving R0-resection rate and better perioperative outcomes, as well as better long-term survival particularly[8]. Recently, with the development of laparoscopic instruments and techniques, total laparoscopic SMA first-approach RAMPS was recently proceeded by some surgeons with optimistic perioperative outcomes versus open SMA first-approach RAMPS[9, 10].With experiment of total laparoscopic SMA first-approach PD, herein we present a novel technique called total laparoscopic left-posterior SMA first-approach RAMPS, with demonstrated on describing the procedure step by step with illustrative images and video.