Feasibility of Middle Colic Artery as a Landmark for Superior Mesenteric Artery – First Approach in Laparoscopic Pancreatoduodenectomy: a Prospective Study

Feasibility of Middle Colic Artery as a Landmark for Superior Mesenteric Artery – First Approach in Laparoscopic Pancreatoduodenectomy: a Prospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Feasibility of Middle Colic Artery as a Landmark for Superior Mesenteric Artery – First Approach in Laparoscopic Pancreatoduodenectomy: a Prospective Study Ham Hoi NGUYEN, Thanh Khiem NGUYEN, Hong Son TRINH, Hai Dang DO, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4018193/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background SMA-first approach in pancreatoduodenectomy (PD) has been widely applied in open surgery as well as laparoscopy. Finding the superior mesenteric artery (SMA), inferior pancreatoduodenal artery (IPDA), first jejunal artery (J1A) has become a great challenge in laparoscopic PD (LPD). Meanwhile, exposing the midde colic artery (MCA) might be a feasible approach to determine SMA, IPDA, and J1A. Our study aims to find the anatomical correlation between MCA and SMA, IPDA, J1A, especially in SMA-first approach LPD from the left. MethodS Uncontrolled clinical trial with 33 patients undergoing LPD had preoperative contrast abdominal CT scan to analyze the anatomical relevance between MCA and SMA, J1A, IPDA. The operation was performed starting with exposing MCA in advance to find SMA, J1A and IPDA. The data was analyzed by SPSS 25.0. Results 90.9% of MCA started at 12–3 o’clock from SMA, the mean distance from the SMA root to the MCA and J1A was 56.4mm and 37.4mm, respectively. The distance between SMA and J1A was 19mm. 72.7% J1A started at 9–12 o’clock, 69.7% J1A and IPDA had a common trunk. 78.8% IPDA started at 3–6 o’clock. 100% of the cases had J1A controlled intraoperatively, 81.8% for IPDA when approached from the left, 3% had MCA injury. The mean time to approach from the left was 98 minutes, median blood loss was 100 ml. Conclusion Exposing MCA first helps determine SMA, J1A and IPDA safely, efficiently and faciliates SMA-first approach LPD from the left and complete dissection of the mesopancreas and lymph nodes. Laparoscopic pancreaticoduodenectomy artery-first approach middle colic artery Figures Figure 1 Figure 2 Figure 3 INTRODUCTION SMA-first approach in PD has proved its efficacy in minimizing blood loss, resecting completely mesopancreas, achieving R0 resection, and prolonging survival time 1 , 2 . LPD with SMA-first approach has been increasingly published in specialized centers 3 . However, this method was still a challenge due to demanding technical skills in dissection and exposure of SMA, IPDA and J1A 4 . Left posterior approach has been proven to be beneficial: first approach to SMA and early control of IPDA and J1A 5 . During dissection, we discovered that MCA could be a helpful landmark in the search for SMA, IPDA and J1A, especially in complicated cases with pancreatitis or obesity. Therefore, we examined the anatomical relationship between MCA and other fundamental vessels in LPD based on preoperative imaging study to apply this landmark in practical scenario of the surgery. METHODS The patient was included if they had periampullary tumor at the resectable stage, indicated for LPD with given protocol with SMA-first approach from the left. The patients should have a good physical status with no contraindications for laparoscopy and normal coagulation function. Preoperative biliary drainage might be indicated if serum bilirubin > 250mmol/L. Exclusion criteria: Vascular invasion suspected, withdrawal from research. Our study was an uncontrolled clinical trial. Totally, 33 patients who agreed to participate with the above-mentioned criteria from January 2021 to August 2023 were included. All of our patients went through a thorough workup, including a contrast CT scan to evaluate anatomical variants of vessels and plan for vascular approach and control. The imaging was made with Maximum Intensity Projection by an experienced radiologist. Surgical protocol All surgeons included in our study were highly experienced with at least 20 cases of LPD and 50 cases of open PD. Place the patient supine, two arms abducted, abduct both legs 60 degrees. Set 5 abdominal trocars. After exploration, approach to the SMA from the left side: The assistant stretches out transverse colon mesentery and first jejunal loop, surgeon ligates Treitz ligament and mobilizes IMV. In case when IMV drained into SMV, ligate the IMV. MCA could be exposed right below transverse colic mesentery. From the MCA, approach to the anterior surface of SMA via posterior peritoneum. After determining the SMA axis, dissect from up to down, from the anterior section to the left posterior side, as the anterior side is considered an avascular region. Expose and ligate the J1A if it is separated or the common trunk with IPDA is short. The first jejunum was then cut. The IPDA is determined by the relative distance and direction with the MCA. If IPDA stems independently from the plane cross 2/3 of the diameter of the SMA left border, we will ligate IPDA. If IPDA/PIPDA stems from the right border, the artery will be preserved to be ligated later. Continuing SMA dissection to the right side till its root (above the left renal vein), perform the lymphadenectomy around the SMA. Mobilize the structure from the anterior surface of inferior vena cava and abdominal aorta. Approach the SMV, ligate the Henle trunk, split the pancreatic neck from the SMV. Cut the gastric antrum, dissect the celiac trunk lymph node, hepatic pedicle, ligate the gastroduodenal artery. Split the pancreatic neck, finalize the mobilization around the SMA. The gallbladder and common bile duct was lastly removed. Do the anastomosis via laparoscopy or mini-open. Place the drainage and do the abdominal closure. Data collection and analysis Patient demographics: age, gender, diagnosis Anatomical parameters: MCA: distance from MCA to SMA root, correlation between MCA position to SMA circumference (classified into 4 quadrants), based on Sobal classification 6 . Type I: Right colic artery (RCA), MCA and ileocolic artery (ICA) originate independently. Type IIa: Common trunk between RCA and MCA Type IIb: Common trunk between RCA and ICA Type IIc: MCA and LCA in one Type III: MCA from celiac trunk Type IV: Others J1A: distance from J1A to SMA root, J1A position, correlation between J1A and IPDA (or PIPDA) IPDA (or PIPDA) on the left, other anatomical variations (if presented). Techniques: time for artery approach, total operative time, J1A ligation, IPDA ligation from the left, peri-SMA nerve plexus preservation, extended lymphadenectomy, intraoperative complications, blood loss and blood transfusion; Conversion to open surgery, total number of lymph nodes, left-side SMA lymph nodes, mesopancreas metastasis Postoperative complications The data was analyzed by SPSS 25.0. We presented the data by mean ± SD for continous variables and percentage for categorical variables. RESULTS There were total 33 patients in our study. The mean age was 58.7 ± 9.1 years (range 35-70). Mean BMI was 20.9 ± 2,0 (16.8 - 25). Table 1. Patient demographics Characteristics Results Age (Mean ± SD, min-max) 30-50 51-70 58.7 ± 9.1 (35 - 70) 6 (18.2) 27 (81.8) Sex Male Female 16 (48.5) 17 (51.5) Medical history Alcohol Chronic liver diseases Chronic pancreatitis 7 (21.2) 1 (3.0) 1(3.0) BMI (Mean ± SD, min-max) <18 18-25 ≥25 20.9 ± 2,0 (16.8 - 25) 2 (6.1) 30 (90.9) 1 (3.0) Anatomical characteristics of MCA In our study, 100% of the patients had independent MCA roots. The mean distance from MCA to SMA root was 56.4 mm. Most of the patients’ MCA (90.9%) originates from the upper right quadrant of the SMA, and only 3% of the cases had MCA on the left side. Anatomical characteristics of J1A The mean distance from J1A to the SMA root was 37.4 mm. Most of the cases (72.7%) had J1A originating from 3 to 6 o’clock of the SMA. In 69.7% of our cases, J1A and IPDA shared a common trunk. The mean distance from J1A to the MCA root was 19 mm. We also recorded other vascular variations, including 3 (9.1%) cases with aberrant RHA, 4 (12.1%) cases with inferior pancreatic artery, 1 (3%) case with left colic artery stemming SMA, 10 (30.3%) IMV draining into SMV. Table 2 : Anatomical characteristics of MCA, IPDA and J1A Characteristics Results Independent MCA root 100 % Distance from MCA to SMA root 56.4 9.8 mm (30-77) MCA position in correlation with SMA 9-12 o’clock 12-3 o’clock 6-9 o’clock 90.9% 6.1% 3% Distance from J1A to SMA root 37.4 mm (22-50.9) J1A position in correlation with SMA 3-6 o’clock: 6-9 o’clock 12-3 o’clock 9-12 o’clock 72.7 % 21.2% 3% 3% Distance from J1A to MCA root 19 7.8 mm (2-33) Correlation between J1A and IPDA (PIPDA) Common trunk Independence 69.7% 30.3% IPDA common trunk present 81.7% IPDA or PIPDA on the left 78.8% Other anatomical variations Aberrant RHA from SMA 3 (9.1%) Inferior pancreatic artery 4 (12.1%) Left colic artery from SMA 1 (3%) J1V anterior to SMA 13 (39.4%) IMV drained into SMV 10 (30.3%) The mean time for the left SMA-approach in our study was 98 minutes. The mean total operative time was 433 minutes. The median total blood loss was 100 mL, ranging from 50 to 1500 mL. Only 1 case had uncontrollable blood loss due to transverse colon mesentery tear, which required intraoperative blood transfusion, and finally, conversion to open surgery. In all of the cases, we succeeded in ligating J1A, preserving peri-SMA neural plexus and performing extended lymphadenectomy. We ligated IPDA from the left in 27 (81.8%) cases. During the post-operative period, we recorded 4 cases with over Grade II complications, including 1 case suffered bleeding from SMV branch injury, requiring reoperation. 1 case with bleeding from the inferior epigastric branch on trocar placement, successfully embolized, 1 case of self-controlled secondary bleeding after grade B pancreatic fistula, and 1 case anastomotic bleeding, treated conservatively with blood transfusion. The mean length of stay at the hospital was 14 days, ranging from 8 – 25 days. Pathology results revealed mean number of collected lymph nodes was 33, with 7.3 collected to the left of the SMA due to extended lymphadenectomy. R0 resection was achieved in 31 (94%) cases. Table 3: Intraoperative techniques and outcomes Characteristics Results Time for left SMA-approach (minutes) 98 27.9 (60 – 153) Total operative time (minutes) 433.3 Blood loss during SMA approach (mL) 84.2 Total blood loss (mL) 143 252 (50 – 1500) Intraoperative blood transfusion (case) 1 (3%) Conversion to open surgery (cases) 1 (3%) J1A ligation 33 (100%) IPDA ligation from the left (cases) 27 (81.8%) Early outcomes Post-operative complications (Clavien-Dindo) II IIIa IIIb 1 (3%) 2 (6%) 1 (3%) Length of stay (days) 14.3 4 (8 – 25) Oncological outcomes Total number of collected lymph nodes 33 Number of lymph nodes to the left of SMA 7.3 Patients with positive lymph nodes 18 (54.5%) Patients with positive left-sided lymph nodes 5 (15.2%) Patients with mesopancreas metastasis 8 (24.2%) R0 resection rate 31 (94%) DISCUSSION Anatomical variations of MCA Anatomical variations cause the most challenge in vascular dissection. Our study showed 39.4% of the cases with J1V anterior to SMA, 30.3% with IMV draining into SMV, 12.1% had inferior pancreatic artery (IPA), 9.1% right hepatic artery (RHA) stemming from SMA and 1% had left colic artery (LCA) . Sobal et al also reported an incidence of 2% of LCA stemming from SMA instead of from inferior mesenteric artery 6 . RHA must be preserved while J1V, IMV, IPA, LCA could be ligated without risk of ischemia. In the case of aberrant RHA, dissection posteriorly to the SMA could be challenging due to a high risk of RHA injury. Although many authors have described different approaches in open surgery, few authors reported a standard protocol for minimally invasive surgery, especially the left posterior approach 5,7,8 . In SMA-first approach, it is important to first identify the SMA, IPDA, and J1A. Studies show that the majority of IPDA originates in the same trunk as the J1A on the left side of the SMA. Left posterior approach has the following advantages: direct access to the SMA, easy control of the IPDA and J1A due to anatomical correlation. Furthermore, according to Nagakawa, the anterior left of the SMA is an avascular space, which facilitates dissection. 9 Anatomical variations of MCA in approach to SMA, J1A, IPDA Basically; RCA, MCA and ICA originate independently from SMA. In Sobal’s study, it is the most common circumstances (82%), and 7 (14%) cases with common MCA and RCA trunk. 6 Soneland et al showed an incidence of type 2a of 26.7%. 10 This was similar to our results, showing the majority of type 1 and a lower incidence of type 2a. We divided the MCA origin from SMA position into 4 regions clockwise: 12–3, 3–6, 6–9, and 9–12 o’ clock. Our study showed 90.9% of MCA stemming at 9-12 o’clock of the SMA (Figure 3 ) . The mean distance between SMA and MCA root was 56 mm, comparable to the inferior border of the pancreas and MCA could be easily found when the colic mesentery and the first jejunal loop were stretched out. This result was similar to that reported by Horiguchi (54 mm) 11 . The author’s study also showed that the distance from MCA to IPDA was significantly shorter than from IPDA to SMA root, and therefore, it was feasible and safe for MCA to be a better landmark than the SMA root to identify IPDA. Horiguchi also highlighted the importance of preoperative measurement of these vessels on imaging study for a better operative plan to find IPDA based on the MCA. 11 MCA frequently stemmed independently at 6-9 o’clock from the SMA. Therefore, MCA should be considered as a helpful and constant landmark in identifying SMA in artery-first approach. In other words, SMA was identified when the MCA was determined (Figure 2) . Analysis of the relationship between MCA and J1A showed that: J1A originated at 37.4mm from the origin of SMA, above MCA and the average distance between MCA and J1A was 19mm (the smallest distance measured on MSCT was 2mm). Evaluation of position of J1A root compared to SMA showed that 72.7% were at 3-6 o’clock, 21.2% were at 6-9 o’clock ( Table 2 ). Thus, to identify J1A, we can find and follow upward the J1A by 19 mm in an upward direction of about 19mm, deviating to the left edge of SMA at about the 3-6 o'clock position. In addition, J1A was closely related to IPDA and PIPDA. Our research results showed that 69.7% of IPDA or PIPDA originated from J1A. This was consistent with other studies like Yoshiya Ishikawa (66%) and Yasunari Kawabata (74.3%) 12,13 . Meanwhile, Murakami reported a common trunk of IPDA and J1A in 58.9% of cases, independent trunk of IPDA from SMA in 24.2%, and 16.9% with IPDA stemming from both sites, 70.6% of which had IPDA (PIPDA) stemming from the left side of the SMA. 14 Our study showed similar results with 78.8% of the cases with common trunk of IPDA and PIPDA branches originating on the left side of the SMA. Our study illustrated a close relationship between J1A and IPDA, and therefore, identifying J1A allowed IPDA to be controlled. Though the race and ethnicity are different, their relationship is similar. Intraoperative and postoperative complications In our study, there is one case of intraoperative MCA injury during vascular dissection. Fortunately, the MCA could be safely ligated without causing colon ischemia. One case required conversion to open surgery due to hemodynamic instability caused by late recognition of bleeding mesentery. This is also a point to pay attention to when using the middle colon landmark, approaching from the left side and dissection of lymph nodes. The incidence of comorbidity in our study was equivalent to others performing left approach, and was not higher than those performing other SMA-first approach. Other publication show higher open conversion rate, such as Treeoongckaruna (17.7%), Boggi (9.1%), Feng Tian (16.7%) 15-17 . The median total blood loss was 100 mL. Our results were lower than that reported by Feng Tian (300ml), and equivalent to Sameer's study (110-350 ml). 17,18 Chen et al compared 2 groups of 89 patients undergoing either open or laparoscopic PD. Total laparoscopic surgery required longer operative time than open surgery, but less blood loss and blood transfusion. 19 Our study implied that left approach did not increase complications in LPD. Boggi et al found complication rates ranging from 18.1 - 64.2%, with an average of 41.2%. The mortality rate varied from 0 - 7.1%. 16 Our study found that the rate of complications at Clavien Dindo classification grade II or higher accounted for 12.1%. Chen et al found that postoperative complications in the laparoscopic group were lower in both incidence and severity but not statistically significant. 19 None of our patients had DGE, bile leakage or bowel anastomosis leak. Our study showed a feasible approach in Whipple’s procedure by using MCA as a landmark for SMA. Further randomized trials with larger sample sizes and longer follow-up should be conducted to prove their effectiveness. CONCLUSION Exposing MCA first helps determine SMA, J1A and IPDA safely, efficiently and faciliates SMA-first approach LPD from the left and complete dissection of mesopancreas and lymph nodes to the left of the SMA. This study was conducted on a small group of patients at a single center. Abbreviations AIPDA: Anterior inferior pancreatoduodenal artery; J1A: First jejunal artery; J1V: First jejunal vein; ICA: inferior colic artery, IMV: inferior mesentery vein; IPA: inferior pancreatic artery; IPDA: Inferior pancreatoduodenal artery; IPDV: Inferior pancreatoduodenal vein; LCA: left colic artery; LPD: Laparoscopic pancreaticoduodenectomy; MCA: middle colic artery; PD: pancreaticoduodenectomy; PIPDA: posterior inferior pancreatoduodenal artery; RCA: right colic artery; RHA: right hepatic artery; SMA: Superior mesenteric artery; SMV: Superior mesenteric vein Declarations Ethics approval and consent to participate. Ethics approval of this study was given by the Research Ethics Committees of Bach Mai Hospital. Written informed consent for publication of their clinical details and clinical images was obtained from the patient’s family. Consent for publication Not applicable. Availability of data and materials All data generated or analyzed during this study are included in this published article. Conflicts of interest The authors declare no conflict of interest regarding the publication of this article. Funding The authors declare no funding for this study. Authors’ contributions HHN, TKN contributed equally as co-first authors, the main doctors to conceive the original idea, design and operate the patients; THL, HDD performed the operations, analyzed the data and wrote the manuscript; HST, HMP collected the data and edited the manuscript; VDL, VMD performed the operations and edited the manuscript; PC, HQP, DVN conceived the original idea, summed up, revised manuscript. All authors have discussed the results together and contributed to the final manuscript Acknowledgements The authors would like to thank to all the colleagues of the Center of Gastrointestinal and Hepato-pancreato-biliary surgery, Bach Mai Hospital, Hanoi, Vietnam for their assistance during the time of our patients’ in-hospital observation. References Ironside N, Barreto SG, Loveday B, Shrikhande SV, Windsor JA, Pandanaboyana S. Meta-analysis of an artery-first approach versus standard pancreatoduodenectomy on perioperative outcomes and survival. Br J Surg . May 2018;105(6):628-636. doi:10.1002/bjs.10832 Jiang X, Yu Z, Ma Z, et al. Superior mesenteric artery first approach can improve the clinical outcomes of pancreaticoduodenectomy: A meta-analysis. Int J Surg . Jan 2020;73:14-24. doi:10.1016/j.ijsu.2019.11.007 Nagakawa Y, Watanabe Y, Kozono S, et al. Surgical approaches to the superior mesenteric artery during minimally invasive pancreaticoduodenectomy: A systematic review. J Hepatobiliary Pancreat Sci . Jan 2022;29(1):114-123. doi:10.1002/jhbp.905 Nagakawa Y, Nakata K, Nishino H, et al. International expert consensus on precision anatomy for minimally invasive pancreatoduodenectomy: PAM-HBP surgery project. J Hepatobiliary Pancreat Sci . Jan 2022;29(1):124-135. doi:10.1002/jhbp.1081 Cho A, Yamamoto H, Kainuma O. Tips of laparoscopic pancreaticoduodenectomy: superior mesenteric artery first approach (with video). J Hepatobiliary Pancreat Sci . Mar 2014;21(3):E19-21. doi:10.1002/jhbp.54 Nigah S, Patra A, Chumber S. Analysis of the Variations in the Colic Branching Pattern of the Superior Mesenteric Artery: A Cadaveric Study With Proposal to Modify Its Current Anatomical Classification. Cureus . May 2022;14(5):e25025. doi:10.7759/cureus.25025 Morales E, Zimmitti G, Codignola C, et al. Follow "the superior mesenteric artery": laparoscopic approach for total mesopancreas excision during pancreaticoduodenectomy. Surg Endosc . Dec 2019;33(12):4186-4191. doi:10.1007/s00464-019-06994-6 Liao CH, Liu YY, Wang SY, Liu KH, Yeh CN, Yeh TS. The feasibility of laparoscopic pancreaticoduodenectomy-a stepwise procedure and learning curve. Langenbecks Arch Surg . Aug 2017;402(5):853-861. doi:10.1007/s00423-016-1541-x Nagakawa Y, Yi SQ, Takishita C, et al. Precise anatomical resection based on structures of nerve and fibrous tissue around the superior mesenteric artery for mesopancreas dissection in pancreaticoduodenectomy for pancreatic cancer. J Hepatobiliary Pancreat Sci . Jun 2020;27(6):342-351. doi:10.1002/jhbp.725 Sonneland J, Anson BJ, LE. B. Surgical anatomy of the arterial supply to the colon from the superior mesenteric artery based upon a study of 600 specimens. Surg Gynecol Obstet . 1958;106:385-98. Horiguchi A, Ishihara S, Ito M, Asano Y, Yamamoto T, Miyakawa S. Three-dimensional models of arteries constructed using multidetector-row CT images to perform pancreatoduodenectomy safely following dissection of the inferior pancreaticoduodenal artery. J Hepatobiliary Pancreat Sci . Jul 2010;17(4):523-6. doi:10.1007/s00534-009-0261-9 Ishikawa Y, Ban D, Matsumura S, et al. Surgical pitfalls of jejunal vein anatomy in pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci . Jul 2017;24(7):394-400. doi:10.1002/jhbp.451 Kawabata Y, Hayashi H, Ishikawa N, Tajima Y. Total meso-pancreatoduodenum excision with pancreaticoduodenectomy in lower biliary tract cancer. Langenbecks Arch Surg . Jun 2016;401(4):463-9. doi:10.1007/s00423-016-1435-y G. Murakami, K. Hirata, T. Takamuro, Mukaiya. M. . J Hep Bil Pancr Surg . 1999;1:55-68. Treepongkaruna S M, Pantanakul S M. . J Med Assoc Thai 2019;102:69-75. Boggi U, Amorese G, Vistoli F, et al. Laparoscopic pancreaticoduodenectomy: a systematic literature review. Surg Endosc . Jan 2015;29(1):9-23. doi:10.1007/s00464-014-3670-z Tian F, Wang YZ, Hua SR, Liu QF, Guo JC. Laparoscopic assisted pancreaticoduodenectomy: an important link in the process of transition from open to total laparoscopic pancreaticoduodenectomy. BMC Surg . May 6 2020;20(1):89. doi:10.1186/s12893-020-00752-5 Sameer A Rege, Ketan F Kshirsagar, Jayati J Churiwala, Shrinivas S Gond, Kaderi. ASA. . World Journal of Laparoscopic Surgery . 2020;13(2) Chen K, Pan Y, Mou Y-p, et al. Total laparoscopic versus open pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a propensity score matching analysis with meta-analysis. BMC Cancer . 2021;21(382):1-25. doi:10.21203/rs.3.rs-20225/v1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 28 Mar, 2024 Reviews received at journal 21 Mar, 2024 Reviews received at journal 18 Mar, 2024 Reviewers agreed at journal 14 Mar, 2024 Reviewers agreed at journal 13 Mar, 2024 Reviewers invited by journal 13 Mar, 2024 Editor assigned by journal 07 Mar, 2024 Submission checks completed at journal 05 Mar, 2024 First submitted to journal 05 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4018193","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":276615227,"identity":"33c54010-6a7c-48eb-82f2-2b47d85cf545","order_by":0,"name":"Ham Hoi NGUYEN","email":"","orcid":"","institution":"Hanoi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ham","middleName":"Hoi","lastName":"NGUYEN","suffix":""},{"id":276615228,"identity":"d77f47dd-1067-4fe6-9697-2cc6a713aae3","order_by":1,"name":"Thanh Khiem NGUYEN","email":"data:image/png;base64,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","orcid":"","institution":"Bạch Mai Hospital","correspondingAuthor":true,"prefix":"","firstName":"Thanh","middleName":"Khiem","lastName":"NGUYEN","suffix":""},{"id":276615229,"identity":"0a3a76d9-e8cd-44bc-a6c3-ee5e55d4cb8e","order_by":2,"name":"Hong Son TRINH","email":"","orcid":"","institution":"Viet Duc Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"Son","lastName":"TRINH","suffix":""},{"id":276615230,"identity":"38c53834-3810-4713-8eee-12f2ba56e4fe","order_by":3,"name":"Hai Dang DO","email":"","orcid":"","institution":"Viet Duc Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hai","middleName":"Dang","lastName":"DO","suffix":""},{"id":276615231,"identity":"65c62630-12dd-4a5f-9d4b-00150313d7fd","order_by":4,"name":"Tuan Hiep LUONG","email":"","orcid":"","institution":"Bạch Mai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tuan","middleName":"Hiep","lastName":"LUONG","suffix":""},{"id":276615232,"identity":"33b944da-87e1-44c4-9847-5b86d68d4d5d","order_by":5,"name":"Hoan My PHAM","email":"","orcid":"","institution":"VinUniversity","correspondingAuthor":false,"prefix":"","firstName":"Hoan","middleName":"My","lastName":"PHAM","suffix":""},{"id":276615233,"identity":"3da58a9c-e226-487b-a140-1ae0b73f853b","order_by":6,"name":"Van Duy LE","email":"","orcid":"","institution":"Bạch Mai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Van","middleName":"Duy","lastName":"LE","suffix":""},{"id":276615234,"identity":"3f1cb85e-6534-4b64-bc42-a257aee0b4a5","order_by":7,"name":"Van Minh DO","email":"","orcid":"","institution":"Bạch Mai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Van","middleName":"Minh","lastName":"DO","suffix":""},{"id":276615235,"identity":"c2ad84ff-39cd-47d1-af73-09d93d9be810","order_by":8,"name":"Pisey CHANTHA","email":"","orcid":"","institution":"Hanoi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Pisey","middleName":"","lastName":"CHANTHA","suffix":""},{"id":276615236,"identity":"538d81db-0034-4f5a-85e2-32ac896f05a6","order_by":9,"name":"Hong Quang PHAM","email":"","orcid":"","institution":"Thai Binh University of Medicine and Pharmacy","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"Quang","lastName":"PHAM","suffix":""},{"id":276615237,"identity":"cdce35e6-5fec-4eb9-aa24-95d3e662c5c1","order_by":10,"name":"Dang Vung NGUYEN","email":"","orcid":"","institution":"Hanoi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Dang","middleName":"Vung","lastName":"NGUYEN","suffix":""}],"badges":[],"createdAt":"2024-03-05 17:35:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4018193/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4018193/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52302639,"identity":"94361929-fed1-47f2-b776-1049f4675c2b","added_by":"auto","created_at":"2024-03-08 18:47:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2647607,"visible":true,"origin":"","legend":"\u003cp\u003eRelationship between MCA, J1A, IPDA and SMA\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4018193/v1/24f53287e7513ae36cb407af.png"},{"id":52301425,"identity":"058fc6f3-8dc7-48a6-bd05-32cd2c19f4ea","added_by":"auto","created_at":"2024-03-08 18:39:26","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2139602,"visible":true,"origin":"","legend":"\u003cp\u003eLigation of IPDA, anterior/posterior IPDA (AIPDA/PIPDA), left-side lymphnode\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4018193/v1/fa02725515281f272f8913f4.png"},{"id":52301426,"identity":"99180d4a-5a79-411e-8652-7c4d5c9d07a1","added_by":"auto","created_at":"2024-03-08 18:39:26","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":456231,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePosition of MCA, J1A in correlation with SMA circumference\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4018193/v1/c2dcbad5eed428e3a9118771.png"},{"id":52303123,"identity":"8e25e359-3662-47cf-9fe8-3edf6a3971d9","added_by":"auto","created_at":"2024-03-08 18:55:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4900111,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4018193/v1/aa7318bf-cdd3-4578-aaf9-e3bde5e38452.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eFeasibility of Middle Colic Artery as a Landmark for Superior Mesenteric Artery – First Approach in Laparoscopic Pancreatoduodenectomy: a Prospective Study\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSMA-first approach in PD has proved its efficacy in minimizing blood loss, resecting completely mesopancreas, achieving R0 resection, and prolonging survival time \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. LPD with SMA-first approach has been increasingly published in specialized centers \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. However, this method was still a challenge due to demanding technical skills in dissection and exposure of SMA, IPDA and J1A \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Left posterior approach has been proven to be beneficial: first approach to SMA and early control of IPDA and J1A \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. During dissection, we discovered that MCA could be a helpful landmark in the search for SMA, IPDA and J1A, especially in complicated cases with pancreatitis or obesity. Therefore, we examined the anatomical relationship between MCA and other fundamental vessels in LPD based on preoperative imaging study to apply this landmark in practical scenario of the surgery.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThe patient was included if they had\u0026nbsp;periampullary\u0026nbsp;tumor\u0026nbsp;at\u0026nbsp;the\u0026nbsp;resectable stage, indicated for LPD with given protocol with SMA-first approach from the left. The patients should have a good physical status\u0026nbsp;with\u0026nbsp;no contraindications\u0026nbsp;for laparoscopy and normal coagulation function. Preoperative biliary drainage\u0026nbsp;might be indicated\u0026nbsp;if serum bilirubin \u0026nbsp;\u0026gt; 250mmol/L.\u0026nbsp;Exclusion criteria:\u0026nbsp;Vascular invasion suspected, withdrawal from research.\u003c/p\u003e\n\u003cp\u003eOur study was an uncontrolled clinical trial.\u0026nbsp;Totally,\u0026nbsp;33 patients\u0026nbsp;who agreed to participate\u0026nbsp;with the above-mentioned criteria from January 2021 to August 2023\u0026nbsp;were included. All of our patients went through a thorough workup, including\u0026nbsp;a\u0026nbsp;contrast CT scan to evaluate anatomical variants\u0026nbsp;of vessels and plan for vascular approach and control.\u0026nbsp;The imaging was made with Maximum Intensity Projection by an experienced radiologist.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical protocol\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll surgeons included in our study were highly experienced with at least 20 cases of LPD and 50 cases of open PD.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePlace the patient supine,\u0026nbsp;two\u0026nbsp;arms\u0026nbsp;abducted, abduct both legs 60 degrees. Set 5 abdominal trocars. After exploration, approach to the SMA from the left\u0026nbsp;side:\u0026nbsp;The assistant stretches\u0026nbsp;out transverse colon mesentery and first jejunal loop, surgeon ligates\u0026nbsp;Treitz ligament and mobilizes\u0026nbsp;IMV. In case when IMV drained into SMV, ligate\u0026nbsp;the\u0026nbsp;IMV.\u003c/li\u003e\n \u003cli\u003eMCA could be exposed right below transverse colic mesentery. From the MCA, approach to the anterior surface of SMA via posterior peritoneum. After determining the SMA axis, dissect from up to down, from the anterior section to the left posterior side, as the anterior side is considered an avascular region. Expose and ligate the J1A if it is separated or the common trunk with IPDA is short. The first jejunum was then cut.\u003c/li\u003e\n \u003cli\u003eThe IPDA is determined by the relative distance and direction with the MCA. If IPDA stems independently from the plane cross 2/3 of the diameter of the SMA left border, we will ligate IPDA. If IPDA/PIPDA stems from the right border, the artery will be preserved to be ligated later. Continuing SMA dissection to the right side till its root (above the left renal vein), perform the lymphadenectomy around the SMA. Mobilize the structure from the anterior surface of inferior vena cava and abdominal aorta.\u003c/li\u003e\n \u003cli\u003eApproach the SMV, ligate the Henle trunk, split the pancreatic neck from the SMV. Cut the gastric antrum, dissect the celiac trunk lymph node, hepatic pedicle, ligate the gastroduodenal artery. Split the pancreatic neck, finalize the mobilization around the SMA. The gallbladder and common bile duct was lastly removed. Do the anastomosis via laparoscopy or mini-open.\u003cul\u003e\n \u003cli\u003ePlace the drainage and\u0026nbsp;do the abdominal closure.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eData collection and analysis\u003c/strong\u003e\u003c/p\u003e\n \u003cul class=\"decimal_type\"\u003e\n \u003cli\u003ePatient demographics:\u0026nbsp;age, gender, diagnosis\u003c/li\u003e\n \u003cli\u003eAnatomical parameters:\u003cul style=\"list-style-type: circle;\"\u003e\n \u003cli\u003eMCA: distance from MCA to SMA root, correlation between MCA position to SMA circumference (classified into 4 quadrants), based on Sobal classification \u003csup\u003e6\u003c/sup\u003e.\u003cul\u003e\n \u003cli\u003eType I: Right colic artery (RCA), MCA and ileocolic artery (ICA) originate independently.\u003c/li\u003e\n \u003cli\u003eType IIa: Common trunk between RCA and MCA\u003c/li\u003e\n \u003cli\u003eType IIb: Common trunk between RCA and ICA\u003c/li\u003e\n \u003cli\u003eType IIc: MCA and LCA in one\u003c/li\u003e\n \u003cli\u003eType III: MCA from celiac trunk\u003c/li\u003e\n \u003cli\u003eType IV: Others\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eJ1A: distance from J1A to SMA root, J1A position, correlation between J1A and IPDA (or PIPDA)\u003c/li\u003e\n \u003cli\u003eIPDA (or PIPDA) on the left, other\u0026nbsp;anatomical variations (if presented).\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eTechniques:\u0026nbsp;time for artery approach,\u0026nbsp;total operative time,\u0026nbsp;J1A ligation, IPDA ligation from the left, peri-SMA nerve\u0026nbsp;plexus\u0026nbsp;preservation, extended lymphadenectomy, intraoperative complications, blood loss\u0026nbsp;and blood transfusion;\u0026nbsp;Conversion to open surgery, total number of lymph nodes, left-side SMA lymph nodes, mesopancreas metastasis\u003c/li\u003e\n \u003cli\u003ePostoperative complications\u003c/li\u003e\n \u003cli\u003eThe data was analyzed by SPSS 25.0. We presented the data by mean \u0026plusmn; SD for continous variables and percentage for categorical variables.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n\u003c/ul\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThere were\u0026nbsp;total\u0026nbsp;33 patients\u0026nbsp;in our study. The mean age was 58.7 \u0026plusmn; 9.1 years (range 35-70). Mean BMI was 20.9 \u0026plusmn; 2,0 (16.8 - 25).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Patient demographics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.118780096308186%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.881219903691814%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.118780096308186%\" valign=\"top\"\u003e\n \u003cp\u003eAge (Mean \u0026plusmn; SD, min-max)\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e30-50\u003c/li\u003e\n \u003cli\u003e51-70\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.881219903691814%\" valign=\"top\"\u003e\n \u003cp\u003e58.7 \u0026plusmn; 9.1 (35 - 70)\u003c/p\u003e\n \u003cp\u003e6 (18.2)\u003c/p\u003e\n \u003cp\u003e27 (81.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.118780096308186%\" valign=\"top\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMale\u003c/li\u003e\n \u003cli\u003eFemale\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.881219903691814%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (48.5)\u003c/p\u003e\n \u003cp\u003e17 (51.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.118780096308186%\" valign=\"top\"\u003e\n \u003cp\u003eMedical history\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eAlcohol\u003c/li\u003e\n \u003cli\u003eChronic liver diseases\u003c/li\u003e\n \u003cli\u003eChronic pancreatitis\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.881219903691814%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (21.2)\u003c/p\u003e\n \u003cp\u003e1 (3.0)\u003c/p\u003e\n \u003cp\u003e1(3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.118780096308186%\" valign=\"top\"\u003e\n \u003cp\u003eBMI (Mean \u0026plusmn; SD, min-max)\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026lt;18\u003c/li\u003e\n \u003cli\u003e18-25\u003c/li\u003e\n \u003cli\u003e\u0026ge;25\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.881219903691814%\" valign=\"top\"\u003e\n \u003cp\u003e20.9 \u0026plusmn; 2,0 (16.8 - 25)\u003c/p\u003e\n \u003cp\u003e2 (6.1)\u003c/p\u003e\n \u003cp\u003e30 (90.9)\u003c/p\u003e\n \u003cp\u003e1 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAnatomical characteristics of MCA\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our study, 100% of the patients had independent MCA roots. The mean distance from MCA to SMA root was 56.4 mm. Most of the patients\u0026rsquo; MCA (90.9%) originates from the upper right quadrant of the SMA, and only 3% of the cases had MCA on the left side.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnatomical characteristics of J1A\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean distance from J1A to\u0026nbsp;the\u0026nbsp;SMA root was\u0026nbsp;37.4 mm. Most of the cases\u0026nbsp;(72.7%) had J1A originating from 3 to 6 o\u0026rsquo;clock of the SMA. In 69.7% of our cases, J1A and IPDA shared a common trunk. The mean distance from J1A to the MCA root was 19 mm.\u003c/p\u003e\n\u003cp\u003eWe also recorded other vascular variations, including 3 (9.1%) cases with aberrant RHA, 4 (12.1%) cases with inferior pancreatic artery, 1 (3%) case with\u0026nbsp;left colic artery stemming SMA, 10 (30.3%) IMV draining into SMV.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003cstrong\u003e: Anatomical characteristics of MCA, IPDA and J1A \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003eIndependent MCA root\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e100 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003eDistance from MCA to SMA root\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e56.4 \u0026nbsp;9.8 mm (30-77)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003eMCA position\u0026nbsp;in correlation with SMA\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e9-12 o\u0026rsquo;clock\u003c/li\u003e\n \u003cli\u003e12-3 o\u0026rsquo;clock\u003c/li\u003e\n \u003cli\u003e6-9 o\u0026rsquo;clock\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e90.9%\u003c/p\u003e\n \u003cp\u003e6.1%\u003c/p\u003e\n \u003cp\u003e3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003eDistance from J1A\u0026nbsp;to SMA root\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e37.4 \u0026nbsp;mm (22-50.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003eJ1A\u0026nbsp;position\u0026nbsp;in correlation with SMA\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e3-6 o\u0026rsquo;clock:\u003c/li\u003e\n \u003cli\u003e6-9 o\u0026rsquo;clock\u003c/li\u003e\n \u003cli\u003e12-3 o\u0026rsquo;clock\u003c/li\u003e\n \u003cli\u003e9-12 o\u0026rsquo;clock\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e72.7 %\u003c/p\u003e\n \u003cp\u003e21.2%\u003c/p\u003e\n \u003cp\u003e3%\u003c/p\u003e\n \u003cp\u003e3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003eDistance from J1A\u0026nbsp;to MCA\u0026nbsp;root\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e19 \u0026nbsp; 7.8 mm (2-33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003eCorrelation\u0026nbsp;between J1A and IPDA (PIPDA)\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eCommon trunk\u003c/li\u003e\n \u003cli\u003eIndependence\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e69.7%\u003c/p\u003e\n \u003cp\u003e30.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003eIPDA common trunk present\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e81.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003eIPDA or\u0026nbsp;PIPDA on\u0026nbsp;the left\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e78.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther anatomical variations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003eAberrant RHA from SMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e3 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003eInferior pancreatic artery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e4 (12.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003eLeft colic artery from SMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003eJ1V anterior to SMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e13 (39.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.88235294117647%\" valign=\"top\"\u003e\n \u003cp\u003eIMV drained into SMV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.11764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e10 (30.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe mean time for\u0026nbsp;the\u0026nbsp;left SMA-approach in our study was 98 minutes. The mean total operative time was 433 minutes.\u0026nbsp;The median\u0026nbsp;total blood loss was 100\u0026nbsp;mL, ranging from 50 to 1500 mL. Only 1 case had uncontrollable blood loss due to transverse\u0026nbsp;colon mesentery tear, which required intraoperative blood transfusion, and finally,\u0026nbsp;conversion to open surgery.\u003c/p\u003e\n\u003cp\u003eIn all of the cases, we succeeded\u0026nbsp;in\u0026nbsp;ligating\u0026nbsp;J1A, preserving\u0026nbsp;peri-SMA neural plexus and performing\u0026nbsp;extended lymphadenectomy. We ligated IPDA from the left in 27 (81.8%) cases.\u003c/p\u003e\n\u003cp\u003eDuring\u0026nbsp;the\u0026nbsp;post-operative period, we recorded 4 cases with\u0026nbsp;over Grade II\u0026nbsp;complications, including 1 case\u0026nbsp;suffered\u0026nbsp;bleeding from SMV branch injury, requiring reoperation. 1 case with bleeding from the inferior epigastric branch on trocar placement, successfully embolized, 1 case of self-controlled secondary bleeding after grade B pancreatic fistula, and 1 case anastomotic bleeding, treated conservatively with blood transfusion.\u0026nbsp;The mean length of stay at the hospital was 14 days, ranging from 8 \u0026ndash; 25 days.\u003c/p\u003e\n\u003cp\u003ePathology results revealed mean number of collected lymph nodes was\u0026nbsp;33, with 7.3 collected to the left of the SMA due to extended lymphadenectomy. R0 resection was achieved in 31 (94%) cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;3: Intraoperative techniques and outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003eTime for left SMA-approach (minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e98 \u0026nbsp; 27.9 (60 \u0026ndash; 153)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003eTotal operative time (minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e433.3 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003eBlood loss during SMA approach (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e84.2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003eTotal blood loss (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e143 \u0026nbsp; 252 (50 \u0026ndash; 1500)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003eIntraoperative blood transfusion\u0026nbsp;(case)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003eConversion to open surgery (cases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003eJ1A ligation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e33 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003eIPDA ligation from the left (cases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e27 (81.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEarly outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003ePost-operative complications\u0026nbsp;(Clavien-Dindo)\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eII\u003c/li\u003e\n \u003cli\u003eIIIa\u003c/li\u003e\n \u003cli\u003eIIIb\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003cp\u003e2 (6%)\u003c/p\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003eLength of stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e14.3 \u0026nbsp; 4 (8 \u0026ndash; 25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOncological outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003eTotal number of collected lymph nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e33\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of lymph nodes to the left of SMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e7.3 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003ePatients with positive lymph nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e18 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003ePatients with positive left-sided lymph nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e5 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003ePatients with mesopancreas metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e8 (24.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.39549839228296%\" valign=\"top\"\u003e\n \u003cp\u003eR0 resection rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.60450160771704%\" valign=\"top\"\u003e\n \u003cp\u003e31 (94%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e\u003cstrong\u003eAnatomical variations of MCA\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnatomical variations cause the most challenge in vascular dissection. Our study showed 39.4% of the cases with J1V anterior to SMA, 30.3% with IMV draining into SMV, 12.1% had\u0026nbsp;inferior pancreatic artery (IPA), 9.1% right hepatic artery (RHA) stemming from SMA and 1% had\u0026nbsp;left colic artery (LCA)\u003cstrong\u003e\u003cem\u003e.\u003c/em\u003e\u003c/strong\u003e Sobal et al also reported an incidence of 2% of LCA stemming from SMA instead of from inferior mesenteric artery \u003csup\u003e6\u003c/sup\u003e. RHA must be preserved while J1V, IMV, IPA, LCA could be ligated without risk of ischemia. In the case of aberrant RHA, dissection posteriorly to the SMA could be challenging due to a high risk of RHA injury.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough many authors have described different approaches in open surgery, few authors reported a standard protocol for minimally invasive surgery, especially the left posterior approach \u003csup\u003e5,7,8\u003c/sup\u003e. In SMA-first approach, it is important to first identify the SMA, IPDA, and J1A. Studies show that the majority of IPDA originates in the same trunk as the J1A on the left side of the SMA. Left posterior approach has the following advantages: direct access to the SMA, easy control of the IPDA and J1A due to anatomical correlation. Furthermore, according to Nagakawa, the anterior left of the SMA is an avascular space, which facilitates dissection. \u003csup\u003e9\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnatomical variations\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;of MCA in approach to\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;SMA, J1A, IPDA\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBasically; RCA, MCA and ICA originate independently from SMA. In Sobal\u0026rsquo;s study, it is the most common circumstances (82%), and 7 (14%) cases with common MCA and RCA trunk.\u003csup\u003e6\u003c/sup\u003e Soneland et al showed an incidence of type 2a of 26.7%.\u003csup\u003e10\u003c/sup\u003e This was similar to our results, showing the majority of type 1 and a lower incidence of type 2a.\u003c/p\u003e\n\u003cp\u003eWe divided the MCA origin from SMA position into 4 regions clockwise: 12\u0026ndash;3, 3\u0026ndash;6, 6\u0026ndash;9, and 9\u0026ndash;12 o\u0026rsquo; clock. Our study showed 90.9% of MCA stemming at 9-12 o\u0026rsquo;clock of the SMA \u003cstrong\u003e\u003cem\u003e(Figure\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e3\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e)\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe mean distance between SMA and MCA root was 56 mm, comparable to the inferior border of the pancreas and MCA could be easily found when the colic mesentery and the first jejunal loop were stretched out. This\u0026nbsp;result was similar to that reported by Horiguchi\u0026nbsp;(54 mm)\u003csup\u003e11\u003c/sup\u003e. The author\u0026rsquo;s study also showed that the distance from MCA to IPDA was significantly shorter than from IPDA to SMA root, and therefore, it was feasible and safe for MCA to be a better landmark than the SMA root to identify IPDA. Horiguchi also highlighted the importance of preoperative measurement of these vessels on imaging study for a better operative plan to find IPDA based on the MCA. \u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eMCA frequently stemmed independently at 6-9 o\u0026rsquo;clock from the SMA. Therefore, MCA should be considered as a helpful and constant landmark in identifying SMA in artery-first approach. In other words, SMA was identified when the MCA was determined\u003cstrong\u003e\u003cem\u003e\u0026nbsp;(Figure 2)\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis of the relationship between MCA and J1A showed that: J1A originated at 37.4mm from the origin of SMA, above MCA and the average distance between \u0026nbsp;MCA and J1A was 19mm (the smallest distance measured on MSCT was 2mm). Evaluation of position of J1A root compared to SMA showed that 72.7% were at 3-6 o\u0026rsquo;clock, 21.2% were at 6-9 o\u0026rsquo;clock (\u003cstrong\u003eTable 2\u003c/strong\u003e). Thus, to identify J1A, we can find and follow upward the J1A by 19 mm in an upward direction of about 19mm, deviating to the left edge of SMA at about the 3-6 o\u0026apos;clock position.\u003c/p\u003e\n\u003cp\u003eIn addition, J1A was closely related to IPDA and PIPDA. Our research results showed that 69.7% of IPDA or PIPDA originated from J1A. This was consistent with other studies like Yoshiya Ishikawa (66%) and Yasunari Kawabata (74.3%)\u003csup\u003e12,13\u003c/sup\u003e. Meanwhile, Murakami reported a common trunk of IPDA and J1A in 58.9% of cases, independent trunk of IPDA from SMA in 24.2%, and 16.9%\u0026nbsp;with IPDA\u0026nbsp;stemming\u0026nbsp;from both\u0026nbsp;sites, 70.6% of\u0026nbsp;which had IPDA (PIPDA) stemming\u0026nbsp;from\u0026nbsp;the left side of the SMA.\u003csup\u003e14\u003c/sup\u003e Our study showed similar results with 78.8% of the cases with common trunk of IPDA and PIPDA branches originating on the left side of the SMA. Our study illustrated a close relationship between J1A and IPDA, and therefore, identifying J1A allowed IPDA to be controlled. Though the race and ethnicity are different, their relationship is similar.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntraoperative\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and postoperative complications \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our study, there is one case of intraoperative MCA injury during vascular dissection. Fortunately, the MCA could be safely ligated without causing colon ischemia. One case required conversion to open surgery due to hemodynamic instability caused by late recognition of bleeding mesentery. This is also a point to pay attention to when using the middle colon landmark, approaching from the left side and dissection of lymph nodes. The incidence of comorbidity in our study was equivalent to others performing left approach, and was not higher than those performing other SMA-first approach. Other publication show higher open conversion rate, such as Treeoongckaruna (17.7%), Boggi (9.1%), Feng Tian (16.7%) \u003csup\u003e15-17\u003c/sup\u003e. The median total blood loss was 100 mL. Our results were lower than that reported by Feng Tian (300ml), and equivalent to Sameer\u0026apos;s study (110-350 ml). \u003csup\u003e17,18\u003c/sup\u003e Chen et al compared 2 groups of 89 patients undergoing either open or laparoscopic PD. Total laparoscopic surgery required longer operative time than open surgery, but less blood loss and blood transfusion. \u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOur study implied that\u0026nbsp;left approach did not\u0026nbsp;increase complications\u0026nbsp;in LPD.\u0026nbsp;Boggi et al found complication rates ranging from 18.1 - 64.2%, with an average of 41.2%. The mortality rate varied from 0 - 7.1%.\u003csup\u003e16\u003c/sup\u003e Our study found that the rate of complications at Clavien Dindo classification grade II or higher accounted for 12.1%. Chen et al found that postoperative complications in the laparoscopic group were lower in both incidence and severity but not statistically significant.\u003csup\u003e19\u003c/sup\u003e None of our patients had DGE, bile leakage or bowel anastomosis leak.\u003c/p\u003e\n\u003cp\u003eOur study showed a feasible approach in Whipple\u0026rsquo;s procedure by using MCA as a landmark for SMA. Further randomized trials with larger sample sizes and longer follow-up should be conducted to prove their effectiveness.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eExposing MCA first helps determine SMA, J1A and IPDA safely, efficiently and faciliates SMA-first approach LPD from the left and complete dissection of mesopancreas and lymph nodes to the left of the SMA. This study was conducted on a small group of patients at a single center.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAIPDA: Anterior inferior pancreatoduodenal artery;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eJ1A: First jejunal artery; J1V: First jejunal vein; ICA: inferior colic artery, IMV: inferior mesentery vein; IPA: inferior pancreatic artery; IPDA: Inferior pancreatoduodenal artery; IPDV: Inferior pancreatoduodenal vein; LCA: left colic artery; LPD: Laparoscopic pancreaticoduodenectomy; MCA: middle colic artery; PD: pancreaticoduodenectomy; PIPDA: posterior inferior pancreatoduodenal artery; RCA: right colic artery; RHA: right hepatic artery; SMA: Superior mesenteric artery; SMV: Superior mesenteric vein\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eparticipate.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval of this study was given by the Research Ethics Committees of Bach Mai Hospital. Written informed consent for publication of their clinical details and clinical images was obtained from the patient\u0026rsquo;s family.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest regarding the publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHHN, TKN contributed equally as co-first authors, the main doctors to conceive the original idea, design and operate the patients; THL, HDD performed the operations, analyzed the data and wrote the manuscript; HST, HMP collected the data and edited the manuscript; VDL, VMD performed the operations and edited the manuscript; PC, HQP, DVN conceived the original idea, summed up, revised manuscript. All authors have discussed the results together and contributed to the final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank to all the colleagues of the Center of Gastrointestinal and Hepato-pancreato-biliary surgery, Bach Mai Hospital, Hanoi, Vietnam for their assistance during the time of our patients\u0026rsquo; in-hospital observation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eIronside N, Barreto SG, Loveday B, Shrikhande SV, Windsor JA, Pandanaboyana S. Meta-analysis of an artery-first approach versus standard pancreatoduodenectomy on perioperative outcomes and survival. \u003cem\u003eBr J Surg\u003c/em\u003e. May 2018;105(6):628-636. doi:10.1002/bjs.10832\u003c/li\u003e\n\u003cli\u003eJiang X, Yu Z, Ma Z, et al. Superior mesenteric artery first approach can improve the clinical outcomes of pancreaticoduodenectomy: A meta-analysis. \u003cem\u003eInt J Surg\u003c/em\u003e. Jan 2020;73:14-24. doi:10.1016/j.ijsu.2019.11.007\u003c/li\u003e\n\u003cli\u003eNagakawa Y, Watanabe Y, Kozono S, et al. Surgical approaches to the superior mesenteric artery during minimally invasive pancreaticoduodenectomy: A systematic review. \u003cem\u003eJ Hepatobiliary Pancreat Sci\u003c/em\u003e. Jan 2022;29(1):114-123. doi:10.1002/jhbp.905\u003c/li\u003e\n\u003cli\u003eNagakawa Y, Nakata K, Nishino H, et al. International expert consensus on precision anatomy for minimally invasive pancreatoduodenectomy: PAM-HBP surgery project. \u003cem\u003eJ Hepatobiliary Pancreat Sci\u003c/em\u003e. Jan 2022;29(1):124-135. doi:10.1002/jhbp.1081\u003c/li\u003e\n\u003cli\u003eCho A, Yamamoto H, Kainuma O. Tips of laparoscopic pancreaticoduodenectomy: superior mesenteric artery first approach (with video). \u003cem\u003eJ Hepatobiliary Pancreat Sci\u003c/em\u003e. Mar 2014;21(3):E19-21. doi:10.1002/jhbp.54\u003c/li\u003e\n\u003cli\u003eNigah S, Patra A, Chumber S. Analysis of the Variations in the Colic Branching Pattern of the Superior Mesenteric Artery: A Cadaveric Study With Proposal to Modify Its Current Anatomical Classification. \u003cem\u003eCureus\u003c/em\u003e. May 2022;14(5):e25025. doi:10.7759/cureus.25025\u003c/li\u003e\n\u003cli\u003eMorales E, Zimmitti G, Codignola C, et al. Follow \u0026quot;the superior mesenteric artery\u0026quot;: laparoscopic approach for total mesopancreas excision during pancreaticoduodenectomy. \u003cem\u003eSurg Endosc\u003c/em\u003e. Dec 2019;33(12):4186-4191. doi:10.1007/s00464-019-06994-6\u003c/li\u003e\n\u003cli\u003eLiao CH, Liu YY, Wang SY, Liu KH, Yeh CN, Yeh TS. The feasibility of laparoscopic pancreaticoduodenectomy-a stepwise procedure and learning curve. \u003cem\u003eLangenbecks Arch Surg\u003c/em\u003e. Aug 2017;402(5):853-861. doi:10.1007/s00423-016-1541-x\u003c/li\u003e\n\u003cli\u003eNagakawa Y, Yi SQ, Takishita C, et al. Precise anatomical resection based on structures of nerve and fibrous tissue around the superior mesenteric artery for mesopancreas dissection in pancreaticoduodenectomy for pancreatic cancer. \u003cem\u003eJ Hepatobiliary Pancreat Sci\u003c/em\u003e. Jun 2020;27(6):342-351. doi:10.1002/jhbp.725\u003c/li\u003e\n\u003cli\u003eSonneland J, Anson BJ, LE. B. Surgical anatomy of the arterial supply to the colon from the superior mesenteric artery based upon a study of 600 specimens. \u003cem\u003eSurg Gynecol Obstet\u003c/em\u003e. 1958;106:385-98. \u003c/li\u003e\n\u003cli\u003eHoriguchi A, Ishihara S, Ito M, Asano Y, Yamamoto T, Miyakawa S. Three-dimensional models of arteries constructed using multidetector-row CT images to perform pancreatoduodenectomy safely following dissection of the inferior pancreaticoduodenal artery. \u003cem\u003eJ Hepatobiliary Pancreat Sci\u003c/em\u003e. Jul 2010;17(4):523-6. doi:10.1007/s00534-009-0261-9\u003c/li\u003e\n\u003cli\u003eIshikawa Y, Ban D, Matsumura S, et al. Surgical pitfalls of jejunal vein anatomy in pancreaticoduodenectomy. \u003cem\u003eJ Hepatobiliary Pancreat Sci\u003c/em\u003e. Jul 2017;24(7):394-400. doi:10.1002/jhbp.451\u003c/li\u003e\n\u003cli\u003eKawabata Y, Hayashi H, Ishikawa N, Tajima Y. Total meso-pancreatoduodenum excision with pancreaticoduodenectomy in lower biliary tract cancer. \u003cem\u003eLangenbecks Arch Surg\u003c/em\u003e. Jun 2016;401(4):463-9. doi:10.1007/s00423-016-1435-y\u003c/li\u003e\n\u003cli\u003eG. Murakami, K. Hirata, T. Takamuro, Mukaiya. M. \u0026lt;Vascular anatomy of the pancreaticoduodenal region. a review.pdf\u0026gt;. \u003cem\u003eJ Hep Bil Pancr Surg\u003c/em\u003e. 1999;1:55-68. \u003c/li\u003e\n\u003cli\u003eTreepongkaruna S M, Pantanakul S M. \u0026lt;Laparoscopic Left Posterior Superior Mesenteric Artery First Approach Pancreaticoduodenectomy. Experience, Outcome and Critical Steps.pdf\u0026gt;. \u003cem\u003eJ Med Assoc Thai \u003c/em\u003e2019;102:69-75. \u003c/li\u003e\n\u003cli\u003eBoggi U, Amorese G, Vistoli F, et al. Laparoscopic pancreaticoduodenectomy: a systematic literature review. \u003cem\u003eSurg Endosc\u003c/em\u003e. Jan 2015;29(1):9-23. doi:10.1007/s00464-014-3670-z\u003c/li\u003e\n\u003cli\u003eTian F, Wang YZ, Hua SR, Liu QF, Guo JC. Laparoscopic assisted pancreaticoduodenectomy: an important link in the process of transition from open to total laparoscopic pancreaticoduodenectomy. \u003cem\u003eBMC Surg\u003c/em\u003e. May 6 2020;20(1):89. doi:10.1186/s12893-020-00752-5\u003c/li\u003e\n\u003cli\u003eSameer A Rege, Ketan F Kshirsagar, Jayati J Churiwala, Shrinivas S Gond, Kaderi. ASA. \u0026lt;Total Laparoscopic Pancreaticoduodenectomy. A Single-center Experience of 33 Cases in Patients with Periampullary Tumor Lessons Learnt.pdf\u0026gt;. \u003cem\u003eWorld Journal of Laparoscopic Surgery\u003c/em\u003e. 2020;13(2)\u003c/li\u003e\n\u003cli\u003eChen K, Pan Y, Mou Y-p, et al. Total laparoscopic versus open pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a propensity score matching analysis with meta-analysis. \u003cem\u003eBMC Cancer\u003c/em\u003e. 2021;21(382):1-25. doi:10.21203/rs.3.rs-20225/v1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopic pancreaticoduodenectomy, artery-first approach, middle colic artery","lastPublishedDoi":"10.21203/rs.3.rs-4018193/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4018193/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSMA-first approach in pancreatoduodenectomy (PD) has been widely applied in open surgery as well as laparoscopy. Finding the superior mesenteric artery (SMA), inferior pancreatoduodenal artery (IPDA), first jejunal artery (J1A) has become a great challenge in laparoscopic PD (LPD). Meanwhile, exposing the midde colic artery (MCA) might be a feasible approach to determine SMA, IPDA, and J1A. Our study aims to find the anatomical correlation between MCA and SMA, IPDA, J1A, especially in SMA-first approach LPD from the left.\u003c/p\u003e\u003ch2\u003eMethodS\u003c/h2\u003e \u003cp\u003eUncontrolled clinical trial with 33 patients undergoing LPD had preoperative contrast abdominal CT scan to analyze the anatomical relevance between MCA and SMA, J1A, IPDA. The operation was performed starting with exposing MCA in advance to find SMA, J1A and IPDA. The data was analyzed by SPSS 25.0.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e90.9% of MCA started at 12\u0026ndash;3 o\u0026rsquo;clock from SMA, the mean distance from the SMA root to the MCA and J1A was 56.4mm and 37.4mm, respectively. The distance between SMA and J1A was 19mm. 72.7% J1A started at 9\u0026ndash;12 o\u0026rsquo;clock, 69.7% J1A and IPDA had a common trunk. 78.8% IPDA started at 3\u0026ndash;6 o\u0026rsquo;clock. 100% of the cases had J1A controlled intraoperatively, 81.8% for IPDA when approached from the left, 3% had MCA injury. The mean time to approach from the left was 98 minutes, median blood loss was 100 ml.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eExposing MCA first helps determine SMA, J1A and IPDA safely, efficiently and faciliates SMA-first approach LPD from the left and complete dissection of the mesopancreas and lymph nodes.\u003c/p\u003e","manuscriptTitle":"Feasibility of Middle Colic Artery as a Landmark for Superior Mesenteric Artery – First Approach in Laparoscopic Pancreatoduodenectomy: a Prospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-08 18:39:22","doi":"10.21203/rs.3.rs-4018193/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-28T15:16:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-21T09:31:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-18T11:08:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4918b3b5-1a19-4174-817a-899a2e611df8","date":"2024-03-14T08:34:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"60d191a3-c388-4527-bc5c-fb9177a8214a","date":"2024-03-13T17:30:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-13T04:32:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-08T04:25:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-05T23:24:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Surgical Oncology","date":"2024-03-05T16:58:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1a1591ef-4c68-4e4c-9b34-4c8f801631b5","owner":[],"postedDate":"March 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-05-20T03:38:32+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-08 18:39:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4018193","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4018193","identity":"rs-4018193","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}