How I Do It: "Artery First Approach" Germany

In patients with pancreatic cancer, surgical resection is the only potentially curative therapy. Intraoperatively, resectabilty of the tumour should be assessed as early as possible; in case of infiltration of the superior mesenteric or portal vein these structures should be resected and reconstructed. Aim of the surgical approach is complete (R0-resection) resection of the tumour. Unfortunately, in many cases tumour cells are detected at the resection margin (R1-resection), mostly along the margin to the superior mesenteric artery.
The “Artery first” approach published by our group in the year 2010 (J Am Coll Surg 2010;210:e1-4) and demonstrated in this video, allows early assessment of tumour resectability, aids in vein resection if necessary and potentially improves the rate of complete tumour resection.

This video shows the steps of a laparoscopic subtotal and total gastrectomy with D2 lymphadenectomy. First, the gastrocolic ligament is divided. Then right gastroepiploic and right gastric vessels (along with nodes groups 6-5) are dissected. The duodenum is transected using an endoscopic linear stapler. Lymphadenectomy of groups 8a and 11p is performed, and left gastric vein and artery are divided along with groups 7-9. Resection of groups 1-3 is completed. For a total gastrectomy dissection continues through the greater curvature. Finally, end to side reconstruction is showed with Roux-en-Y esophagojejunostomy for total gastrectomy.and a Billroth II technique for subtotal gastrectomy.

Video Contributed to the SSAT International Relations Committee "How I Do It" Video Series: Pancreatic Head Resection by:
Prof. Dr. J. Weitz, MSc
Chairman
Department of Visceral-, Thoracic and Vascular Surgery
University Hospital Carl Gustav Carus
Technical University Dresden, Germany