Inframesocolic Artery-First Approach with SMA Divestment to Confirm Resectability in Minimally Invasive Modified Appleby Procedure.

Abstract

Usually conducted through open access, minimally invasive (MIS) distal pancreatectomy with celiac axis resection (DP-CAR) is uncommon and technically demanding.^1,2 Resectability, especially when the superior mesenteric artery (SMA) is potentially involved, is usually assessed only after irreversible steps, such as pancreatic transection, are undertaken.^2,3 PATIENT AND METHODS: We describe a laparoscopic DP-CAR with left gastric artery (LGA) preservation in a 68-year-old woman with locally advanced pancreatic ductal adenocarcinoma. After neoadjuvant FOLFIRINOX therapy, surgery was scheduled. Temporary clamping of the common hepatic artery, combined with indocyanine green (ICG) fluorescence and intraoperative ultrasound, verified adequate hepatic perfusion via the gastroduodenal artery. Given the tumor's proximity to the SMA, a ligament of Treitz artery-first approach allowed the periadventitial dissection of the SMA, confirming resectability before any irreversible maneuvers.^3,4 This approach also facilitated a posterior plane beneath Gerota's fascia. Gastric viability was also determined using ICG, as the patient refused gastrectomy. Intraoperatively, an independent origin of the LGA without tumor infiltration enabled its preservation. A small arterial injury during celiac dissection was successfully managed laparoscopically without conversion. The surgery was achieved with no requirement for conversion to open surgery. The patient's postoperative course was uneventful, with discharge on day seven and confirmed R0 resection on pathology. At eight months follow-up, she remains recurrence-free and asymptomatic. The ligament of Treitz approach facilitates the assessment of tumor resectability and dissection of the SMA adventitia before undertaking irreversible surgical steps.