EAES Academy

Purpose:
Pancreaticoduodenectomy has been one of the most challenging surgical procedures. Pancreatic cancer is associated with dismal outcomes and surgery remains the main modality of treatment. R0 resection with a negative resection margin would be an essential factor for a long-term survival. Retropancreatic margin or the medial margin is the most common site of positive resection margin. Mesopancreas is considered as a fusion fascia formed embryologically during the development of pancreas. This mesopancreas lies posterior to the pancreas and contains pancreaticoduodenal vessels, lymphatics, nerve plexus and loose areolar tissue. There is an increased rate of R0 resection by total mesopancreas resection, which is considered as mesopancreas level III dissection.
Materials and Methods: The mesopancreas level III dissection includes excision of total mesopancreas and right circumferential tissues of superior mesenteric artery (SMA). This level III dissection with pure robotic approach was applied to those with preoperative diagnosis of pancreatic cancer or bile duct cancer. The surgical outcomes including surgical parameters and risks were evaluated and compared between level III and non-level III dissection RPD.
Results:

Up to August of 2019, 266 cases of RPD were performed. level III mesopancreas dissection RPD took longer operation time, as compared with non-level III RPD (median: 10.4 vs. 7.4 hours), but the yield of lymph node harvested was higher by level III mesopancreas dissection RPD (median: 23 vs. 16). There was no significant difference regarding blood loss (median: 230 vs. 160 c.c.), POPF (11.1% vs. 10.7%), DGE (0% vs. 3.8%), PPH (5.6% vs. 3.8%), and chyle leakage (16.7% vs. 16.4%) between level III and non-level III mesopancreas dissection RPD.
Conclusion:
Mesopancreas level III dissection is technically feasible with acceptable surgical risks in RPD. Moreover, yield of lymph node harvested is higher by this mesopancreas level III dissection RPD.