Mesopancreas Excision and Triangle Operation During Robotic Pancreatoduodenectomy.

backgroundThe retropancreatic space between the superior mesenteric artery, celiac axis, and portal vein is called the mesopancreas. Total mesopancreas excision and skeletonization of both celiac axis and superior mesenteric artery are used to reduce R1 resection in high-risk patients and in those with locally advanced disease. The aim of this study was to present a series of video clips from several patients showing the mesopancreas excision and the triangle operation with a detailed technical description of both techniques with different approaches.

methodsVideo clips were compiled from several robotic pancreatoduodenectomies to demonstrate the total mesopancreas excision and triangle operation technique, as follows: (1) main steps for mesopancreas excision and triangle operation, (2) anterior approach for mesopancreas excision, and (3) triangle operation.

resultsA total of 87 patients underwent robotic PD at our center between March 2018 and March 2021. Of these, 22 patients underwent robotic mesopancreas excision. This technique was used for patients at high risk for R1 resection in 18 patients and triangle operation in four patients. Partial portal vein resection was necessary in 6 cases. One patient had R1 resection and was treated with adjuvant therapy. The remaining patients presented free surgical margins. The mean number of harvested lymph nodes was 40 (range: 27-77). The median interval between the operation and chemotherapy was 23 days.

conclusionsThe robotic total mesopancreas excision and the triangle operation are feasible and safe for selected patients. The indication for this radical operation is the presence of a high risk for R1 resection and for those with locally advanced disease. The presented video may help oncological surgeons to perform these techniques.