腹腔镜下Treitz韧带途径钩突优先、动脉优先入路胰十二指肠切除术的临床应用

Laparoscopic pancreaticoduodenectomy with a novel artery first and uncinate process first approach through Treitz ligament

目的 探讨腹腔镜下经Treitz韧带途径、从侧后方视角完成钩突优先、动脉优先入路的胰十二指肠切除术的临床效果.方法 2016年4-11月南京医科大学第一附属医院胰腺中心共完成18例腹腔镜下经Treitz韧带途径、钩突优先、动脉优先的保留幽门胰十二指肠切除术.所有患者术前均诊断为胰头或壶腹部占位,无血管侵犯和远处转移.术中首先利用常规足侧视角,分离胰腺钩突前缘和肠系膜上静脉（SMV）右缘、门静脉（PV）,完成肝十二指肠韧带前方淋巴组织清扫;第二步：采用左后侧视角（左侧腹Trocar进镜）,Treitz韧带途径游离肠系膜上动脉（SMA）起始部;将钩突从系膜根部后方向左侧牵引,在左后侧视野直视下显露SMA、胰十二指肠下动脉（IPDA）、SMV空肠支后方、胰腺钩突之间的解剖关系,切断IPDA,以SMA左侧缘为切除线剥离结缔组织,实现以SMA为轴,从SMA起始部至其跨越钩突全长的剥离,在肠系膜根部左侧完成胰腺钩突远端系膜的离断;第三步：交替采用右后侧视角和足侧视角,从后向前、从足侧向头侧整体剥离近端胰腺钩突系膜（SMA起始部、腹腔干起始部和肝十二指肠韧带后方神经淋巴结缔组织）;第四步：切断胰颈和胆总管,完成切除.结果 18例患者均经Treitz韧带途径实现SMA起始部的游离、悬吊和沿SMA轴的远端钩突的大部分离,其中8例在SMA左侧即完成了钩突远端完全离断.术后病理检查结果显示,胰腺或壶腹部恶性肿瘤13例,良性肿瘤5例.术后发生A级胰瘘6例,B级胰瘘l例;腹腔出血1例;A级胃排空延迟2例,B级胃排空延迟2例.术后平均住院（15.5±6.8）d.结论 腹腔镜下经Treitz韧带途径、钩突优先、动脉优先入路胰十二指肠切除术可以实现腹腔干-SMA为轴全长胰腺钩突系膜的完整切除.

Objective To explore the clinical effect of a novel artery first and uncinate process first approach for laparoscopic pancreaticoduodenectomy （LPD）,emphasizing the left lateral and posterior dissection of uncinate process （UP） via Treitz ligament approach.Methods From April to November 2016,18 patients received LPD with a novel approach in Pancreas Center of the First Affiliated Hospital with Nanjing Medical University.All patients were diagnosed as pancreatic head or peri-ampulla tumor,without major vessel invasion nor distant metastasis.For resection,routine caudal view was used in the first step,to dissect the anterior medial border between uncinate process and superior mesenteric vein（SMV）.Lymphatic tissues were completely dissected form anterior surface of hepatoduodenal ligament.In the second step,left lateral view with camera from left para-umbilical trocar was used,Treitz ligament was incised,SMA root was exposed.After anticlockwise rotation and retraction of mesentery,the anatomic relationship between SMA trunk,inferior pancreaticoduodenal artery （IPDA）,jejunal branch of SMV,and distal part of UP,could be perfectly exposed from left lateral view.SMA was dissected from its root until the position above the uncinate process and duodenum,IPDA was transected,distal part of UP was freed from SMA.In the third step,right lateral view and caudal view were alternatively used;proximal UP mesentery was completely dissected out from SMA root,CA root and posterior surface of hepatoduodenal ligament.Pancreaticoduodenectomy was completed in the forth step after transection of pancreatic neck and common hepatic duct.Results The SMA root and distal UP were successfully dissected out via Treitz ligament approach in all 18 patients,among them,distal UP was completely excised in 8 patients from left view.Postoperative pathology showed R0 resection rate in 69%.Postoperative complication included intra-abdominal hemorrhage in 1 patient,pancreatic fistula in 7 patients（6 cases with grade A and 1 case with grade B）,delayed gastric emptying in 4 patients （2 cases with grade A,2 cases with grade B）.Average postoperative hospital stay was （15.5±6.8）days.Conclusion The novel artery first and uncinate process first approach through Treitz ligament could help surgeons to completely dissect the full length of meso-pancreas along celiac axis-SMA axis in LPD.