Pancreaticoduodenectomy with the Superior Mesenteric Artery Approach: How I Do It

The superior mesenteric artery (SMA) approach to pancreaticoduodenectomy (PD) is considered extremely important for early determination of resectability with negative margins. In addition, transecting the feeding arteries, including the inferior pancreaticoduodenal (IPDA) and gastroduodenal (GDA) arteries, before division of the pancreas can reduce blood loss during surgery and is a reasonable method for performing oncologic resection. This approach has promoted the development of an “artery-first” technique. Several techniques have been described under the heading of “artery-first.” We use the “Tora-no-Ana” approach, which consists of division of the ligament of Treitz, an entry into the retroperitoneal space behind the pancreatic body, and circumferential dissection around the SMA, with preservation of the nerve plexus around the SMA to prevent intractable diarrhea. A hanging maneuver of the pancreatic body facilitates a good operative view through the “Tora-no-Ana” approach. The IPDA and GDA are divided before division of the pancreatic body. In this chapter, we describe our techniques of the “artery-first” approach to PD with a review of the literature.