From December 2018 to February 2020, 10 patients underwent LRAMPS for pancreatic cancer at the our institute. The preoperative assessment included laboratory examination, computed tomographic (CT) scan, magnetic resonance imaging (MRI), endoscopic ultrasound (EUS) or fine-needle aspiration (FNA), and positron emission computed tomography.
The data studied were the patient demographics, intraoperative variables (operative time, estimated blood loss (EBL), conversion to open operation, blood transfusion requirement), postoperative hospital stay, morbidity , mortality (within 30 days from surgery),pathologic findings(tumor size, count of retrieved lymph nodes, margin status) and follow-up.
Pancreatic fistula (PF) was assessed according to the International Study Group on Pancreatic Fistula recommendations . PF grade A was considered an asymptomatic biochemical leak and not counted as a complication, according to the modifications of the International Study Group definition of PF.
Patients were followed up via out-patient examination. The final follow-up was taken in February 2020. Recurrence or distant metastasis was diagnosed pathologically by surgical resection, biopsy, or cytology and/or radiological examination.
The Institutional Review Board of Zhejiang provincial people’s Hospital and The First people’s Hospital of Jiashan approved this study. The written informed consent was obtained from the patients before inclusion in the study.
Patients were placed in supine position with the head slightly elevated. The surgeon and the second assistant who held the laparoscope stood on the right side of the patient and the first assistant stood on the left. One initial 10-mm trocar was placed for laparoscopy below the umbilicus. A 30-degree telescope was inserted to examine the peritoneal cavity to rule out metastatic disease. After general exploration, the other four trocars (one 12 mm, three 5 mm) were inserted into the left upper flank, left flank, right upper flank, and right flank quadrants; the five trocars were arranged in a V shape.
The gastrocolonic ligament was divided for entrance to the lesser sac with harmonic scalpel (Harmonic Ace scalpel, Ethicon Endo-Surgery, Inc, Cincinnati, OH, United States). The mobilization of the pancreas began at the inferior border to visualize the superior mesenteric vein the splenomesenteric confluence and the portal vein. The lymph nodes along the common hepatic artery and gastroduodenal artery were removed after sufficient mobilization of the pancreas through dissecting the tissue around the upper border of the pancreas. After creating a tunnel behind the neck of the pancreas, the pancreas neck was transected with an endoscopic linear stapler (Endocutter 60 staple, white or blue cartridge; Ethicon Endo-Surgery, Inc, Cincinnati, OH, United States).Lymph nodes around the celiac axis were dissected to expose the origin of the splenic artery. Then the splenic artery and splenic vein were divided . The lymph nodes anterior to the aorta between the celiac artery and superior mesenteric artery and those anterior and to the left of the superior mesenteric artery were dissected. The distal pancreas was dissected with soft tissue of retroperitoneum in a medial-to-lateral fashion and the resection range was up to the diaphragmatic crus, down to the left renal vein, and to the left lateral portion of the aorta on the posterior side(Figure 1,2). Either the anterior or posterior RAMPS procedure was based on the principles emphasized by Strasberg et al.After completely resecting the distal pancreas and spleen with en bloc lymph node dissection, the specimen was bagged and retrieved through enlarged umbilical incision. One drainage tubes was left close to the proximal pancreatic remnant.Drainage tubes were routinely removed on postoperative day 3, when amylase of drain fluid was less than 3 times the upper normal serum value. In patients with any measurable volume of drain fluid of amylase-rich (>3 times the upper normal serum value), drainage tubes were kept in place and removed individually, depending on the enzyme levels.