It is very important to perform the hanging maneuver of the RNP to ensure the entry and exit of the hanging tape and to keep kocherization to the left side of the aorta. Therefore, it is important to understand the branching of the vascular vessels by performing a preoperative 3D simulation. With the correct implementation of the hanging maneuver, we believe that it would be possible to obtain reliable R0 resection as well as a reduction in blood loss and operation time.
There are a few similar existing reports on the hanging maneuver of the retropancreatic nerve plexus [3, 4, 6, 7]. Although these reports have many discussions regarding the order for the hanging maneuver of the RNP, it is important to clarify the entrance and exit of the hanging taping in this procedure. In open surgery, because of the ventral approach, it is desirable to pull the hanging tape after dissection of the duodenum and pancreatic parenchyma. Since laparoscopic surgery uses a caudal approach, we believe that this procedure may be useful before dissection of the duodenum or pancreatic parenchyma.
In this case, the hanging maneuver of the retropancreatic nerve plexus was performed after dividing the duodenum and pancreatic parenchyma. This permitted the wide spaces between the SMA, SMV, and the resected side, and it was easier to identify the IPDA. Moreover, since the branching of the IPDA was identified during preoperative 3D simulation, the traction of the hanging maneuver tape was very useful in reducing the operation time and blood loss after dividing the IPDA.
Finally, the hanging maneuver of the retropancreatic nerve plexus enabled reliable R0 resection. Due to the anatomical features of the SMA, SMV, and retropancreatic nerve plexus, the reliable excision line always appears as an oblique line in computed tomography (CT) (Fig. 2). In the ventral approach to laparotomy, the cutting direction is diagonally inward unless the hanging maneuver is performed. Therefore, resection of the retroperitoneal plexus is the most difficult procedure in PD. However, it is thought that the diagonal excision line can be facilitated by securing the entrance and exit of the hanging maneuver and performing sufficient kocherization. By traction of the hanging maneuver tape, a clear line may be drawn between the resection side and the remaining side. However, whether the artery-first approach improves R0 resection rate and contributes to survival benefit remains unclear . In addition, whether resection using this procedure produces an oncological benefit remains unclear and requires further study.