Surgical Practice

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doi:10.1111/1744-1633.12101 Review Article

Superior mesenteric artery first approach with first

jejunal vein-oriented mesenteric excision in
pancreatoduodenectomy
Takao Ohtsuka,1* Masafumi Nakamura2 and Masao Tanaka1
1
Departments of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, and 2Department
of Digestive Surgery, Kawasaki Medical School, Kurashiki, Japan.

The superior mesenteric artery (SMA) first approach prior to the isolation of the portal vein (PV)/superior
mesenteric vein (SMV) from the pancreatoduodenal region during pancreatoduodenectomy was introduced to
reduce blood loss due to congestion caused by the PV/SMV first approach. There are several SMA first
approaches: the mesenteric approach for pancreatic head cancer and the anterior approach for other
periampullary diseases are usually employed at our institution. In these approaches, identification of the first
jejunal vein is a critical step to determine the optimal area for lymph node dissection along the SMA
(mesoduodenum), and to identify the starting point of the SMA first approach to insulate the flow of the inferior
pancreatoduodenal artery. We herein describe our SMA first approach with first jejunal vein-oriented
mesenteric excision during pancreatoduodenectomy.
Key words: lymph node dissection, pancreatoduodenectomy, portal vein, superior mesenteric artery.

Introduction distal border of lymph node dissection along the

SMA. Nakamura et al.7 recently introduced first
Division of the pancreatic uncinate process from the
jejunal vein-orientated mesenteric excision during
superior mesenteric artery (SMA) is traditionally the
pancreatoduodenectomy to complete the SMA first
final step of pancreatoduodenectomy. Bleeding from
approach. This technique reduces blood loss and
the pancreatic head region often occurs during this
allows for adequate lymph node dissection along the
step because the portal vein (PV)/superior mesenteric
vein (SMV) is isolated prior to insulation of the blood
supply from the SMA, leading to congestion of the
pancreatic head region. The SMA first approach was
introduced to reduce the congestion and bleeding
during this step (Fig. 1).15 Several SMA first
approaches are performed, including the posterior,
medial uncinate, inferior infracolic (mesenteric), left
posterior, inferior supracolic (anterior) and superior
approaches. Each of these approaches has both
advantages and disadvantages, and the selection of
the optimal SMA first approach is based on the sur-
geons preference and patient characteristics, includ-
ing body shape, location of the origin of the SMA and
variation of the arterial system.6
Identification of the distal border between the pan-
creatic uncinate process and SMA is an important
initial step, because this border is consistent with the Fig. 1. Artery first approach during pancreatoduodenectomy.
Pancreatic uncinate process is divided from the superior
mesenteric artery (SMA), and the pancreatoduodenum is con-
*Author to whom all correspondence should be addressed. nected with only the portal vein (PV)/superior mesenteric vein
Email: takao-o@surg1.med.kyushu-u.ac.jp (SMV). CHA, common hepatic artery; PHA, proper hepatic
Received 18 July 2014; accepted 23 September 2014. artery; SpV, splenic vein.

2014 College of Surgeons of Hong Kong Surgical Practice (2015) 19, 2932
30 T Ohtsuka et al.
Fig. 2. Identification of the first jejunal vein during the
mesenteric approach. After identifying and taping the superior
mesenteric vein (SMV) and superior mesenteric artery (SMA) at
the base of the mesocolon, the middle colic artery (MCA) and
mesocolon are resected with preservation of the marginal
vessels of the transverse mesocolon. SMV and SMA tapes are
pulled in opposite directions to stretch the mesoduodenum
between the SMV and SMA, and the first jejunal vein (jejunal
branch of the SMV) is detected at the level of the origin of the
MCA.
SMA, and we have been performing this procedure
since its introduction. We usually apply the mesenteric
approach to pancreatic head cancer and the anterior
approach to other periampullary diseases. We herein
describe the techniques of these two different
approaches.
Rationale of the procedures
The distal border of the lymph node station along the
SMA (station no. 14) is defined as the origin of the
middle colic artery (MCA), according to the Japanese
general rules for pancreas cancer.8 The origin of the
MCA is usually located at the same level of the con-
fluence of the first jejunal vein (jejunal branch) to the
SMV (iliac branch) (Fig. 2), and at the same level of
the third part of the duodenum.7 The inferior
pancreatoduodenal artery (IPDA), which is a branch of
the first jejunal artery, usually courses in a cross-
direction to the pancreatic uncinate process between
the origin of the SMA and first jejunal vein; it is some-
times located dorsally to the first jejunal vein.7 There-
fore, identification of the first jejunal vein is an
important initial step to determine the optimal
area for lymph node dissection along the SMA
(mesoduodenum), and to begin the SMA first
approach to insulate the flow of the IPDA.
Techniques
Mesenteric approach
The presence or absence of invasion of pancreatic
head cancer to the SMA is a critical issue in the com-
2014 College of Surgeons of Hong Kong
pletion of margin-negative (R0) operations. The
mesenteric approach allows for evaluation of R0
resectability during the initial step of pancreato-
duodenectomy for pancreatic head cancer. If the sur-
gical margin by frozen section is positive at this time,
a palliative procedure, such as gastric or biliary
bypass, is performed. If the surgical margin is nega-
tive, lymph node dissection along the SMA and divi-
sion of the IPDA are performed during the initial step
of pancreatoduodenectomy. A good surgical view
between the SMV and SMA can be obtained after
excision of the MCA with the mesocolon. Additionally,
the SMV is effectively mobilized by this procedure,
thus PV/SMV resection and reconstruction, if neces-
sary, can be safely performed without tension. The ilial
branch and/or jejunal branch (first jejunal vein) of the
SMV are sometimes involved in pancreatic cancer that
affects the uncinate process; however, one of these
two veins can be removed without reconstruction.9
After identifying and taping the SMV and SMA at the
base of the mesocolon, the MCA and mesocolon are
resected with preservation of the marginal vessels of
the mesocolon. The SMV and SMA tapes are pulled in
opposite directions to stretch the mesoduodenum
between the SMV and SMA. The first jejunal vein is
then detected at the level of the origin of the MCA
(Fig. 2).7 Notably, approximately 80 per cent of the first
jejunal vein runs dorsally to the SMA, while the remain-
ing 20 per cent travels ventrally to the SMA.9 Excision
of the mesoduodenum combined with the right half of
the neural plexus of the SMA begins from the level of
the origin of the MCA. After division of the posterior
margin of the neural plexus of the SMA, the IPDA can
be identified within the deeper level. The origin of the
SMA is usually located dorsally to the splenic vein, and
the IPDA is usually identified between the origins of the
SMA and MCA (Fig. 3). If the IPDA cannot be detected
at this site, the area dorsal to the first jejunal vein is
evaluated, because the IPDA often runs in a cross-
direction to the pancreatoduodenal region. We some-
times identify two IPDA or no visible IPDA; therefore,
arterial phase-enhanced computed tomography
should be checked preoperatively to evaluate the con-
dition of the IPDA.10
The mesenteric approach is also included in the
no-touch isolated pancreatoduodenectomy technique
introduced by Nakao et al. in 1993.11 This procedure is
advantageous because it prevents the squeezing out
of cancer cells when hanging the pancreatic head
tumour after Kochers manoeuvre, and allows for
evaluation of R0 resectability during the initial step of
pancreatoduodenectomy for pancreatic head cancer.
However, a disadvantage of the mesenteric approach
is the risk of requiring emergent haemostasis for
Surgical Practice (2015) 19, 2932
 Superior mesenteric artery first approach
Fig. 3. Ligation of the inferior pancreatoduodenal artery during
the mesenteric approach. Inferior pancreatoduodenal artery
(IPDA) is usually identified between the origin of the superior
mesenteric artery (SMA) and middle colic artery (MCA). SMV,
superior mesenteric vein.
incidental bleeding around the pancreatic head
region; conversely, hanging of the pancreatoduodenal
region after Kochers manoeuvre allows for emergent
constriction as described in the next section.
Anterior approach
At our institution, the anterior approach during the later
steps of pancreatoduodenectomy is the standard
SMA first approach for various periampullary dis-
eases, with the exception of pancreatic head cancer.
After the operator hangs the pancreatoduodenal
region with his or her left hand, the mesoduodenum
between the SMV and SMA is pushed and stretched
by the operators left middle and ring fingers in the
posterior-to-anterior direction (Fig. 4). The mesoduo-
denum is then cut layer by layer using a vessel-sealing
system without ligation, because the IPDA does not
run ventral to the SMA.7 The neural plexus of the SMA
is usually preserved during this procedure. At the
deeper level of the SMA, the IPDA can be detected
between the first jejunal vein and the origin of the SMA
(Fig. 5); it is sometimes detected in the area dorsal to
the first jejunal vein, as described earlier.7 Prior to this
procedure, the pancreas is usually cut at the level of
the PV/SMV, and the splenic vein is taped, which leads
to good visualization around the origin of the SMA.
Notably, a small drainage vein runs from the pan-
creatic uncinate process to the first jejunal vein in most
cases (Fig. 6), and injury to this drainage vein leads to
intractable bleeding that potentially requires removal
of the first jejunal vein. Injury to this drainage vein
seems to occur during implicit dissection of the
2014 College of Surgeons of Hong Kong
31
Fig. 4. Identification of the first jejunal vein during the
anterior approach. After the operators left hand hangs the
pancreatoduodenum, the mesoduodenum between the superior
mesenteric vein (SMV) and artery is pushed and stretched by
the operators left middle and ring fingers in the posterior to
anterior direction. First jejunal vein (jejunal branch of SMV) is
then identified. SpV, splenic vein.
Fig. 5. Ligation of the inferior pancreatoduodenal artery during
the anterior approach. Inferior pancreatoduodenal artery (IPDA)
is detected between the first jejunal vein and the origin of the
superior mesenteric artery. In this case, the neural plexus of the
superior mesenteric artery is preserved, and the middle colic
artery is not divided. SMV, superior mesenteric vein.
mesoduodenum when the pushed and stretched first
jejunal vein is shifted from the posterior to the left side
of the SMV. At this time, the small drainage vein
becomes located dorsal to the first jejunal vein, and
careful attention should be paid to prevent injuring this
drainage vein. This drainage vein should be ligated
during the last step of isolation of the PV/SMV from the
pancreatoduodenal region (Fig. 6).
Nakamura et al.7 reported that the earlier-described
anterior approach of the SMA first method with first
jejunal vein-oriented mesenteric excision during
Surgical Practice (2015) 19, 2932
32 T Ohtsuka et al.
Fig. 6. Ligation of the small drainage vein from the pancreatic
uncinate process to the first jejunal vein. Small drainage vein
runs from the pancreatic uncinate process to the first jejunal
vein. Drainage vein is ligated during the last step of isolation
of the portal vein/superior mesenteric vein (SMV) from the
pancreatoduodenum. Jejunal branch of the SMV (first jejunal
vein) is shifted to the right side of the SMV. IPDA, inferior
pancreatoduodenal artery; SMA, superior mesenteric artery.
Fig. 7. Posterior approach. SMA, superior mesenteric artery;
SMV, superior mesenteric vein; IPDA, inferior pancreato-
duodenal artery.
pancreatoduodenectomy resulted in significantly less
intraoperative blood loss than the conventional
PV/SMV first method. However, in obese patients, it is
often difficult to push and stretch the mesoduodenum,
as described earlier. In such cases, conversion to the
posterior approach (Fig. 7)6 might be helpful, although
the operators left hand cannot provide constriction.
Alternatively, an inverted T-shaped abdominal incision
might allow the operators left hand to access the
2014 College of Surgeons of Hong Kong
pancreatoduodenum more comfortably than the use of
a middle abdominal incision.
Conclusion
The SMA first approach with first jejunal vein-oriented
mesenteric excision seems to be ideal in terms of
reduced blood loss and a greater oncological benefit
provided by adequate lymph node dissection during
pancreatoduodenectomy. Further investigation is nec-
essary to obtain scientific evidence as to whether this
approach consistently shows these benefits in the
clinical setting.
Declaration of conflict of interest
All authors declare that they have no conflicts of
interest.
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Surgical Practice (2015) 19, 2932
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