Combining Appleby with RAMPS - Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Celiac Trunk Resection.

Background: Radical Antegrade Modular Pancreatosplenectomy (RAMPS) minimizes the risk of a positive retroperitoneal margin and maximizes lymph node harvest in distal pancreatic cancers.1-7 In those with celiac trunk involvement, resection of the celiac trunk (modified Appleby procedure) is a surgical option in which postoperative liver perfusion relies on blood flow via superior mesenteric artery (SMA) and gastroduodenal artery (GDA).8, 9 PATIENT: A 66-year-old male was diagnosed with a 3.8 × 2.5 cm pancreatic body adenocarcinoma abutting the celiac trunk. Neoadjuvant FOLFIRINOX was initiated with a uniquely good response.

Technique: Prior to surgery, a novel preoperative 3D simulation technique accounting for organ displacement during pneumoperitoneum with the goal of optimizing port placement and surgical decision making was employed. At surgery, a RAMPS procedure was performed with the renal vessels and adrenal gland being dissected first (reversed from typical open approach). Following dissection along the SMA towards the celiac axis, desmoplastic reaction enveloping the celiac trunk necessitated its resection. Arterial liver perfusion was confirmed with intraoperative ultrasound.

Conclusion: L-RAMPS and modified Appleby procedure is a curative option for patients with distal pancreatic cancers that invade the celiac trunk and in whom the tumor biology is well controlled. A preplanned approach with 3D reconstruction accounting for organ displacement due to pneumoperitoneum optimizes surgical decision making and port placement for visual alignment caudally along the SMA.