Intermittent superior mesenteric artery occlusion for en bloc resection of the uncinate process during laparoscopic pancreaticoduodenectomy: A novel technique

Abstract Background: En bloc resection of the uncinate process of the pancreas represents the most important yet difficult step in laparoscopic pancreaticoduodenectomy (LPD), given the risk of major intraoperative bleeding which often necessitates the conversion to open surgery. We therefore developed the intermittent superior mesenteric artery occlusion (ISMAO) technique as a means of blood flow control during uncinate process resection, and investigated its role in LPD. Methods: Consecutive patients who underwent LPD at the Department of Biliary and Pancreatic Surgery, Sun Yat-sen Memorial Hospital between August 2020 and May 2022 were enrolled. Patients were divided into 2 groups, the ISMAO and non-ISMO group. Parameters such as operation time, intraoperative blood loss volume, conversion rate to open surgery, R0 resection rate, bowel function recovery time, postoperative hospital stay length, and rate of postoperative complications (including pancreatic fistula, delayed gastric emptying, and postoperative bleeding) were compared. Results: A total of 51 patients were included, of whom 22 (43.1%) underwent ISMAO. Significantly shorter mean operation time was observed in the ISMAOgroup compared to the non-ISMAO group (349.8 ± 84.9 min vs. 533.5 ± 105.9 min; P < 0.001). In addition, ISMAO associated with significantly lower intraoperative blood loss volume [112.5 (87.5-200.0) mL vs. 400.0 (250.0-600.0) mL; P < 0.001], and significantly lower conversion rate to open surgery (4.54% vs. 26.0%; P = 0.0485). R0 resection rate in the ISMAO group was significantly higher (95.5% vs. 79.3%; P = 0.0485). No significant differences were observed in postoperative hospital stay length, bowel function recovery time, and postoperative complication rate between the groups. Conclusions: ISMAO represents a novel blood flow control technique for en bloc resection of the uncinate process. Our study demonstrated its role in improving surgical safety and reducing intraoperative bleeding, and suggests its potential as a standard surgical procedure in LPD.