Ligament of Treitz approach in laparoscopic modified radical antegrade modular pancreatosplenectomy: Report of three cases

Laparoscopic distal pancreatectomy for pancreatic cancer is being applied increasingly in selected cases. Open radical antegrade modular pancreatosplenectomy (RAMPS) was introduced to obtain a higher rate of tumorfree margins and a higher lymph node (LN) count. However, there is no standard laparoscopic technique for pancreatic cancer. We treated three patients with RAMPS using a ligament of Treitz approach. We started each procedure by dissecting the ligament of Treitz. We entered and spread the anterior space of the aorta and inferior vena cava. We then dissected the LN of the root of the supra-mesenteric artery and performed RAMPS. The mean number LN retrieved from the patients was 43 +/- 22. All three patients underwent pancreatectomy to obtain tumor-free margins, and two patients began adjuvant chemotherapy by postoperative day 14. The ligament of Treitz approach in laparoscopic modified RAMPS offered tumor-free margins and the resection of sufficient regional LN. The procedure also allowed adjuvant chemotherapy to be started early.