The management of pancreatic tumor adherence to the lateral wall of the superior mesenteric and portal veins (SMPV) represents the most challenging technical aspect of pancreaticoduodenectomy (PD). Prior studies have demonstrated that partial or segmental venous resection and reconstruction is an ideal means of managing tumor adherence to the SMPV. Options for conduit during SMPV reconstruction include synthetic or autogenous vein grafts; however, the infectious risks of PD make autogenous tissue preferable. Our institution has extensive experience with use of the superficial femoral vein (SFV) for aortic and venous reconstruction. We describe herein the use of the SFV in the reconstruction of the SMPV in patients undergoing PD and vein resection for periampullary tumors. Our early experience with this specific technique has generated several observations. First, our experience has confirmed that safe performance of SMPV resection and graft placement requires complete dissection of the specimen and SMPV away from the superior mesenteric artery and retroperitoneal attachments. Second, we have found that harvesting of a short segment of SFV is easily achieved and safe in these patients if one adheres to the technique of SFV harvest as described by Clagett et al.1 Lastly, the SFV vein is an excellent size match for the SMPV, and its superior handling properties and durability make it our preferred conduit for SMPV reconstruction at the time of PD for cancer.
The operative view after transsection of the stomach and pancreas exposes a pancreatic head tumor with lateral involvement of the superior mesenteric vein confluence (SMV).
Reflection of the specimen medially (arrow) allows dissection of the retroperitoneal attachments from the superior mesenteric artery (SMA) to mobilize the specimen and attached superior mesenteric veins (SMV).
The medial-to-lateral view of the tumor and attached veins after dissection from surrounding structures. Note the divided pancreas (P) and superior mesenteric artery (SMA). SMV indicates superior mesenteric vein; PV, portal vein; and SV, splenic vein.
The lateral-to-medial view of the tumor and attached superior mesenteric vein (SMV) and portal vein (PV) after dissection from surrounding structures and the superior mesenteric artery (SMA).
These figures provide an anatomic basis for the surgical approach for superficial femoral vein harvest. A, The skin incision and soft-tissue dissection is performed over the lateral border of the middle third of the sartorious muscle. B, The vein lies within the Hunter canal along with the superficial femoral artery and saphenous nerve.
The superficial femoral popliteal vein (SFV) ready for harvest from the right leg. Multiple side branches have been divided from the SFV so that it is now separate from the superficial femoral artery (SFA) and saphenous nerve (SN) that have been reflected medially with the sartorious muscle.
Placement of the graft in the superior mesenteric portal vein (SMV) confluence. A, The proximal portion of the graft (closest to the heart) is used to reconstruct the portal vein (PV)–splenic vein confluence and preserve splenic flow. Note the Rumel tourniquet at the mesenteric root. P indicates pancreas; SMA, superior mesenteric artery. B, The SMV anastomosis is nearly complete in this photo; note the excellent size match of the SFV with the SMV. PV indicates portal vein; SV, splenic vein; and SFV, superficial femoral vein.
A typical superior mesenteric vein (SMV) and portal vein graft in place prior to reconstruction of the gastrointestinal tract.
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