Review

Artery-first approaches to pancreatoduodenectomy

P. Sanjay1,6 , K. Takaori3 , S. Govil4 , S. V. Shrikhande5 and J. A. Windsor1,2
1
Hepatopancreatobiliary/Upper Gastrointestinal Unit, Department of General Surgery, Auckland City Hospital, and 2 Department of Surgery, School of
Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand, 3 Division of Hepato-Biliary-Pancreatic Surgery and
Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan, 4 Division of Gastrointestinal Oncology,
Bangalore Institute of Oncology, Bangalore, and 5 Department of Gastrointestinal and Hepatopancreatobiliary Surgical Oncology, Tata Memorial
Centre, Mumbai, India, and 6 Department of Surgery, Ninewells Hospital and Medical School, Dundee, UK
Correspondence to: Professor J. A. Windsor, 12th oor, Support Building, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand
(e-mail: j.windsor@auckland.ac.nz)

Background: The technique of pancreatoduodenectomy (PD) has evolved. Previously, non-resectability

was determined by involvement of the portal veinsuperior mesenteric vein. Because venous resection
can be achieved safely and with greater awareness of the prognostic significance of the status of the
posteromedial resection margin, non-resectability is now determined by involvement of the superior
mesenteric artery (SMA). This change, with a need for early determination of resectability before an
irreversible step, has promoted the development of an artery-first approach. The aim of this study was
to review, and illustrate, this approach.
Methods: An electronic search was performed on MEDLINE, Embase and PubMed databases from
1960 to 2011 using both medical subject headings and truncated word searches to identify all published
articles that related to this topic.
Results: The search revealed six different surgical approaches that can be considered as artery first.
These involved approaching the SMA from the retroperitoneum (posterior approach), the uncinate
process (medial uncinate approach), the infracolic region medial to the duodenojejunal flexure (inferior
infracolic or mesenteric approach), the infracolic retroperitoneum lateral to the duodenojenunal flexure
(left posterior approach), the supracolic region (inferior supracolic approach) and through the lesser sac
(superior approach).
Conclusion: The six approaches described provide a range of options for the early determination of
arterial involvement, depending on the location and size of the tumour, and before the point of no
return. Whether these approaches will achieve an increase in the proportion of patients with negative
margins, improve locoregional control and increase long-term survival has yet to be determined.
Paper accepted 7 March 2012
Published online 9 May 2012 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.8763

Introduction

The technique of pancreatoduodenectomy (PD) has

evolved, particularly in relation to the techniques used
to achieve negative resection margins. Early emphasis
was on establishing a dissection plane along the lateral
aspect of the portal vein (PV)superior mesenteric vein
(SMV)1 . Involvement of these veins was once considered
unresectable disease, but it is now accepted that venous
resection can and should be undertaken if this can be done
safely and negative margins achieved2 5 . As a result, the
focus has shifted to the superior mesenteric artery (SMA),
and resectability is now dictated by whether or not this is
involved. Resection of the SMA increases postoperative
2012 British Journal of Surgery Society Ltd
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morbidity and mortality rates without demonstrable

improvement in survival, and this radical approach has
now been largely abandoned6,7 .
The rst step in achieving a resection with negative margins is accurate preoperative staging. Highresolution dynamic computed tomography (CT) predicts
resectability with an accuracy of around 95 per cent8,9 , but
this falls dramatically in the neoadjuvant setting where
periarterial stranding makes the identication of unresectable disease less accurate, with a positive predictive value of only 25 per cent10 . A trial dissection is
necessary for patients in whom there is uncertainty about
resectability, and this patient group is likely to increase with
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P. Sanjay, K. Takaori, S. Govil, S. V. Shrikhande and J. A. Windsor

R
M

Diagram showing the six approaches to the superior

mesenteric artery: S, superior approach; A, anterior approach; P,
posterior approach; L, left posterior approach; R, right/medial
uncinate approach; M, mesenteric approach

Fig. 1

more widespread use of neoadjuvant therapy. Borderline

resectable disease has been dened as those tumours with:
venous involvement of SMV/PV without encasement of
nearby arteries; gastroduodenal artery and short-segment
hepatic artery encasement without extension on to the
coeliac axis; and tumour abutment of the SMA not exceeding more than 180 of the circumference of the vessel
wall11 . It is in the context of borderline resectable disease
that an artery-rst approach to dissection makes most
sense.
The artery-rst approach has come to mean that the
artery is given primary place in determining resectability,
and trial dissection is directed towards the early
determination of whether there is arterial involvement
before committing an irreversible step in the operation. A
number of different operative techniques and approaches
have been described under the heading of artery rst
(Fig. 1)12 21 , although it is acknowledged that similar
techniques were reported before the term artery-rst
approach was coined. Although a formal taxonomy of these
techniques may not be required, the purpose of this study
was to review the literature, illustrate the different arteryrst techniques, and discuss them in relation to indications
and potential benets.
Methods

A broad denition of artery rst is used and is applied

to any description of a PD in which there is an early
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and deliberate dissection of peripancreatic arteries for

the purposes of determining resectability and achieving a
negative resection margin. The use of the term artery rst
does not preclude previous manoeuvres, including exposure
of the PVSMV, but generally refers to an approach that
seeks to determine the status of the arterial margin before
an irreversible step in the dissection. Although the SMA
is the artery most commonly involved by local extension
of a pancreatic head cancer, an artery-rst approach might
also be appropriate in approaching the coeliac trunk or
common hepatic artery (CHA) if, on the basis of staging,
these structures were considered the critical determinants
of borderline resectable status. As these other arteries are
only rarely the critical vessels in pancreatic head cancers,
they are not discussed in this article.
An electronic search was performed of the MEDLINE,
Embase and PubMed databases from 1960 to 2011 using
the search terms pancreatic cancer, pancreatoduodenectomy, superior mesenteric artery, artery rst approach
and isolated pancreatectomy, using both medical subject
headings (MeSH) and truncated word searches to identify
articles. Abstracts were screened electronically, from which
potentially relevant papers were obtained. All languages
were considered. References from the selected articles
were used to complete the search. Further references were
identied by a manual cross-check of reference lists.
Results

The search identied 94 articles that were screened.

Fourteen articles relating to the artery-rst approach were
selected for this review, including three that compared two
different artery-rst approaches.
Indications for, and advantages and disadvantages of,
various artery-rst approaches are summarized in Table 1.

Posterior approach
In 2006, Pessaux and colleagues12 published a technical
description of the posterior approach to the SMA.
Since then there have been other descriptions of a
posterior approach without signicant modication13 15 .
The dissection begins with liberal kocherization of the
duodenum and rm retraction of the pancreatic head to
the left to dissect and expose the origin of the SMA
where it passes in front of the left renal vein in front
of the abdominal aorta (Fig. 2). Dissection of the SMA
commences with incision of the perivascular connective
tissue and is continued in a caudal direction along the SMA,
posterior to the pancreatic head, to where it crosses the
duodenum. Attachments between the SMA and uncinate
are divided to expose the lateral border of the PVSMV.
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Table 1

1029

Summary of indications, advantages and disadvantages of various artery-rst approaches

Approach

Indication(s)

Advantages

Disadvantages

Posterior12

Posteromedial tumour in
head/neck, especially involving
PVSMV
Periampullary tumour extending
from body to head

Difficult in patients with

peripancreatic inflammation and
adhesions around head of
pancreas

Medial uncinate18,22

Malignant tumours of uncinate

process

Inferior infracolic
(mesenteric)19

Locally advanced tumours with

questionable infiltration of SMA
at its origin from aorta
Malignant tumours of uncinate
and ventral pancreas
Tumours along uncinate and
ventral pancreas

Early identification of SMA involvement

Identification of replaced RHA
Enables adequate retropancreatic
lymphadenectomy
Early identification of SMV involvement and
facilitates en bloc resection
Early identification of SMA involvement at
uncinate
Early ligation of IPDA minimizes bleeding
Useful approach in peripancreatic
inflammation with difficulty tunnelling above
PV
Useful approach for total pancreatectomy as
mobilization can be achieved without
transecting gland
Early identification of replaced RHA
Allows better exposure and dissection of
region posterior to SMA
Early ligation of IPDA minimizes bleeding

Left posterior20

Inferior supracolic
(anterior)21

Tumours along inferior border of

pancreas

Superior

Malignant tumours of superior

border of pancreas

Facilitates skeletonization of SMA in

retroperitoneum without kocherization of
duodenum
Early ligation of IPDA
Facilitates better retroperitoneal dissection,
especially with locally advanced tumours
with neoadjuvant treatment
No-touch technique with en bloc
kocherization theoretically prevents tumour
cell dissemination
Early identification of CHA, coeliac and SMA
involvement

Late identification of replaced

RHA

Difficult in morbidly obese patients

Difficult exposure in patients with
high origin of SMA

Extensive dissection of SMA

requiring antidiarrhoeals

Early division of stomach and

neck of pancreas

Difficult exposure in patients with

low origin of SMA

PV, portal vein; SMV, superior mesenteric vein; SMA, superior mesenteric artery; RHA, right hepatic artery; IPDA, inferior pancreatoduodenal artery;
CHA, common hepatic artery.

The origins of the superior pancreatoduodenal and inferior

pancreatoduodenal (IPDA) arteries can be identied and
ligated as they enter the pancreatic head and uncinate
process respectively.
Dumitrascu and co-workers16 compared 21 patients
who had standard PD with 21 matched patients who
underwent this posterior approach, and found no
signicant differences in early morbidity or mortality rates,
hospital stay and overall survival. There was a signicant
reduction in intraoperative blood loss and duration of
operation with the SMA-rst approach, but no difference
in lymph node yield or in the number of patients who
had an R0 resection. Figueras et al.17 compared 18 patients
who underwent standard PD with 38 patients who had
initial posterior dissection of the SMA. Intraoperative and
postoperative transfusion rate, postoperative complications
and hospital stay were signicantly lower in patients who
underwent dissection of the SMA rst. There was no

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IPDA
SMA
LRV

Aorta
IVC

Posterior approach, exposing the origin of superior

mesenteric artery (SMA) in front of the left renal vein after
kocherization. For clarity the SMA has been made more
apparent. IPDA, inferior pancreatoduodenal artery; LRV, left
renal vein; IVC, inferior vena cava

Fig. 2

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P. Sanjay, K. Takaori, S. Govil, S. V. Shrikhande and J. A. Windsor

signicant difference in the positive margin rate or in

overall survival between the techniques, although the study
was not adequately powered for these endpoints. Both
studies demonstrated a signicant reduction in blood loss
and postoperative complications, thought to result from
early ligation of the pancreatoduodenal arteries. Neither
study reported the number of resections abandoned owing
to SMA invasion. It is worth noting that this posterior
approach was not associated with any improvement in
lymph node yields, negative margin status or overall
survival.

Medial uncinate approach

In 2007, Shukla and colleagues22 published a modied
version of PD involving division of the ligament of Treitz
and translocation of the proximal jejunum with its intact
mesentery into the supracolic compartment, by passing it
to the right under the superior mesenteric vessels. This
is thought to facilitate alignment of the uncinate process
with the jejunal mesentery, enabling complete dissection
of the SMV and SMA. Although the description did not
specically address approaching the SMA rst, it does
allow this to be performed. In 2010, Hackert and coworkers18 described a medial or uncinate-rst approach
for the purpose of early dissection of the SMA. Similar to
the posterior approach, an initial extended kocherization
is performed to the ligament of Trietz and the aorta.
The CattellBraasch manoeuvre, which involves dissection
along the right-sided white line of Toldt and then across
the small bowel mesenteric root, allows the colon and
small bowel to be retracted well to the left, facilitating
exposure of the SMV as it passes over the third part
of the duodenum. The pancreas is dissected free from
the SMV, often requiring the division of two or three
venous tributaries. The duodenojejunal (DJ) exure is
then mobilized, and the proximal jejunum transected and
transposed to the right abdomen by passing it behind the
superior mesenteric vessels. Although division of jejunum
is not always necessary, further exposure of the SMA and
SMV is facilitated by doing so. With the right colon and
small bowel retracted to the left, which lifts and rotates the
SMV up and to the left, along with retraction of the third
and fourth parts of the duodenum to the right, the SMA
is rotated into view under the SMV. It is then possible
to dissect down on the medial aspect of the SMA. This is
carried out in a cephalad direction under the neck of the
pancreas, on to the aorta, encountering and dividing the
IPDA on the way (Fig. 3). The medial uncinate approach
allows excellent exposure of the SMA, retroperitoneal and
para-aortic tissue, and, starting distally, the dissection is
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SMV
SMA
IPDA
UP
IPDV

Medial uncinate approach, demonstrating the uncinate

process (UP), inferior pancreatoduodenal artery (IPDA) and vein
(IPDV), superior mesenteric artery (SMA) and vein (SMV) after
kocherization and mobilization of the duodenojejunal exure

Fig. 3

safe and accurate. It would appear most useful for bulky

tumours arising in the superior aspect of the pancreatic
head.
Shrikhande et al.23 compared 30 patients who underwent
an SMA-rst uncinate approach with 14 patients who had
standard PD with an uncinate approach, and found no
signicant difference in blood loss, duration of operation,
complications, lymph node yield and margin status.

Inferior infracolic approach (mesenteric approach)

In 1993, Nakao and Takagi24 reported a case series of
isolated pancreatectomy, in which they used a catheter
to bypass SMV blood to the intrahepatic PV or systemic
circulation. They advocated approaching the SMVSMA
at the base of the transverse mesocolon before mobilization
of the pancreas head, and named this procedure the
mesenteric approach. It allows early division of the IPDA
and dissection of the right lateral border of the SMA.
The mesenteric approach and similar techniques, with
or without a bypass catheter, have become popular in
Japan. Some surgeons, including one of the present authors
(K.T.), routinely divide the middle colic artery at its origin
to make a wide opening at the base of the transverse
mesocolon for better exposure.
In 2010, Weitz and co-workers19 coined the term
artery-rst approach and described the inferior approach
to the SMA from the infracolic compartment, at the base
of the transverse mesocolon. The peritoneum is divided
over the palpable SMA, and this dissection is aided by
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1031

rst mobilizing the DJ exure and dividing the inferior

mesenteric vein. The SMA is exposed, with the SMV to
the right. The middle colic artery is identied arising from
the SMA and coursing anteriorly within the transverse
mesocolon (Fig. 4). The IPDA is identied on the right
aspect of the SMA as it enters the uncinate process under
the SMV. The IPDA is divided, and dissection continues
up and along the anterior and right medial aspect of
the SMA to its origin, under the neck of the pancreas
and splenic vein. This approach exposes the SMA in
the infracolic compartment at the root of the mesentery.
The terms inferior infracolic approach and mesenteric
approach are essentially synonymous. These procedures
allow early determination of SMA involvement, do not
require handling of the pancreatic head and tumour, and
facilitate early ligation of the IPDA. There are, however, no
randomized trials conrming these advantages or dening
the situation in which the technique is best applied. It
would appear that this approach is most useful for tumours
that arise from the uncinate process.

Left posterior approach

In 2011, Kurosaki and colleagues20 described the left
posterior approach to the superior mesenteric vascular
pedicle. Although not strictly necessary, the origin of the
SMA was identied by rst kocherizing the duodenum, as
for the posterior approach. By pulling the proximal jejunum
to the left, the rst and second jejunal arteries are divided

at their origin on the SMA (Fig. 5). Further traction on the

proximal jejunum produces a counterclockwise rotation
to the SMA that allows identication and division of the
IPDA, arising from the posterior surface of the SMA. This
manoeuvre enables clearance of the posterior and right
aspects of the SMA. With the SMA freed and retracted
to the right, and with the proximal jejunum still retracted
to the left, the SMV appears under the SMA and the
rst jejunal branch of the SMV is divided. The SMV is
then skeletonized up to its conuence with the splenic
vein. This frees the superior mesenteric pedicle from
the uncinate process and the mesentery of the proximal
jejunum. The jejunum is then divided and the duodenum
transposed to the right, allowing exposure and division of
the remaining connective tissue where it attaches to the
superior mesenteric pedicle.
This approach allows adequate assessment of the SMA
without mobilization of the duodenum or colon, and is
particularly useful for tumours arising from the uncinate
and posterior aspect of the head of the pancreas. It allows
adequate dissection of the posterior and right aspects of
the SMA, and early identication of any aberrant hepatic
artery. In contrast to the posterior approach proposed by
Pessaux et al.12 , which deals with identication of the SMA
in the retroperitoneum after duodenal mobilization, the left

MCA

P
SV
IPDA

MCV
MCA

SMV SMA

SMA
DJF
IPDA

SMV

Inferior infracolic approach (mesenteric approach)

exposing the superior mesenteric artery (SMA) and vein (SMV)
and branches after dividing the peritoneum to the right of the
duodenojejunal exure (DJF) in the transverse mesocolon.
P, pancreas; SV, splenic vein; MCV, middle colic vein; IPDA,
inferior pancreatoduodenal artery; MCA, middle colic artery

Fig. 4

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Left posterior approach, exposing the rst and second

jejunal arteries at their origin on the superior mesenteric artery
(SMA) in the transverse mesocolon. Further traction on the
proximal jejunum produces a counterclockwise rotation to the
SMA that allows identication and division of the inferior
pancreatoduodenal artery (IPDA) arising from the posterior
surface of the SMA (inset). MCA, middle colic artery; SMV,
superior mesenteric vein

Fig. 5

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posterior approach allows circumferential skeletonization

of the SMA in the retroperitoneum without this additional
step. With an extensive dissection of the SMA there is an
increased risk of diarrhoea, but there is evidence that this
can be controlled pharmacologically20 . In a series of 40
patients who underwent PD with a left posterior approach
compared with 35 patients who underwent a standard
PD, there were no signicant differences in operating
time, blood loss or hospital stay between the groups20 .
The overall morbidity was not signicantly increased by
the left posterior approach. In addition, the left posterior
approach was associated with fewer recurrences (10 versus
37 per cent; P = 0006) and improved survival (1- and 3year survival rates 902 and 532 per cent respectively in
left posterior group versus 80 and 16 per cent in control
group; P = 0004).

Inferior supracolic approach (anterior approach)

In 2010, Hirota and co-workers21 described the inferior
supracolic approach, which could also be considered an
anterior approach. Although division of the gastric antrum
is described, it is possible to expose the pancreatic neck
by cephalad retraction of the stomach after division of
the gastrocolic ligament. The next step in this technique
is to divide the pancreatic neck to expose the SMVPV
junction (Fig. 6), but it is worth doing as much dissection
as possible by elevating the inferior edge of the pancreas
to determine resectability before division of the pancreas.
The authors then describe the hanging manoeuvre, which
involves passing a tape along the right surface of the aorta
to the origin of the SMA and coeliac trunk, and then
passing it between the CHA and the superior margin of the
pancreatic neck, after rst dissecting this area. Traction on
this tape exposes the peripancreatic retroperitoneal margin
with the neural plexi and lymphatics, and facilitates their
division. The next step is a reversed kocherization with en
bloc mobilization of the duodenum and pancreatic head, in a
medial to right lateral direction, in a plane deep to Gerotas
fascia and anterior to the left renal vein and inferior vena
cava.
This approach allows the assessment of arterial
involvement at an early stage of the operation, especially
for tumours involving the lower pancreatic head. The
disadvantage of the technique as originally described is
the transection of the stomach and pancreatic neck at
an early stage to achieve adequate exposure of the SMA,
but this is not always necessary. A purported advantage
of this technique is that it is no touch25 , with en bloc
mobilization of the duodenum and pancreatic head, after
vascular control and before the tumour itself is handled or
retracted.
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P. Sanjay, K. Takaori, S. Govil, S. V. Shrikhande and J. A. Windsor

LGA
CHA

SA

PV
SV

SMV

IMV
IPDA
SMA

Inferior supracolic approach (anterior approach),

demonstrating the superior mesenteric artery (SMA) and vein
(SMV), splenic vein (SV) and coeliac axis and its branches after
division of the neck of the pancreas. LGA, left gastric artery;
CHA, common hepatic artery; SA, splenic artery; PV, portal
vein; IMV, inferior mesenteric vein; IPDA, inferior
pancreatoduodenal artery

Fig. 6

Hirota and colleagues21 published a series of 42 patients

operated on using this technique, including 28 with
pancreatic or biliary adenocarcinoma, of whom 24 had
stage III or IV disease and 15 required venous resection.
The R0 rate was 82 per cent for pancreatic and 91 per cent
for biliary adenocarcinoma, and the combined overall 2year survival rate for these subgroups was 75 per cent.

Superior approach
In this approach, the hepatoduodenal ligament is dissected
rst to expose the CHA and the gastroduodenal artery by
dissecting from right to left to remove the anterior lymph
nodes en bloc or separately. This is then dissected from the
superior margin of the pancreas down to its origin from
the coeliac trunk (Fig. 7). The dissection is then carried
down the coeliac trunk, inside the perineural and lymphatic
tissue, on to the aorta and origin of the SMA, aided by
caudal retraction of the pancreas.
The superior approach is another way to expose the
origin of the SMA and, although this exposure can be
technically difcult in patients with a low origin of the
SMA, it provides good exposure for tumours with suspected
CHA involvement. For borderline resectable tumours
arising from the dorsal pancreas with increased propensity
of lymph node and nerve plexus involvement around the
CHA26 , an artery-rst superior approach directed towards
the CHA is an another option to conrm resectability and
improve the opportunity to achieve an R0 resection.
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LGA
CHA
PV

SA
SMA

GDA

Superior approach demonstrating the coeliac axis and its

branches and the superior mesenteric artery (SMA) in the lesser
sac above the neck of the pancreas. LGA, left gastric artery;
CHA, common hepatic artery; SA, splenic artery; PV, portal
vein; GDA, gastroduodenal artery

Fig. 7

Discussion

This review highlights the issue that the term artery

rst means different things to different surgeons. Some
standardization is needed. It is suggested that artery rst
is considered to be the principle on which the six different
techniques are based. In discussing an artery-rst approach,
it is therefore important to specify which technique is being
referred to.
Three factors seem to have contributed to the
development of an artery-rst approach to PD. The rst
was the move to determine unresectability on the basis
of arterial rather than venous involvement27 . The second
was the desire to know early in the operation whether the
SMA was involved or not11,19 , and the third was awareness
that accurate dissection of the posteromedial margin of the
pancreas yielded the best chance of a negative resection
margin and that this required the right side of the SMA
and its origin to be skeletonized28 30 .
The most important prognostic factors in patients
undergoing PD are biology of the tumour, tness of
the patient and ability to achieve negative resection
margins31,32 . Only resection margins are under the control
of the surgeon. Of the different resection margins, it is
the posteromedial resection margin, limited by the right
aspect of the proximal SMA, that usually presents the major
technical challenge. In traditional PD dissection, this is
usually the last to be addressed33 . It has been suggested
that the most accurate descriptive term for this margin is
the SMA margin34 . The majority of studies investigating
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margin status after PD showed that a positive SMA margin

was an independent negative predictor of survival35,36 .
The SMA-rst technique may also add to the safety
of venous resection. Early dissection of the SMA results
in tumour being attached only to the involved veins, so
clamping of the portomesenteric conuence may be easier
and shorter37 . A recent consensus statement concluded that
patients with disease involving the gastroduodenal artery
and short-segment hepatic artery encasement, without
extension on to the coeliac axis and tumour abutment
of the SMA not exceeding 180 of the circumference of the
vessel wall, should be considered for potentially curative
resection11 .
The late determination of this margin in a traditional PD
means that the surgeon has already committed to resection.
Early determination of this situation, before transection of
the pancreatic neck, would avoid resection that would not
confer a survival advantage.
This review has outlined a number of recent descriptions
of techniques that place increased emphasis on dissection of
the posterior pancreatic capsule and early dissection of the
SMA without dividing the pancreatic neck28 . In all except
the left posterior approach, dissection of the lymphatic and
neural tissue around the SMA is limited to its posterior and
right aspect to reduce the risk of intractable postoperative
diarrhoea38 , and the plane of dissection is on the adventitia
of the SMA to maximize tumour clearance.
There are a number of situations when an artery-rst
approach is particularly helpful, in addition to the group
with borderline resectable disease11 . Previous chemotherapy and/or radiotherapy may produce periarterial stranding, increasing the difculty in condently determining
resectability based on CT. The technique facilitates early
identication and control of an anomalous or accessory
hepatic artery arising from the SMA39 . Specic pathologies can also call for early arterial dissection. In dealing with
intraductal papillary mucinous neoplasms extending from
the head to the body of the pancreas40,41 and requiring
division of the body of the pancreas rather than the neck,
resection can be facilitated by an artery-rst approach.
Early division of the SMA margin allows pancreatic mobilization towards the left, with dissection of splenic vessels
and ligation of collaterals. This allows transection of the
pancreas at any level28 . For tumours arising from the dorsal
pancreas, recent data suggest preferential perineural and
lymphatic spread towards the CHA, whereas those arising from the ventral pancreas have a propensity to spread
towards the SMA26 . This suggests that lymph node dissection should be based on the primary tumour location. This
means directing an artery-rst approach towards the CHA
for borderline tumours arising from the dorsal pancreas.
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The evidence for the indications and benets of an

artery-rst approach is sparse, especially with regard to
lymph node yield, margin status and long-term survival.
Only a small proportion of patients have borderline
resectable disease on preoperative staging, but it is these
patients who require a trial dissection. The various
techniques described in this review provide the pancreatic
surgeon with a range of options depending on the location
and size of the tumour, and will help achieve an early
determination of arterial involvement before the point
of no return. Although the philosophy of the artery-rst
approach has been applied mainly to the SMA, borderline
resectable tumours in the dorsal pancreas warrant a
CHA-rst approach to ensure resectability. The various
approaches to the SMA provide primary access to different
portions of the artery. In some patients, a combination of
approaches may be necessary to access the length of the
artery.
Although the artery-rst approach is routine in some
specialized centres, available evidence suggests that it is
indicated only in the situations described above. It is
important, however, that the pancreatic surgeon should
be familiar with the different techniques, as there will
be occasions when using one or more of them will be
necessary to determine, safely and early, whether there is
arterial involvement that precludes R0 resection.

Disclosure

The authors declare no conict of interest.

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