Langenbecks Arch Surg
DOI 10.1007/s00423-012-0957-1
LETTER TO THE EDITOR
Combined posterior and anterior approach to the superior
mesenteric artery : the advantages of the “hanging maneuver”
Ettore Marzano & Tullio Piardi & Jacques Marescaux &
Patrick Pessaux
Received: 27 March 2012 / Accepted: 24 April 2012
# Springer-Verlag 2012
We read with great interest the article by Shrikhande and
colleagues [1] recently published in Langenbecks Arch Surg
entitled “Superior mesenteric artery first combined with
uncinate process approach versus uncinate process first
apporach in pancreatoduodenectomy: a comparative study
evaluating perioperative outcomes.” Firstly, we want to
congratulate the authors for describing the “artery first”
approach in pancreatic head resection, which strives for a
complete tumor resection, especially at the superior mesen-
teric artery (SMA). The retroperitoneal peripancreatic tissue
is often invaded at the time of pancreaticoduodenectomy
resulting in R1 resection with dismal survival. Since several
years, we are convinced that it is of utmost importance to
remove “en bloc” together with the head of the pancreas all
the retroperitoneal peripancreatic tissue, in order to increase
the number of R0 resections and to extend the circumferen-
tial resection margins. However, as the author cited our
technique only partially, some comments seem necessary to
better clarify our surgical approach to SMA and especially the
evolution that characterized the technique since 2003 [2].
Posterior approach of SMA with en bloc retroperitoneal
pancreatic tissue ablation was initially introduced by our
team [2, 3]. Later on, based on our experience, we modified
the original technique adding new surgical tricks to facilitate
and standardize the surgical dissection and easily control the
SMA. The posterior approach could be technically demanding
E. Marzano : T. Piardi : J. Marescaux : P. Pessaux (*)
Universitaires de Strasbourg – Université de Strasbourg – Faculté
de Médecine — IRCAD/EITS- Institut Hospitalo-Universitaire
(IHU) MixSurg,
1 place de l’hôpital,
67091 Strasbourg, France
e-mail: patrick.pessaux@chru-strasbourg.fr
in some cases, especially in obese patients [4]. We recently
described a combination of posterior and anterior approach to
the SMA with “hanging maneuver,” which finally blends the
advantages of both approaches [5]. In fact, the initial dissec-
tion at the origin of the SMA allows easier identification and
preservation of replaced right hepatic artery and rapidly gives
clear information on the posterior extension of the tumor and
its resectability. The left anterior aspect of the superior mes-
enteric vein (SMV) is successively dissected, and the SMV is
gently retracted to the right. At this time, first jejunal vein is
often isolated and ligated allowing a safe approach to the distal
part of the SMA and its distal branches. Finally, a tape is
passed along the SMA from its origin on the aorta up to its
emergence in the mesentery, “hanging” retroperitoneal pan-
creatic tissue.
Compared to the combined technique described by
Shrikhande et al. [1], the SMA is totally dissected without
section of the first jejunal loop, identifying immediately an
arterial invasion which contraindicates a non-curative resec-
tion (R1 or R2 resection). Furthermore, the traction on the
tape pulls the retroperitoneal pancreatic tissue to the right
side, resulting in a better exposure of the SMA, facilitating
the dissection at the origin of all its proximal branches.
Finally, in case of bleeding, a temporary hemostasis can be
achieved lifting up the tape by the assistant, allowing the
surgeon to fulfil selective and definitive hemostasis. Thanks
to this combined approach with “hanging maneuver,” we
were able to achieve a low rate of R1 resection, as was also
succesfully obtained by Shrikhande et al. [1] (4.5 %).
In conclusion, independently to a surgeon’s preferred
approach, spread and standardization of SMA first dissection
seem of utmost importance in order to reduce R1 resection,
increase survival, and improve the transmission of fine onco-
logical practice.

Conflicts of interest None.
References
1. Shrikhande SV, Barreto SG, Bodhankar YD, Suradkar K, Shetty G,
Hawaldar R et al (2011) Superior mesenteric artery first combined
with uncinate process approach versus uncinate process first
apporach in pancreatoduodenectomy: a comparative study eval-
uating perioperative outcomes. Langenbeck’s Arch Surg
396:1205–1212
Langenbecks Arch Surg
2. Pessaux P, Regenet N, Arnaud J (2003) Resection of retroportal
pancreatic lamina during a cephalic pancreaticoduodenectomy:
first dissection of the superior mesenteric artery. Ann Chir
128:633–636
3. Pessaux P, Varma D, Arnaud J (2006) Pancreaticoduodenectomy: supe-
rior mesenteric artery first approach. J Gastrointest Surg 10:607–611
4. Weitz J, Rahbari N, Koch M, Büchler MW (2010) The “artery first”
approach for resection of pancreatic head cancer. J Am Coll Surg
210:e1–e4
5. Pessaux P, Rosso E, Panaro F, Marzano E, Oussoultzoglou E,
Bachellier P et al (2009) Preliminary experience with the hanging
maneuver for pancreaticoduodenectomy. Eur J Surg Oncol 35:1006–
1010