British Journal of Surgery 1998, 85, 125–126 Surgical workshop Avoiding pancreatic necrosis following pancreas-preserving D 3 lymphadenectomy for gastric cancer F. PACELLI, G. B. DOGLIETTO, S. ALFIERI, C. CARRIERO, M. MALERBA, P. CRUCITTI and F. CRUCITTI Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168 Roma, Italy Correspondence to: Dr F. Pacelli Pancreas-preserving lymphadenectomy for gastric cancer is a method of removing lymph nodes along the upper border of the pancreas without performing a distal pancreatic resection 1 . The surgical technique includes ligation of the splenic artery at its origin and is effective in reducing the incidence of complications related to pancreatic resection, but carries the risk of pancreatic necrosis 1 . A technique has been developed of pancreas- preserving D 3 lymphadenectomy for gastric cancer which reduces the risk of pancreatic necrosis. Surgical technique The surgical procedure involves dissection of the entire greater omentum, superior leaf of mesocolon and the serosa of the pancreatic surface 2 ; node dissection is then performed in the infraduodenal and supraduodenal areas, along the retropancreatic region (nodes n13 according to the Japanese Research Society for Gastric Cancer 3 ), the hepatic pedicle (nodes n12), the mesenteric root (nodes n14) and along the common hepatic (nodes n8) and coeliac (nodes n9) arteries. The left gastric artery (nodes n7) is ligated at its origin and node dissection (nodes n11) is extended along the proximal third of the splenic artery, which is ligated distally approximately 5 cm from its origin. The spleen and distal pancreas are then mobilized and retracted. The tail of the pancreas is exposed carefully and the splenic vein and caudal pancreatic arteries are ligated and divided. Finally, the upper border of the pancreas is exposed and the spleen (nodes n10) and the middle and distal third of splenic artery with the surrounding fatty connective tissue and nodes (n11) are removed en bloc, together with the stomach, gastric omentum and perigastric nodes (n1–6). The pancreatic parenchyma and splenic vein are preserved. Discussion The dorsal pancreatic artery usually arises from the proximal third of the splenic artery 4,5 and joins the posterosuperior pancreaticoduodenal artery (so-called Kirk arcade 4 ) after giving off the transverse pancreatic artery. In the absence of the Kirk arcade (about 40 per cent of cases) the dorsal pancreatic artery is the sole blood supply to the left pancreas. Thus, ligation of the origin of the splenic artery exposes four in ten patients to the risk of pancreatic necrosis. The authors therefore preserve the proximal third of the splenic artery during pancreas-preserving lymphadenectomy by ligating the artery approximately 5 cm distal to its origin ( Fig. 1). Paper accepted 18 May 1997 Anterior and posterior pancreaticoduodenal arcades Transverse pancreatic artery Lymph nodes along splenic artery (middle and distal third) Gastroduodenal artery Hepatic artery Lymph nodes along left gastric artery Lymph nodes along splenic artery (proximal third) Splenic vein Dorsal pancreatic artery Kirk arcade Fig. 1 Reported technique of pancreas-preserving D 3 lymphadenectomy. The splenic artery is ligated approximately 5 cm distal from its origin to preserve the blood supply to the left pancreas through the dorsal pancreatic artery © 1998 Blackwell Science Ltd 125