RAMPS Procedure for Adenocarcinoma of the Body and Tail of the Pancreas: How I Do It
Executive Summary
Radical Antegrade Modular Pancreatosplenectomy (RAMPS) is a specialized surgical procedure designed for treating adenocarcinoma in the body and tail of the pancreas. This document details an evolved methodology—the infra-mesocolic SMA first approach—which addresses a critical limitation of the traditional RAMPS procedure. While standard RAMPS facilitates high visibility and negative posterior margins, it often requires irreversible operative steps before the surgeon can determine if the tumor has involved the superior mesenteric artery (SMA), a condition that generally indicates unresectability.
The methodology outlined herein emphasizes early exposure and taping of the SMA via an infra-mesocolic route. This allows for a "trial dissection" to assess resectability before the division of the pancreatic neck, ensuring a safer and more reliable surgical introduction. Key outcomes of this approach include improved lymph node dissection, early arterial severance for tumor isolation, and the ability to achieve negative tangential margins more consistently.
Overview of the RAMPS Procedure
Originally reported by Strasberg et al., RAMPS differs from the traditional left-to-right surgical approach by advancing dissection from right to left.
Key Advantages
Negative Posterior Margins: Provides a higher frequency of negative margins compared to traditional distal pancreatectomy.
Enhanced Visibility: The antegrade approach allows for better visualization of the surgical field.
Early Vascular Control: Facilitates early arterial severance, which is critical for tumor isolation and effective lymphadenectomy.
Modular Flexibility: The dissection plane can be adjusted (modular) depending on the depth of tumor invasion, specifically regarding the preservation or resection of the left adrenal gland.
The SMA First Approach: Addressing Resectability
The primary challenge in traditional RAMPS is that the SMA is typically dissected from right to left only after the pancreatic stump is tilted. Consequently, SMA involvement—often a marker for unresectability—cannot be confirmed until irreversible steps have already been taken.
The Infra-Mesocolic Method
The "SMA first" approach involves a trial dissection to estimate resectability by exposing and taping the SMA prior to the division of the neck of the pancreas. This is achieved through the following sequence:
Abdominal Exploration: Excluding extrapancreatic metastases.
Retraction and Incision: The omentum and transverse colon are retracted superiorly while the small intestine is moved to the right. The peritoneum is incised at the duodenal recess.
Vascular Exposure: The aorta, inferior vena cava (IVC), and left renal vein (LRV) are exposed by mobilizing the fourth portion of the duodenum and the uncinate process.
Identification: The ligament of Treitz is opened, the duodenojejunal flexure is pulled down, and a vessel loop is passed around the SMA to assess its relationship with the tumor.
Detailed Surgical Methodology
The procedure is structured into several distinct phases to ensure oncological radicality and patient safety.
Phase 1: Exposure of the Superior Mesenteric Vein (SMV)
The omental bursa is opened by incising the anterior layer of the gastrocolic ligament.
The stomach is lifted anteriorly to expose the inferior border of the pancreas.
The SMV is identified; if the tumor has invaded the middle colic vein, that vessel is severed.
Phase 2: Lymphadenectomy and Pancreatic Division
Skeletonization: The common hepatic artery (CHA) and distal celiac axis (CA) are skeletonized.
Arterial Division: The splenic artery is confirmed and divided at its origin.
Tunneling: The neck of the pancreas is tunneled above the SMV.
Transection: After using intraoperative ultrasonography to confirm the transection line, the pancreas is divided using a linear stapler with bioabsorbable felt.
Venous Division: The splenic vein is identified and divided at its origin.
Phase 3: Mobilization and Retroperitoneal Dissection
The surgeon mobilizes the left kidney, left colon, left pancreas, and spleen en masse.
Conclusion
The infra-mesocolic SMA first approach serves as a reliable and safe introduction to the RAMPS procedure. By establishing the right dissection plane early—specifically by exposing the left renal vein and left aortic wall—surgeons can determine resectability with high confidence. This method integrates critical dissection early in the operation, ensuring that the oncological goals of negative margins and comprehensive lymphadenectomy are met while minimizing the risks associated with irreversible involvement of major mesenteric vasculature.
