Identification of the Lymphatic Drainage Pathways from the Pancreatic Head Guided by Indocyanine Green Fluorescence Imaging during Pancreaticoduodenectomy

Digestive Surgery, 04/24/2012

Authors found that several lymphatic drainage routes were observed from the pancreatic head, suggesting that a lymphadectomy around the SMA might have a similar oncological impact as that of the PA region.


  • The lymphatic pathways in 20 patients undergoing pancreaticoduodenectomy were analyzed.
  • They injected ICG into the parenchyma in the anterior (n = 10) or posterior surface (n = 10) of the pancreas head and observed the intraoperative lymphatic flows by ICG fluorescence imaging.


  • The seven main lymphatic drainage pathways were identified:
    • Along the anterior or posterior pancreaticoduodenal arcade,
    • Running obliquely down behind the superior mesenteric vein (SMV),
    • Reaching the left side of the superior mesenteric artery (SMA),
    • Running longitudinally upward between the SMV and SMA,
    • Along the middle colic artery toward the transverse colon,
    • Reaching the paraaortic (PA) region,
    • Reaching the hepatoduodenal ligament.
  • The lymphatic pathway reaching the left side of the SMA was observed in 4 patients (20%), while that reaching the PA region in 17 patients (85%).
  • The mean time to reach around the SMA was longer than that to reach the PA region.

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