Early retropancreatic dissection during pancreaticoduodenectomy

Background During pancreaticoduodenectomy, early neck division may be inadequate, particularly in cases of replaced or accessory right hepatic artery (RHA) or diffuse intraductal papillary and mucinous neoplasm (IPMN) or when invasion of superior mesenteric artery is suspected. Methods Modification of the technique of pancreaticoduodenectomy with dissection of the superior mesenteric vessels performed from behind the head of the pancreas before any pancreatic or digestive transection. The pancreas is divided later, after adequate mobilization of the specimen from the vessels, on either the neck or the body, according to underlying disease. Results We used this technique successfully in 20 patients with a replaced or accessory RHA, which was successfully preserved in 19; one patient had inadvertent division of a 2-mm diameter accessory RHA that was ligated with no postoperative complications. Additionally, we used this technique in 18 patients with IPMN—14 pancreaticoduodenectomies extended to the body and 4 total pancreatectomies—and in 3 patients with adenocarcinoma involving the porto-mesenteric confluence and needing en-bloc vascular resection. Conclusions Early division of retroperitoneal margin is a useful technical variant of pancreaticoduodenectomy, which can be recommended in selective indications to improve safety and radicality of the procedure.