Early Retropancreatic Dissection during Pancreaticoduodenectomy - Technical Notes

EARLY RETROPANCREATIC DISSECTION DURING PANCREATICO-DUODENECTOMY TECHNICAL NOTES (ABSTRACT): Background: Pancreaticoduodenectomy (PD) is the procedure of choice for malignant tumors of the pancreatic head and periampullary region. During PD, early pancreatic neck division may be inadequate, especially in cases of hepatic artery (HA) anatomic variants, when invasion of the superior mesenteric artery (SMA) is suspected, or in cases of intraductal papillary mucinous neoplasms (IPMN). Methods: We perform an early approach of the retroportal lamina (RPL) from behind the pancreatic head, before pancreatic transection. This is accomplished after lymphadenectomy and adequate mobilisation of the specimen from the vessels, on either the neck or the body, according to the tumor extension. Results: We successfully used this approach during 28 PD. There were 21 patients to whom we detected anatomic variants of right hepatic artery (RHA), which was spared in 19 cases; arterial reconstruction was required in one case. We also used this technique in 5 patients with IPMN 3 PD extented to the body and 2 total pancreatectomies, and in other 2 patients with adenocarcinoma involving the porto-mesenteric jonction, requiring limited venous resection and reconstruction. Conclusions: Retropancreatic approach with early RPL dissection is an useful technical variant of pancreaticoduodenectomy which we recommend in selective indications.