PDF
Citation
Print
INTRODUCTION
Pancreaticoduodenectomy (PD), also commonly known as the ‘Whipple’s procedure’, has undergone significant evolution over several decades since its original description by pioneers such as Kausch and Whipple [1]. As this remains the only established procedure offering curative potential for patients with periampullary and pancreatic head malignancies, substantial efforts have been made to refine and standardize this technically demanding surgery to reduce its historically high morbidity. Achieving an R0 resection is widely recognized as a critical prognostic determinant for survival in pancreatic head and periampullary cancer cases [2,3]. For preoperative evaluation and assessment of resectability, the National Comprehensive Cancer Network (NCCN) guidelines recommend use of a pancreatic protocol contrast-enhanced computed tomography (CECT) [4]. However, the positive predictive value of CECT for determining resectability is limited to 81%, and this figure declines further to 60% in the context of borderline resectable pancreatic cancers [5,6]. Additionally, the diagnostic accuracy of CECT for determining resectability is further compromised after administration of neo-adjuvant therapy [7,8]. Because only direct intraoperative assessment can definitively determine resectability and facilitate avoidance of an R1 resection, it is essential to refrain from committing to any irreversible steps prior to clear establishment of resectability. Initiating an irreversible step before confirmation of resectability increases the likelihood of futile surgery and necessitates potentially harmful palliative interventions, which may worsen morbidity without improving prognosis. To address these challenges, we present our technique, which facilitates early assessment of resectability via the ‘SMA (superior mesenteric artery) first approach,’ ensures oncological adequacy through ‘total mesopancreas excision (TMpE),’ and simultaneously prevents any irreversible steps until resectability is fully established by the end of the procedure.
DESCRIPTION OF SURGICAL TECHNIQUE
Incision and exposure
A rooftop/chevron incision is utilized to perform the laparotomy. Thorough intra-abdominal exploration is undertaken to rule out the presence of metastatic disease. The falciform ligament is transected, ensuring that a long proximal segment is preserved and tied securely to facilitate cranial retraction of the liver. The lower abdominal flap is anchored to the left iliac fossa using sutures to provide improved operative exposure. A Thompson retractor is then placed as shown in (Fig. 1).
Cattell Braasch Valdoni maneuver [9,10]
The right Toldt’s line is incised from the hepatic flexure to the cecum in a reverse J-shaped manner, followed by lateral-to-medial mobilization of the ascending colon and cecum. Dissection then proceeds medially along the root of the mesentery toward the ligament of Treitz, carefully preserving the plane within Toldt’s fascia [11]. The infracolic greater omentum is dissected from the transverse mesocolon, allowing entry into the right lesser sac through the fourth layer of the greater omentum. The dissection is carried out anterior to the supramesocolic pancreas and the second part of the duodenum. Next, the hepatocolic and phrenocolic ligaments are divided, and the inframesocolic duodenum and pancreas are separated from the colon by dividing Fredet’s fascia [11]. Special care must be taken to avoid injury to the venous branches of the loop of Henle. Ligation of the loop of Henle and/or right gastroepiploic vein and anterosuperior pancreaticoduodenal veins may be required in select situations. This sequence leads to complete cranial and lateral mobilization of the right colon and small bowel (Fig. 2).
Kocher’s Maneuver [12]
Kocherization is accomplished by incising lateral to the second part of the duodenum and dissecting within the Treitz fascia, thus mobilizing the duodenum and pancreatic head away from the inferior vena cava and aorta. The dissection is extended medially past the left border of the aorta. Para-aortic lymph node sampling (stations 16a2, 16b1) is performed and sent for frozen section analysis. If metastases are identified, resection may be halted based on tumor biology [13,14]. If no metastases are present, the procedure continues (Fig. 3).
Division of ligament of Treitz
The ligament of Treitz is divided to mobilize the duodenojejunal flexure. Subsequently, the small bowel is rotated cranially and rightward, resulting in a 270-degree counter-clockwise derotation along the SMA/superior mesenteric vein (SMV) axis. This configuration, known as “reverse 3,” repositions the duodenojejunal flexure to the right of the SMA and moves the right colon to its left. As a result, the SMA-SMV relationship is altered, facilitating anatomic orientation and enhancing exposure of the mesopancreas for complete resection (Fig. 4).
‘SMA-first’ approach
A hybrid technique combining the posterior approach (as described by Pessaux et al. [15]) and the medial uncinate approach (as detailed by Hackert et al. [16]) is utilized. Dissection is initiated at the SMA root, progressing caudally along its right border. If a replaced right hepatic artery is present, it is carefully protected. The inferior pancreaticoduodenal artery (IPDA) is encountered and encircled during the dissection. The celiac trunk is exposed cranially up to the right diaphragmatic crus, clearly identifying both the SMA and celiac origins in a “V” configuration (Fig. 3).
A mesenteric window is developed between the first and second jejunal arteries. The first jejunal vein is followed to its convergence with the SMV to facilitate identification of the dorsally positioned SMA [17]. The inferior pancreaticoduodenal vein and IPDA are meticulously isolated but remain unligated at this stage. In the presence of root involvement, an inferior infracolic technique as described by Weitz et al. [18] may be employed.
Dissection of hepatoduodenal ligament, gastroduodenal artery, and distal stomach
Dissection is initiated from the left to the right over the common hepatic artery (CHA). Station 8a lymph nodes are removed, and the right gastric artery may be ligated to facilitate station 5 lymphadenectomy. The gastroduodenal artery (GDA) is isolated and encircled with a loop (Fig. 5). Within the anatomical triangle defined by the CHA medially, the GDA laterally, and the superior border of the pancreas inferiorly, the portal vein is located posteriorly [19]. Nodes at stations 8p, 12b, 12a, and 12p are then dissected. The bile duct is precisely looped, which is especially important in the presence of an aberrant right hepatic artery. For technical convenience, the gallbladder is separated from its fossa. Subpyloric station 6 nodes are accessed by dissecting and ligating the right gastroepiploic vessels.
Total mesopancreas excision
A bulldog clamp is positioned on the GDA, and hepatic artery flow is confirmed (Fig. 5). With the GDA clamped and the IPDA looped, an en bloc excision of the mesopancreas commences between the SMA and the celiac trunk. Dissection moves toward the pancreatic head and uncinate process. Based on the tumor characteristics, either a type 2 or 3 mesopancreas excision with plPh-II nerve plexus dissection is conducted [20,21]. Irreversible maneuvers are deferred until resectability is definitively established.
Circumferential clearance of the right aspect of the SMA is achieved, including removal of station 14t nodes. The GDA and IPDA are ligated if this has not been carried out earlier. Following neoadjuvant therapy, suspected SMA involvement is further assessed by periadventitial dissection and intraoperative frozen section [22]. If malignancy is identified, the surgical approach is tailored accordingly. The mesopancreas, uncinate process, and pancreatic head are then mobilized en bloc from the portal vein (Fig. 6). Venous invasion is managed with prior vascular control of the portal vein, SMV, and splenic vein.
The jejunum is divided using a linear stapler, while the stomach is resected proximal to the pylorus. Before transecting the pancreas at the neck or body, stay sutures are applied to the superior and inferior pancreatic borders. The order of transection—stomach → pancreas → bile duct (if stented), or stomach → bile duct → pancreas—depends on the presence of biliary stenting. For cases requiring complex venous resections, all relevant structures are transected before venous resection is attempted.
Reconstruction
Following haemostasis and copious lavage, the small bowel and right colon are restored to their anatomical positions. The distal jejunal limb is delivered into the supracolic compartment via a mesenteric window to the right of the middle colic artery. Pancreaticojejunostomy is performed using either the Heidelberg or modified Blumgart technique, guided by the pancreatic duct diameter and gland consistency [23,24]. Hepaticojejunostomy is performed with interrupted 4-0 or 5-0 polydioxanone sutures. An antecolic gastrojejunostomy is constructed, and a naso jejunal tube is placed distally. A Jackson-Pratt drain is inserted posterior to the pancreaticojejunostomy, with a second drain positioned in the pelvis.
The mean operative time for this procedure is 450 ± 40 minutes. Detailed key steps and critical aspects of the procedure are presented in Table 1. Furthermore, Table 2 and 3 provide a review and comparison of various types of pancreaticoduodenectomies described in the literature with our technique. Supplementary Video 1 includes a demonstration of the principal operative steps.
DISCUSSION
PD remains the only definitive and potentially curative intervention for patients with periampullary and pancreatic head carcinomas. Although only 20% of these malignancies are initially resectable, nearly 30% to 40% of borderline resectable and locally advanced tumors can become amenable to surgical resection following neoadjuvant therapy [25-27]. As surgical techniques have become increasingly advanced, accurate assessment of both resectability and the radical nature of the procedure has become essential for predicting prognostic outcomes. While a pancreatic protocol CECT is highly valuable for predicting resectability and planning for potential vascular resections, we contend that its predictive value may diminish after neoadjuvant treatment, making definitive assessment of resectability dependent upon intraoperative findings.
Our approach begins with the Cattell Braasch Veldoni maneuver [9,10]. This technique, combined with the Kocher’s maneuver, substantially clarifies the anatomy of the principal vessels and their relationships with the mesopancreas and uncinate process [28,29]. To achieve early vascular control, we utilize both the ‘posterior SMA-first approach’ initially described by Pessaux et al. [15] and the ‘right medial uncinate approach’ introduced by Hackert et al. [16]. This strategy facilitates preservation of the aberrant right hepatic artery—encountered in 10% to 21% of patients—and enables early control of the IPDA, thereby reducing venous congestion and minimizing intraoperative blood loss from the pancreatic head and uncinate process [30,31]. Additional benefits of the SMA-first approach, which include improved R0 resection rates, reduced postoperative complications, and enhanced overall survival, as recently reported in meta-analyses, are also achieved by our method [32,33].
Another crucial element of ‘radicality’ in our approach involves the complete excision of the mesopancreas. The mesopancreas was initially described by Gockel et al. [34] and is composed of fibrofatty tissue containing neurovascular bundles (perineural plexus of pancreatic head; plPh-I and plPh-II), lymph nodes, IPDA, and the first jejunal artery and vein [20,35]. Undertaking TMpE leads to a marked improvement in R0 resection rates and lymph node retrieval while reducing locoregional recurrence, all with acceptable complication rates compared to the standard PD [36]. Within our method, the ‘reverse 3’ arrangement of D3 and DJ flexure enables clearer anatomical orientation and facilitates an en bloc type 2 or type 3 mesopancreas excision (type 2: mesopancreas divided along the right side of the SMA without nerve plexus; type 3: mesopancreas division includes periadventitial dissection to the right of SMA incorporating the nerve plexus) depending on the underlying pathology, and achieves complete clearance of tissue between the SMA and CHA over the right 180 degrees [20,21]. The dissection level, either periadventitial or sub adventitial, is determined by the specific disease context [22].
Additional benefits of our approach include minimized bile contamination and reduced intraoperative blood loss. Bile duct division is performed at the end of the operation, which significantly reduces the risk of contamination, particularly important for stented patients who are more prone to surgical site infections [37]. This also shortens the duration of bulldog clamp application on the common bile duct, potentially lowering rates of ischemic injury and subsequent strictures. Delayed pancreatic transection permits the attainment of broader surgical margins beyond the pancreatic neck and further decreases blood loss by enabling greater control over the vasculature.
The combination of the SMA-first approach with TMpE has now been adopted at several institutions and has demonstrated improved oncological results [38,39]. We implement this technique alongside the principle of maintaining the intactness of all critical structures until the end of the operation. As per our review, this precise combination is not previously reported in the literature (Table 2, 3). Our approach aligns with the strategic principle of the ‘path of escape’ as articulated by Sun Tzu, the Chinese military strategist and philosopher: “Always leave an escape route and make it obvious, hence the ‘golden bridge’ to retreat across.” This philosophy highlights the value of maintaining an option for tactical withdrawal to prevent disastrous confrontations.
CONCLUSION
This innovative PD technique is both safe and oncologically robust, achieving adequate radicality while preserving the opportunity for retreat when R0 resection cannot be attained. We plan to report our short-term and long-term outcomes using this technique in subsequent publications. Additional comparative and multicenter research is needed to confirm the efficacy and broader relevance of this PD method.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found at https://doi.org/10.14701/ahbps.25-097.
XML Download