Tricks and tips in pancreatoduodenectomy

Abstract

Author contributions: Pallisera A wrote the introduction and the section on the artery-first approach; Ramia JM wrote the section on arterial complications during pancreatoduodenectomy; Morales R wrote the section on extended lymphadenectomy for pancreatic head adenocarcinoma. AbstractPancreaticoduodenectomy (PD) is the standard surgical treatment for tumors of the pancreatic head, proximal bile duct, duodenum and ampulla, and represents the only hope of cure in cases of malignancy. Since its initial description in 1935 by Whipple et al , this complex surgical technique has evolved and undergone several modifications. We review three key issues in PD: (1) the initial approach to the superior mesenteric artery, known as the artery-first approach; (2) arterial complications caused by anatomic variants of the hepatic artery or celiac artery stenosis; and (3) the extent of lymphadenectomy.

Hepatic artery classification based on three-dimensional CT

“…For instance, most of the blood supply to the extrahepatic biliary tree comes from the RHA or rRHA. Accidental injury to these arteries during hepatic surgery might lead to ischaemia of the biliary anastomosis. Ishigami and colleagues reported that variant hepatic artery anatomy in a liver transplant recipient increased the risk of hepatic artery complications after transplantation by 18 per cent.…”

Awareness of hepatic arterial variants is required in surgical oncology decision making strategy: Case report and review of literature

“…Regarding liver arterial supply, it is described as ‘normal anatomy’ when the CHA originates the PHA after the emergence of the GDA; next, the PHA separates into right and left hepatic arteries within the hepatoduodenal ligament. The knowledge of hepatic artery supply is essential to avoid iatrogenic complications during HPB surgery; in the presence of anatomical variations accidental ligation, provoking hepatic necrosis, ischemic biliary injury and anastomotic fistula can complicate the peri- and postoperative course ( 14 ). With the grooving number of liver transplantation, the importance of the hepatic artery anatomy become crucial and many authors proposed classifications describing liver vascular variations based on their studies ( 7 ).…”

“…With the grooving number of liver transplantation, the importance of the hepatic artery anatomy become crucial and many authors proposed classifications describing liver vascular variations based on their studies ( 7 ). The most often described hepatic artery anatomical variations are: i) An anomalous RHA from the SMA (10–21%); ii) displaced LHA from the LGA (4–10%); iii) displaced RHA and LHA; iv) an accessory RHA and/or LHA (1–8%); v) displaced CHA from SMA or aorta (0,4-4,5%); or vi) quadrifurcation of hepatic artery ( 14 ). In our study we described two independent cases of hepatic arterial anatomic variants where a HAS arised directly from SMA and traveling posterior to the pancreatic head and vena porta.…”

“…In our study we described two independent cases of hepatic arterial anatomic variants where a HAS arised directly from SMA and traveling posterior to the pancreatic head and vena porta. It is named as hepatomesenteric trunk and is the second most common variation of HA (2–3%) ( 14 ). Described cases belong to type V in Hiatt's classification ( Table II ).…”

“…The issue is crucial for, liver transplantation and resection, hepatic artery chemotherapy, gastrectomy, biliary reconstruction and especially for pancreatoduodenectomy ( 17 , 18 ). According to Pallisera et al ( 14 ) problems related to anatomical variations of hepatic artery and coeliac axis stenosis are most prevalent arterial complications during HPB surgery. It is highlighted that intraoperative arterial complications generate longer operative time, higher transfusion rate and more postoperative complications ( 19 ).…”