Management of anatomical challenges during laparoscopic cephalic duodenopancreatectomies

Abstract

Introduction: Laparoscopic cephalic duodenopancreatectomy (LCDP) is considered a surgery of high technical complexity. It has a long learning curve because of the need of high laparoscopic technical skills, especially in the presence of anatomical variations. The aim of this video is to present three cases of LDCP (pure and hybrid) with difficult anatomical challenges and how to approach them. Case 1: A 76 years old woman presents with painless jaundice and workup reveals an infiltrating 20 mm adenocarcinoma of the Vater´s ampulla. During LCDP, a right posterior bile duct draining independently distal to the common bile duct is found, so two-separated laparoscopic bilio-enteric anastomosis are performed. Case 2: A 70 years old men presents with painless jaundice and workup reveals a 30 mm dysplastic adenoma of the Vater´s ampulla. He had a surgical history of an open gastric antral resection due to a perforated peptic ulcer 40 years ago. During LCDP, multiple lysis adhesions of the hepatic hilium are required and a right hepatic artery arising from the superior mesenteric artery is identified and preserved. Case 3: A 70 years old men with Child-B cirrhosis presents with jaundice and workup reveals an adenocarcinoma of the Vater´s ampulla not suitable for endoscopic resection. Hepatic venous gradient pressure (HVGP) measurement is 7 mmHg, so after multidisciplinary discussion a hybrid LCDP is performed with no complications. Conclusion: anatomical challenges can be safely approached under laparoscopic surgery during LCDP.