Laparoscopic Pancreatic Head Preserving Total Duodenectomy: The Parenchymal Sparing Alternative to a Whipple.

Abstract

BACKGROUND: When endoscopic options fail, laparoscopic pancreatic head-preserving duodenectomy (LPHPD) for benign duodenal lesions is a parenchymal sparing and safe alternative to a pancreaticoduodenectomy.1-3 LPHPD may be the optimal "amount" of surgery, because such lesions are at risk for undertreatment (partial endoscopic resection associated with recurrence) or overtreatment (Whipple associated with morbidity and loss of pancreatic parenchyma).4,5 PATIENT: A 80-year-old, healthy female patient was diagnosed endoscopically with two, flat, symptomatic adenomas (7-cm D2; 2-cm D3). She had no family history of polyposis. Germline testing, tumor markers, and colonoscopy did not show any abnormality. TECHNIQUE: With the patient in French position, a wide laparoscopic Kocherization was performed past IVC and aorta. Following prepyloric gastric transection, the entire duodenum was carefully dissected off the pancreas. After transection of the proximal jejunum, the reconstruction begins. A two-layer, duct-to-mucosa, ampullary-jejunal anastomosis and a type II Billroth gastrojejunostomy were performed. CONCLUSIONS: LPHPD avoids under- or overtreatment of benign duodenal lesions unamenable to an endoscopic approach. If the stepwise approach described in this video is followed, LPHPD represents a safe and parenchymal-sparing alternative to pancreaticoduodenectomy for benign duodenal lesions with reduced morbidity.