Ann Hepatobiliary Pancreat Surg.  2024 May;28(2):262-265. 10.14701/ahbps.23-109.

The duodenal window approach to pancreatoduodenectomy

• Tebala GD
• Desiderio J
• Nardo DD
• Gemini A
• Cirocchi R

• KMID: 2555936
• DOI: http://doi.org/10.14701/ahbps.23-109

Abstract

The pancreatoduodenectomy (PD) technique is yet to be standardized. One of the most difficult passages in PD is the mobilization of the second, third, and fourth parts of the duodenum. This maneuver is classically performed from the supramesocolic space after the division of the gastrocolic ligament, but traction on the transverse mesocolon and the superior mesenteric pedicle can cause bleeding from the venous and arterial branches of the pancreatic head and uncinate process. We hereby describe a technique to access and mobilize the distal duodenum and proximal jejunum (D2 to J1) through the duodenal window and the Treitz’s foramen, performing an almost complete Kocher’s maneuver before opening the gastrocolic ligament and mobilizing the hepatic flexure. The anatomical basis and the surgical technique of the duodenal-window-first PD are discussed. The duodenal-window-first approach is a standardizable step of PD that allows an easy and safe mobilization of D2 to J1. This technique has been applied to 15 cases of PD, both open and robotic, with no specific morbidity. Therefore, we propose the adoption of the duodenal-window-first technique as a routine standardized step of PD.

Keyword

Pancreatoduodenectomy; Robotic-assisted surgery; Pancreatic cancer

Figure

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  Fig. 1 Preparation of the duodenal window in open pancreatoduodenectomy. (A) The duodenal window can be found at the root of the transverse mesocolon, at the right side of the superior mesenteric pedicle, and mirrors the site of the Treitz’s foramen that is located on the left side of the superior mesenteric pedicle. (B) The duodenal window can be easily opened to obtain access to the Fredet’s fascia and distal duodenum. (C) After dissection of the Treitz’s foramen, the virtual spaces dorsal and ventral to D3 and D4 are easily developed from right to left and from left to right.

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  Fig. 2 Preparation of the duodenal window in robotic pancreatoduodenectomy. (A) Robotic access to the duodenal window. (B) Preparation of the distal duodenum and division of the Treitz’s ligament from right to left.

Reference

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