3D Laparoscopy-Assisted Procedure of Duodenum, Common Bile Duct, and Oddi's Sphincter Preserving Pancreatic Head Total Resection

Summary

Here, we present a protocol to provide an ideal minimally invasive surgical approach for the pancreatic head in treating benign, borderline, and low-grade malignant pancreatic tumors as well as chronic pancreatitis.

Abstract

Surgical intervention has demonstrated established efficacy for benign, borderline, and low-grade malignant tumors of the pancreatic head, as well as for chronic pancreatitis. While conventional surgical approaches are associated with significant trauma and considerable loss of digestive function, the current focus in managing these conditions has shifted toward preserving functional organs through minimally invasive techniques. Through an in-depth understanding of the peripancreatic vascular arches, our team has modified the classic Beger procedure to achieve complete en bloc resection of pancreatic head tissue. By leveraging 3D laparoscopic technology, we have successfully integrated the advantages of minimal invasiveness and precise resection. This refined technique preserves duodenal and biliary integrity while ensuring complete removal of pancreatic head tissue, effectively reducing surgical complications, minimizing operative trauma, and decreasing postoperative gastrointestinal dysfunction. Consequently, patient outcomes are substantially improved. This article aims to elucidate the key technical details of this procedure, enabling more surgeons to master and enhance its success rate, thereby providing better treatment options for eligible patients.

Introduction

Chronic pancreatitis (CP) and benign, borderline, or low-grade malignant tumors of the pancreatic head often impose significant suffering and health risks on patients¹. Surgical intervention plays a crucial role in the comprehensive management of chronic pancreatitis and pancreatic head tumors of these types^2,3,4. Its objectives include pain relief, improvement of pancreatic function, management of complications, and curative resection of tumors, representing the most effective treatment strategy currently available⁵.

In 1972, Beger et al. pioneered the duodenum-preserving pancreatic head resection (DPPHR)⁶. This procedure allows for the resection of lesions in the pancreatic head while preserving the inherent anatomical integrity of the duodenum, common bile duct (CBD), and the sphincter of Oddi. This approach reduces surgical trauma and postoperative gastrointestinal functional decline, significantly increasing patient benefits^7,8. To avoid CBD ischemia, the Beger procedure and its subsequent modifications emphasize preserving a 0.5-0.8 cm rim of pancreatic tissue adjacent to the duodenal side around the CBD⁹. While this reduces surgical difficulty, it inherently imposes limitations on the procedure: preserved pancreatic tissue leads to a higher incidence of postoperative pancreatic fistula; residual pancreatic head tissue retains a risk of malignant transformation; pain relief may be incomplete¹⁰.

Through three-dimensional reconstruction studies of the peripancreatic vasculature, our team discovered that the anterior and posterior pancreaticoduodenal vascular arcades, which supply the duodenum and CBD, course within the loose connective tissue between the pancreatic head and the duodenum and do not penetrate into the pancreatic parenchyma of the pancreatic head itself. Consequently, dissection along the plane between the pancreatic parenchyma of the pancreatic head and this loose connective tissue allows for the complete resection of the pancreatic head while preserving the vascular arcades supplying the duodenum and CBD.

Based on this anatomical foundation, we developed the procedure of duodenum, CBD, and Oddi's sphincter-preserving pancreatic head total resection (DCOPPHTR, Wang's procedure) for the treatment of chronic pancreatitis, and benign, borderline, and low-grade malignant tumors of the pancreatic head¹¹. With the advancement of laparoscopy, 3D Laparoscopy-Assisted DCOPPHTR has become the optimal choice. It truly achieves the perfect integration of laparoscopic minimally invasive surgery and organ function preservation, offering the best therapeutic solution for these conditions. This article details the key operative principles and steps of this procedure, provides representative surgical images and outcome data, and aims to promote its wider adoption.

Protocol

This surgical approach has received approval from the Ethics Committee of Chongqing General Hospital, Chongqing University. All patients undergoing this procedure provided written informed consent.

1. Exclusion and inclusion criteria

1. Include patients with benign tumors: e.g., serous cystadenoma, mucinous cystadenoma, solid pseudopapillary neoplasm (SPN), low-grade malignant tumors: e.g., neuroendocrine tumors (NETs G1/G2), intraductal papillary mucinous neoplasms (IPMNs) without invasive components¹², Pancreatic head ductal calculi and chronic pancreatitis, and anatomical anomalies: e.g., pancreas divisum¹³.
2. Besides general contraindications to surgery, exclude patients with these specific contraindications: high suspicion of malignancy (e.g., invasive ductal adenocarcinoma), tumor invasion of the duodenum or ampulla of Vater, severe intra-abdominal adhesions, or vascular invasion. Additionally, exclude patients with large medial duodenal wall diverticula that carry a risk of postoperative diverticular perforation or bleeding and warrant careful evaluation, though this is not an absolute contraindication.

2. Intraoperative preparation

1. Administer a single dose of prophylactic broad-spectrum antibiotics (e.g., Piperacillin and Tazobactam, 4.5 g) intravenously 30 min preoperatively.
2. Position the patient supine and perform routine general anesthesia with endotracheal intubation. Establish central venous access and insert a nasogastric tube.
3. After routine iodine-based antiseptic disinfection and draping, pneumoperitoneum was established (intra-abdominal pressure maintained at 12-15 mmHg). Trocars were then placed to create ports for 3D laparoscopic visualization and operative instruments. The specific trocar arrangement and corresponding surgeon positions are illustrated in Figure 1.

3. Key surgical procedure

1. Exposure of the surgical field: Initiate dissection lateral to the gastroepiploic vascular arcade. Using an ultrasonic scalpel, divide the gastrocolic ligament from its midpoint toward the hepatic flexure. Subsequently, separate the pancreaticogastric plane and mobilize the hepatic flexure of the colon off the retroperitoneum - thereby facilitating optimal exposure of the pancreatic head (Figure 2A).
2. Exposure of the superior mesenteric vein (SMV) and portal vein (PV)
   1. Separate the transverse mesocolon from the anterior pancreatic capsule down to the inferior border of the pancreas uncinate process. Identify the right colic vein, then trace it proximally to expose the right gastroepiploic vein, the gastrocolic trunk (Henle's trunk), and the SMV up to the pancreatic neck (Figure 2B).Apply a small Hem-o-lok clip at the confluence of the right gastroepiploic vein before transecting it with scissors to facilitate exposure of the surgical field by lowering the transverse mesocolon.
   2. Dissect the suprapancreatic triangle to expose the PV and gastroduodenal artery (GDA). Carefully separate the space between the pancreatic neck and the SMV and transect the pancreatic neck using the ultrasonic scalpel. Hemostasis the pancreatic stump meticulously and leave it in situ for subsequent anastomosis (Figure 2C).
3. Dissection of the pancreatic head off the duodenum: Incise the anterior pancreatic capsule over the horizontal part of the duodenum. Under direct vision, staying close to the pancreatic parenchyma while avoiding the inferior anterior pancreaticoduodenal arterial (IAPDA) arcade, dissect the pancreatic head free progressively (Figure 2D). Preserve the anterior and posterior pancreaticoduodenal vascular arcades throughout the dissection.
   NOTE: This step is critical for success. The general principle is to avoid transecting any vasculature until it is confirmed to enter the pancreatic parenchyma.
4. Preservation of the uncinate mesentery and posterior capsule and identification of CBD: Dissect the pancreatic head from the right side of the SMV superiorly to the upper border of the pancreas. The supraduodenal CBD becomes visible posteriorly and to the right of the GDA.
   1. Use intraoperative indocyanine green (ICG, 0.5 mg/kg administered 24 h preoperatively) fluorescence navigation to significantly aid in identifying the CBD¹⁴ (Figure 2E-F).
5. Exposure of the pancreaticobiliary junction: Continue dissection along the medial wall of the descending duodenum to gradually expose the pancreaticobiliary junction. Suture the distal pancreatic duct using 5-0 PDS suture and transect, thereby exposing the distal CBD (Figure 3A).
6. Division of pancreatic parenchyma around the intrapancreatic CBD: Dissect the pancreatic parenchyma surrounding the intrapancreatic CBD. Keep the active blade of the ultrasonic shears away from the CBD to prevent thermal injury (cold knife dissection). Control bleeding primarily with gauze pressure rather than electrocautery to preserve the CBD's nutrient vessels.
7. Management of the Wang's Bare Area: During medial dissection of the pancreatic head off the descending duodenum, identify an area devoid of serosa (Figure 3B), we term this Wang's bare area. While this area poses a risk for duodenal injury, as long as the integrity of the anterior and posterior pancreaticoduodenal vascular arcades is maintained to ensure duodenal blood supply, imbricating sutures over this area will not cause duodenal ischemia.
8. Completion of resection: mobilize the gastroduodenal artery fully. Within the capsule of the pancreatic head, preserve the anterior and posterior superior pancreaticoduodenal branches meticulously. Separate the pancreatic head gradually from the medial aspect of the duodenum, resulting in its complete resection. Achieve hemostasis at the resection site. To avoid compromising blood supply to the duodenum and CBD, avoid excessive use of energy devices. Use appropriate vascular sutures as the most reliable method for securing hemostasis (Figure 3C-E).
   NOTE: Given that this patient has a variant GDA originating from the SMA (Figure 3D), another figure is provided to show the vessel in its normal anatomical position (Figure 3E).
9. Specimen handling and frozen section: Place the specimen in a retrieval bag. Send for intraoperative frozen section analysis to confirm the tumor's nature. If malignancy is detected, convert to a standard pancreaticoduodenectomy.
10. Pancreaticojejunostomy (PJ): Transect the jejunum approximately 15 cm distal to the ligament of Treitz. Bring the distal jejunal limb up through a defect in the right mesocolon. Perform a pancreaticojejunostomy. Our team routinely employs the modified Blumgart-method¹⁵ (Figure 3F). For benign, borderline, and low-grade malignant tumors, place a pancreatic duct stent for external drainage.
11. Jejunojejunostomy: Perform a side-to-side jejunojejunostomy approximately 55 cm distal to the PJ.
12. Drainage: Effective drainage is paramount for preventing postoperative pancreatic complications. Make a 10-mm incision in the anterior retroperitoneum below the right costal margin, through which place a customized pleated drainage tube with irrigation capability (Supplementary Figure 1) anterior to the pancreaticojejunostomy anastomosis. Insert another irrigation-enabled pleated drainage tube through the assistant's left operating port and position it posterior to the anastomosis. Place an additional conventional drainage tube in the resection cavity after pancreatic head removal to ensure adequate drainage of postoperative fluid accumulation in this area.
13. Closure: Close all incisions to complete the procedure.
14. Postoperatively, continue broad-spectrum antibiotics (e.g., Piperacillin and Tazobactam, 4.5 g, every 8 h),or adjust antibiotics based on the bacteriological culture results of the drainage fluid. Administer somatostatin analogs (0.25 mg/h) to suppress pancreatic secretion, and use proton pump inhibitors (Omeprazole, 40 mg, 1x daily) for gastroprotection. Ensure adequate nutritional support and stable organ perfusion, which are critical components of enhanced recovery.
15. Monitor drain fluid amylase levels and their dynamic trends every other day to determine the presence and grading of pancreatic fistula. For cases classified as non-Grade A pancreatic fistula, implement continuous low-negative-pressure irrigation drainage (using normal saline at a rate of 60 drops/minute).
16. Monitor laboratory parameters, including complete blood count, CRP, procalcitonin, liver function, and electrolytes, regularly, with prompt symptomatic treatment as required. Perform an abdominal contrast-enhanced CT scan on postoperative day 4 to evaluate potential complications such as fluid collection, hemorrhage, or pseudoaneurysm in the surgical area. Remove drainage tubes progressively in the absence of significant abnormalities.

Results

Between December 2023 and April 2025, our surgical team performed 3D laparoscopy-assisted DCOPPHTR on 8 patients. All cases involved benign or low-grade malignant tumors. Two patients had postoperative follow-up durations of less than 3 months, while the remaining 6 patients were followed for over 3 months. The baseline characteristics of these 6 patients are presented in Table 1. The cohort included pancreatic NETs, SPNs, and IPMNs.

All patients successfully underwent the pro...

Discussion

The cornerstone of this procedure's success is the preservation of the pancreaticoduodenal vascular arcades. Compromise of these arcades can lead to duodenal or CBD ischemia, potentially resulting in severe complications such as duodenal or biliary necrosis, major bile leak, infection, or hemorrhage. While preservation of both anterior and posterior arcades is ideal, it can be technically challenging with large tumors or severe peripancreatic inflammation. A team from West China Hospital noted that anatomical variati...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
4K-3D NIR/ICG Videoendoscope	KARL STORZ	OTV-S400	Imaging System
Endoscopic Camera Equipment	KARL STORZ	TC304	Image 1 S 4U-Link High-Definition Connection Main Unit Module
Endoscopic Surgical Instruments	Aesculap AG	20162223321	Endoscopic Surgical Instruments
Esomeprazole Sodium for Injection	AstraZeneca PLC	86979096001287	Proton Pump Inhibitor
Ethicon Endo-Surgery Generator	Johnson & Johnson	20153230137	Provide ultrasound and radiofrequency energy
HARMONIC Ultrasonic Scalpel	Johnson & Johnson	HAR1120	Ultrasonic Energy Cutting
HEM-O-LOK Polymer Ligating Clips	WECK	544230 Medium-Large	Locking ligation system.
LED Cold Light Source for Endoscope	KARL STORZ	TL400	Main Unit of Medical Endoscope Cold Light Source
Piperacillin Sodium and Tazobactam Sodium for Injection	Wyeth Piperacillin Div. of Wyeth Holdings Corporation	J20110021	Broad-spectrum antibiotics
Pleated Drainage Tube	Sumitomo Bakelite Akita Co., Ltd	MD-45110	Surgical Site Drainage
Polydioxanone Suture	Ethicon	29943	Soft Tissue Suture
Somatostatin for Injection	Merck Serono SA Aubonne Branch	8.69793E+13	Synthetic Somatostatin Analogues