Overcoming the Challenges of Uncinate Process Oncologic Management: The Left-Side Approach in Minimally Invasive Pancreatoduodenectomy: Step-by-Step Technique and Video.

Abstract

Background: The uncinate process (UP) represents one of the greatest challenges in laparoscopic pancreatoduodenectomy (LPD) due to its deep anatomic location and proximity to major vascular structures. Ensuring complete resection of the UP and mesopancreas is crucial for achieving negative surgical margins and adequate lymphadenectomy with tumors of this region. The standard approach from the right-side of the superior mesenteric artery (SMA) often requires significant tension on mesenteric vessels, increasing the risk of vascular injury. This video describes a step-by-step, left-side approach to UP that minimizes these risks and enhances surgical safety.

Methods: A 79-year-old woman underwent LPD for an intraductal papillary mucinous neoplasm (IPMN) of the pancreatic head. Preoperative imaging showed three key anatomic variants that significantly impacted surgical planning. The first variant was a lateral deviation of the abdominal aorta, altering usual retroperitoneal landmarks. The second variant was an aberrant right hepatic artery arising from the SMA, running behind the pancreas and requiring careful preservation during uncinate dissection. The third variant was a rare inferior pancreaticoduodenal artery originating from the posterior aspect of the SMA, posing a challenge during retroperitoneal dissection. The left-side approach begins with an incision of the left duodenomesocolic fold and longitudinal opening of the retroperitoneum. The pancreatic head and duodenum are mobilized from the anterior face of the inferior vena cava. By shifting the lower pancreatic head and third portion of the duodenum leftward, the SMA and superior mesenteric vein (SMV) are exposed. The SMV is fully skeletonized. The first jejunal loop is sectioned at the Treitz ligament, allowing a clear vision of the UP, which is dissected from the SMA with minimal traction on the mesenteric vessels. The SMA then is skeletonized in a left-to-dorsal direction. The small bowel is finally transposed to the right, and the UP is mobilized by careful division of its remaining attachments to the mesenteric vessels. Resection concludes with division of the retro-portal lamina along the SMA's right border.

Results: In this case, the operative time was 300 min, with an estimated blood loss of 200 ml, an uneventful recovery, and discharge on postoperative day 14. Histology confirmed IPMN without involvement of the lymph nodes.

Conclusions: Although this video illustrates a case of IPMN that typically requires less extensive lymphadenectomy, the principles demonstrated remain relevant and translatable to more aggressive pathologies. By reducing vascular tension and improving surgical visibility, the left-side approach minimizes complications and ensures complete retroportal lamina resection, achieving the best oncologic results even in challenging cases. A key advantage is the early identification of the SMA, which allows for a precise and safe evaluation of mass resectability. Although underrepresented in the current literature, this technique represents a valuable addition to the surgical skillset for LPD.^1-5.