Technical Guidelines for Safe Mesojejunum Dissection During Pancreaticoduodenectomy: Unveiling Critical Techniques in a Complex Procedure.

Background: Pancreaticoduodenectomy (PD) is a complex procedure involving the dissection of the superior mesenteric artery and vein. However, a safe and standardized technique for dissecting the jejunal veins (JVs) in the mesojejunum during PD remains elusive.

Methods: We retrospectively analyzed 198 patients who underwent open PD with mesojejunum dissection using an anterior artery-first approach and evaluated anatomical variations in the first JV trunk (FJVT) and its tributaries. This study introduces the concept of a "dangerous crossover vein" (DCV) to describe tributaries that cross the transection line of the mesojejunum. Surgical techniques and perioperative outcomes were assessed.

Results: The FJVT drained the territory supplied by the first to second jejunal arteries in 144 patients (75%) and the first to third or more in 50 patients (25%). The FJVT was preserved in 100 patients (50.5%) and sacrificed in 98 (49.5%). Dangerous crossover veins were encountered in 117 patients (59%) and safely managed with standardized mesojejunal dissection. There were no significant differences in blood loss or operative time between patients with or without DCVs.

Conclusions: Understanding the anatomy of JVs and the concept of DCVs is critical for safe mesojejunal dissection during PD. Our approach facilitates secure dissection of JVs regardless of their anatomical variations.