Abstract
Purpose Pancreaticoduodenenctomy is a complex surgery and the sequence of steps is affected
by anatomical variations involving small intestine and major vascular structures.
This article depicts our approach to two such cases and highlights the importance
of identifying these variations preoperatively on imaging, so as to modify the surgery
plan accordingly.
Cases We report following two cases of pancreatic head adenocarcinoma (1) one with incomplete
intestinal rotation with a replaced right hepatic artery and (2) one with intestinal
nonrotation. In both cases, the small bowel was aggregated on the right side of the
abdomen, making duodenal mobilization challenging. The surgical approach was modified
to prevent injury to these vessels. A superior mesenteric artery (SMA)-first approach
helped in early isolation of vascular structures especially when vascular anomaly
was also present. Interbowel adhesiolysis, limited kocherisation, tracing all vessels
to its origin before division, paracolic anastomotic limb after a longer jejunal limb
resection in nonrotation cases, and modification in retropancreatic tunnel creation
are few of the key surgical adaptations.
Conclusion Asymptomatic Intestinal malrotation is rare in adults and must be identified on preoperative
imaging. Resultant intestinal and vascular anatomical variations need meticulous surgical
planning and modification of conventional surgical approach for safe performance of
PD.
Keywords Whipple's procedure - incomplete intestinal rotation - pancreatic cancer - intestinal
nonrotation
