Anatomical Challenges during Pancreaticoduodenectomy for Adenocarcinoma Head of Pancreas in Presence of Intestinal Rotation Abnormalities: A Report of Two Cases

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

Authors' Contributions

G.S.D.: collecting data, analysis of data, preparing the initial draft of the manuscript, critical revision of the manuscript for intellectual content, technical support, material support, and study supervision.

S.S.: collecting data, analysis of data, and preparing the initial draft of the manuscript.

P.M.P.: critical revision of the manuscript for intellectual content, technical support, material support, and study supervision.

P.K.W.: study concept, critical revision of the manuscript for intellectual content, administrative, technical support, material support, and study supervision.

Ethics Statement

The study was performed after the approval of research protocols by the Ethics Committee of Lilavati Hospital and Research Centre in accordance with international agreements (World Medical Association Declaration of Helsinki “Ethical Principles for Medical Research Involving Human Subjects,” amended in October 2013, www.wma.net)

Informed Consent

Written informed consent was obtained from the patient involved in the study.

Financial Disclosure

The authors declare that this study has received no financial support.

Informed Consent

Informed consent was obtained from the patients for this publication.

Publication History

Received: 11 January 2020

Accepted: 03 September 2021

Article published online:
15 December 2021

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