Intestinal derotation procedure for facilitating pancreatoduodenectomy

In pancreatoduodenectomy (PD), mesopancreas excision with division of the inferior pancreatoduodenal artery (IPDA) is technically difficult because of the complex anatomy resulting from intestinal rotation occurring during embryological development. We have developed an intestinal derotation procedure for facilitating mesopancreas excision. The perioperative factors of PD were retrospectively compared between our derotation and the conventional procedure.

The entire small intestine and right colon are mobilized from the retroperitoneum, and intestinal rotation is reduced. This procedure simplifies the anatomic situation, in which (1) the mesopancreas stretches from the right side of the superior mesenteric artery (SMA) in a horizontal plane, (2) the IPDA arises from the right wall of the SMA, and (3) the SMA is situated at the right-posterior side of the superior mesenteric vein. In 232 cases undergoing PD, perioperative factors were compared retrospectively between the derotation (n = 117) and conventional (n = 115) procedure groups.

The derotation procedure significantly decreased operative time (434 vs 516 minutes) and blood loss (521 vs 908 mL), and tended to increase the rate of R0 resection (90% vs 78%), compared with the conventional procedure. The derotation group had a significantly higher incidence of early, that is, before division of the drainage vein, IPDA division. Postoperative complication rates did not differ, between the 2 groups.

The derotation procedure is a simple but useful technique that facilitates mesopancreas excision and early IPDA division during PD.