Anterior and transmesocolic approaches for duodenal laparoscopic and endoscopic cooperative surgery

The Kocher maneuver is the most common surgical approach for duodenal tumors. However, the extensive dissection required for the second and third portions of the duodenum complicates laparoscopic procedures. This study introduces the anterior and transmesocolic approaches in laparoscopic and endoscopic cooperative surgery for duodenal neoplasms (D-LECS). Thirty patients who underwent D-LECS at our institute between November 2016 and August 2024 were included. The median age was 62.5 years, and the median pathological tumor size was 15 mm. Tumors were located in the first, second, and third portions of the duodenum in 5, 20, and 5 patients, respectively. The anterior approach was performed in the first to upper second portion of the duodenum in seven patients; the transmesocolic approach was performed in the second to third portions of the duodenum in 23 patients. All patients underwent full-thickness suture reinforcement after endoscopic submucosal dissection. The median operation time and bleeding volume were 281 min and 10 mL, respectively, for the anterior approach and 297 min and 0 mL, respectively, for the transmesocolic approach. Postoperative complications, such as delayed perforation, were not observed. All patients underwent curative resection. Pathological analyses revealed 21, 7, 1, and 1 case of adenoma, adenocarcinoma, gastrointestinal tumor, and neuroendocrine tumor, respectively. Disease recurrence was not observed during the follow-up (median, 35 months). D-LECS using the anterior and transmesocolic approaches based on tumor location may allow for individualized surgical management in patients with early duodenal neoplasms.