Beyond East and West: Anatomical Convergence of Radical Dissection Techniques in Pancreatoduodenectomy

Pancreatic cancer remains a leading cause of cancer-related mortality, and pancreatoduodenectomy is the only potentially curative treatment. Despite surgical resection, local recurrence rates remain high. Three surgical procedures have been described to improve oncological outcomes: Pancreatoduodenectomy with Systematic Mesopancreas Dissection (SMD-PD) using a Supracolic Anterior Artery-first Approach, Staged Approach for Dissection Along the Celiac and Hepatic Artery (CA-HA System) During Pancreaticoduodenectomy, and the TRIANGLE operation. In this expert comparative review, we considered the SMD-PD and the CA-HA system as a single combined approach (Level 3 SMD-PD/CA-HA system) and compared it with the TRIANGLE operation. We analysed the two surgical techniques, focusing on their surgical principles, technical descriptions, and anatomical extent. Although described using different terminology and dissection strategies, analysis of their representative images reveals that both approaches clear the same anatomical area: the soft tissue within the triangle bordered by the superior mesenteric artery, celiac axis, and portal vein. This convergence in actual anatomical clearance, despite divergent descriptions, represents the central finding of this review. Given the available evidence suggesting lower local recurrence rates with these radical approaches, wider adoption is encouraged, while acknowledging that further studies are still needed to confirm long-term oncological outcomes.