Total Laparoscopic Pancreaticoduodenectomy with Venous Reconstruction for Pancreatic Head Cancer with Involvement of the Superior Mesenteric Vein-Portal Vein Confluence

Background: Laparoscopic pancreaticoduodenectomy with venous reconstruction is not commonly performed due to its technical challenges. In this video, we focus on the technical aspects for how to perform this procedure safely. Methods: In a 69-year-old female with jaundice and diarrhea, a computed tomography scan showed a mass in the head of the pancreas, with a 180-degree involvement of the superior mesenteric vein. Endoscopic retrograde cholangiopancreatography with stenting was performed together with endoscopic ultrasound and fine-needle aspiration. Biopsy showed well-differentiated adenocarcinoma. The patient underwent six cycles of neoadjuvant chemotherapy, with reduction of the vein involvement to 90 degrees. The mass invaded the right lateral aspect of the superior mesenteric vein–portal vein confluence. As a result, this portion of the vein was removed en bloc with the specimen. The vascular defect was repaired using two running sutures. Once the choledocojejunostomy and intussuscepted pancreatico-gastric anastomosis were completed, the specimen was removed via a small subxiphoid incision. Results: Operative time was 6 h and 30 min, blood loss was 50 mL, and hospital stay was 12 days. Histopathological examination was ypT3 N1 (1 of 18 lymph nodes was positive). All margins were negative. Conclusion: Laparoscopic pancreaticoduodenectomy with vascular reconstruction can be performed safely in selected cases of pancreatic head cancer with vein involvement. Advanced laparoscopic skills are necessary to complete such procedures safely.