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Left lateral sectionectomy and left hepatectomy for living donation 279
perform today. In France, more than 70 laparoscopic graft
harvests have been performed [11].
20.2 Donor evaluation process
The selection of an eligible donor involves the evaluation
of both technical feasibility and operative risk for the
donor. Both issues mandate an extensive work-up,
including an extensive search for any medical contraindications, donor psychological assessment, and evaluation of the suitability of the intended graft in terms of
anatomy, volume, and function.
Currently, there is no consensus for donor age, and we
rely more on physiological age than chronological age.
However, an upper age limit is arbitrarily set at 55 in many
centers. In our center, the oldest donor so far has been
56 years old. Every eligible donor has to be thoroughly
informed about the risks involved, not only for the donor
operation but also the recipient mortality (5%), together
with donor mortality (0.2–1%) and morbidity rates
(15–40%). Left living donor liver transplantation is
favored at many centers because the mortality and morbidity rates are significantly lower for left than for right
hepatectomy.
An extensive medical history should be conducted,
including personal and/or familial history of diabetes
mellitus, cardiovascular disease, pulmonary disease,
malignancy, psychological disorders, alcohol consumption and smoking, and deep vein thrombosis risk factors
(oral contraception use for women). This must be augmented by a complete physical examination with body
mass index (BMI), which also includes arterial blood
pressure measurements. Biological tests include classic
blood hematology and biochemistry, complete glycemic
and lipid profile, common viral serology screening
(human immunodeficiency virus [HIV], hepatitis B and
C, cytomegalovirus [CMV], varicella zoster virus [VZV]),
and, in our center, extensive research on coagulation
disorders (factor V Leiden, factor II, antithrombin III,
antiphospholipid antibodies, protein C, protein S). Specific markers for malignancy can be added in case of any
clinical suspicion.
A psychiatrist should conduct a complete psychological
evaluation, and the donor case should be presented for
approval by an ethics committee. All donors must give
their informed consent. According to the French law “Loi
Bioéthique” (1994), which was modified in 2004 and
Figure 20.1 CT scan 3D arterial reconstruction.
2012, a judge of the civilian court records the donor’s
written consent.
The graft assessment work-up includes multiple imaging evaluations by a combination of ultrasound, computed tomograhy (CT) scan and magnetic resonance
imaging (MRI) cholangiography. CT scan with threedimensional (3D) vascular reconstruction is mandatory
for arterial mapping (Figure 20.1). The course and size of
the hepatic artery, and detection of anatomical variations
such as a right hepatic artery arising from the superior
mesenteric artery or left hepatic artery arising from the
left gastric artery, are noted. The origin of the segment IV
hepatic artery should be outlined (from the left or right
hepatic artery). Portal venous anatomy is also assessed
(Figure 20.2), in order to identify division abnormalities
(i.e. portal trifurcation). Particular attention is paid to
hepatic venous drainage, especially the course of the
Figure 20.2 CT scan 3D portal reconstruction.
280 Chapter 20
Figure 20.3 CT scan hepatic venous drainage mapping.
segment IV drainage vein in case of left donor hepatectomy (Figure 20.3).
Computed tomography volumetric measurement of
the liver remnant and the intended graft should be performed (Figure 20.4) in order to obtain a safety limit for
donor remnant volume of 30–35% and to ensure the
0.8% graft to body weight ratio considered a safe volume
to weight ratio for the recipient [12–15].
At our center, we then perform an MR cholangiography, which is currently the best way to detect biliary
anatomy abnormalities (Figure 20.5). This investigation is
fundamental to search for variations, such as a right
posterior or anterior sectorial duct joining the left hepatic
duct; such a situation represents a formal contraindication to the intervention. The position of the left
hepatic duct division and site of segment IV duct joining
should also be documented.
Figure 20.4 CT scan left lateral section volumetric
measurement.
Figure 20.5 Preoperative MR cholangiography.
We do not routinely perform liver biopsy, endoscopic
retrograde cholangiopancreatography (ERCP), or
arteriography.
Finally, the decision to perform a living donor left
lateral sectionectomy is validated by a multidisciplinary
review committee, where all potential medical contraindications are considered and suitability of the intended
graft in terms of anatomy and volume is closely examined. It should be highlighted that there are very few
anatomical contraindications for left liver graft harvesting
comparedwith the right liver. The two absolute contraindications are existence of an exclusive right hepatic
artery arising from the mesenteric artery (around 9%
of cases) and/or the absence of portal bifurcation (less
than 1%).
20.3 Surgical technique
To enhance donor safety, this intervention should ideally
be performed by two senior surgeons. Any incident that
might compromise donor safety or graft integrity should
lead to prompt conversion from the laparoscopic procedure to an open procedure. In our team, we defined these
events or criteria of conversion as: significant bleeding,
failure to accurately recognize bile duct anatomy, any
vessel injury, and inadequate exposure of the surgical site,
leading to failure or slow progression during parenchymal
transection.
The operation is divided into three steps: left pedicle
dissection, parenchymal transection including left bile
duct division, and graft extraction. Usually, these steps
are performed in rotation between the two surgeons, one
Left lateral sectionectomy and left hepatectomy for living donation 281
performing the pedicle dissection and the other doing the
parenchymal transection and graft removal.
20.3.1 Preparation
The donor is placed in the supine position, legs apart
(French position). Devices to prevent hypothermia
(warming coverage) and deep vein thrombosis (compression stockings) are routinely used. Two monitors are
placed above the patient’s left and right shoulders.
A carbon dioxide pneumoperitoneum is created
and maintained at 12 m mHg pre ssure. Five trocars,
three of 12 mm diameter and two of 5 mm diameter,
are inserted (Versa step Plus, Tyco Healthcare, Norwalk, Connecticut), as shown in Figure 20.6. The
middle trocar is placed 2– 3 cm above the umbilicus
to avoid any tangential vision to the whole left lateral
section.
A30° laparoscope is useful to obtain an optimal visual
field of every region of the abdominal cavity, to facilitate
visualization of the hepatic vein, and to avoid forcing the
operating surgeon into an unnatural viewing angle in
case of a tangential dissection plane.
Figure 20.6 Donor position and trocar placement.
282 Chapter 20
Figure 20.7 Access and mobilization of the left lateral section.
20.3.2 Access and mobilization of the left
lateral section
After a general inspection of the liver and the abdominal
cavity, the left lateral section is mobilized by first dividing the
round and falciform ligaments (Figure 20.7); the lesser
omentum is opened, and the left triangular ligament is
divided. The dissection of the falciform ligament is continued to the level of the insertion of the hepatic veins. This first
mobilization step is preferentially performed with the Harmonic Scalpel (Ethicon Endo-Surgery Inc., Cincinnati,
Ohio), which offers the advantage of simultaneous cutting
and coagulating of the surgical site. Alternatively, the procedure may be completed using bipolar forceps and scissors.
20.3.3 Left pedicle preparation
The left arterial and portal branches are dissected free and
taped (Figure 20.8). A left hepatic artery, arising from the
left gastric artery, is isolated as well. Arterial and portal
branches to segment I are divided, either between clips or
using the Harmonic Scalpel, depending to the vesseldiameter (Figure 20.9); this also facilitates control of the left
hepatic artery and portal vein by gaining length. This step
of the pedicledissectionshould be performedin such a way
that it facilitates the future implantation of the left pedicle
when the graft is transplanted into the recipient.
Figure 20.8 Left pedicle dissection. Left hepatic artery (red arrow)
and left portal (blue arrow) branches are dissected and taped.
Exposure during transection is maintained by traction
of the round ligament and left lateral segment with an
atraumatic retractor.
We use the Harmonic Scalpel for incision of the liver
capsule and the superficial part of the transection (no
more than 1 cm deep in the parenchyma). We prefer the
ultrasonic dissector for deeper transection (Figure 20.10).
The parenchyma is thus divided step by step and the
encountered pedicles are identified before dividing and
clipping. Vessels larger than 2 mm, such as portal pedicles
to segment IV, are dissected free using the ultrasonic
dissector and taped using polytetrafluoroethylene
(PTFE) tapes. This is done to clearly expose both sides
of the pedicle to be transected. The pedicle is then clipped,
20.3.4 Parenchymal transection
The parenchymal transection is performed along the right
side of the falciform ligament, in contrast to the conventional left lateral sectionectomy, which is typically performedto the left of the falciformligament.Posteriorly,the
transection line follows the ligament of Arantius.
Figure 20.9 Dissection of a segment I portal branch.
Left lateral sectionectomy and left hepatectomy for living donation 283
Figure 20.10 Parenchymal transection using ultrasonic
dissector and bipolar coagulation simultaneously.
using secured Hem-o-lok clips (Teleflex Medical, Morrisville, North Carolina), and divided (Figure 20.11).
Bleeding is controlled using bipolar cautery for minor
vessels and clips for larger vascular structures. No inflow
control is used to minimize ischemic damage to both
donor liver and graft. A transient increase in pneumoperitoneum pressure up to 16 mmHg can be applied, if
well tolerated by the donor, to improve bleeding control.
20.3.5 Left bile duct division
Once the liver transection has reached the hilar plate, the
left bile duct is divided with scissors (Figure 20.12). To
avoid injuring it, the left portal vein is pulled downwards
using tape. This maneuver allows the surgeon to safely
Figure 20.12 Left bile duct division with scissors.
divide the bile duct and may improve visualization of the
hilar plate. Moreover, no electric cautery should be
applied at this stage to avoid thermal injury of the bile
duct and the hilar plate. The distal stump of the bile duct is
closed using a secured Hem-o-lok clip (Figure 20.13). We
prefer these locking clips at our center after we experienced one case of bile leakage after dislodgment of a
regular titanium clip.
20.3.6 End of transection and control of
the left hepatic vein
After bile duct division, the transection progresses along
Arantius’s line towards the left hepatic vein, which is then
Figure 20.11 Segment IV pedicle exposure and clipping.
Figure 20.13 Distal stumps of the left bile duct closed with a
secure clip.
284 Chapter 20
Figure 20.14 Left lateral graft ready for harvesting. Left hepatic
vein, left portal branch, and left hepatic artery are taped.
dissected free, controlled, and encircled with tape. At
this stage, the graft is only attached by its vessels
(Figure 20.14).
20.3.7 Graft harvesting
A7–8 cm suprapubic incision without muscular division is
performed. A 15 mm port is inserted to introduce a large
extraction bag (Endocatch, Tyco Healthcare, Norwalk,
Connecticut). After the bag has been introduced, first
the left hepatic artery is clipped and divided. The proximal
end of the left arterial branch (donor side) is closed with a
locking clip while the distal end (graft side) is left free
without any clippingor clamping to avoid arterial damage.
The left portal branch is transected using a unilateral
linear stapling device (EndoTA 30, Tyco Healthcare, Norwalk Connecticut). Clocking of warm ischemia time
begins with this step. The left hepatic vein is then stapled
with the same stapler. Finally, the left portal branch and
left hepatic vein are divided using scissors.
The graft is rapidly inserted into the bag. CO
tion is stopped and the fascia is incised to allow externalization of the bag.
The graft is immediately weighed and perfused with a
cold preservation solution through the left portal vein.
This marks the end of the warm ischemia period, which is
typically less than 10 minutes; clocking of cold ischemia
time begins with the introduction of the cold preservation
solution. The bile ducts of the graft are flushed out with
the same preservation solution.
Concurrently, peritoneal reinsufflation is re-established in the donor. Hemostasis and biliostasis are
insuffla-
2
confirmed. No drain is used. CO
pneumoperitoneum
2
is evacuated completely to reduce postoperative pain.
The fascias of port sites greater than 5 mm are carefully
closed with absorbable suture material.
20.3.8 Special considerations for left
living donor hepatectomy
(see Video 19)
The operative time for a living donor left hepatectomy is
similar to that of left lateral sectionectomy. Below we
outline some specific technical aspects of living donor left
hepatectomy.
After liver mobilization, the preparation of the portal
pedicle starts with a cholecystectomy, followed by dissection and encircling of the structure of the portal pedicle
with tape as described previously.
The parenchymal transection starts in the middle of
the gallbladder bed, and follows the left side of the middle
hepaticveintoreachthelefthepaticveinorigin.Themiddle
hepatic vein could be left with the right liver of the donor,
and it should be nicely exposed throughout the transection.
Nevertheless, ultrasonography is mandatory to check its
position during the parenchymal transection.
Particular attention should be paid to the venous drainage
of segment IV during preoperative evaluation when a left
hepatectomy is considered. The course of the segment IV
drainage vein and its main tributaries should be extensively
mapped and classified into the following three main types:
majority/exclusive from left vein, majority/exclusive from
middle vein, or shared left and middle vein tributary segment IV drainage. In the same manner, the origin of the
segment IV hepatic artery should be preoperatively outlined. The preoperative vascular mapping helps to identify
patients at risk for vascular complications involving segment
IV congestion and/or necrosis; these patients may benefit
from a planned peroperative segment IV removal to avoid
potential severe complications. The surgical team needs to
consider this latter point preoperatively.
20.4 Postoperative care
Prevention of deep vein thrombosis by use of prophylactically dosed low molecular weight heparin and compression stockings is routine from postoperative day 1. Proton
pump inhibitors are used routinely to prevent gastric
ulcer. No postoperative gastric tube is retained.
Oral intake is allowed in the evening of the procedure,
and early mobilization is encouraged on postoperative
Left lateral sectionectomy and left hepatectomy for living donation 285
day 1. Particular attention is paid to postoperative pain
and appropriate pain medication is prescribed; their efficiency and necessity are re-evaluated daily.
Clinical features and biological tests are closely monitored
every day; particular attention is paid to pulmonary examination, and any sign of pulmonary embolism is promptly
addressed. Biological liver function is assessed by daily
biochemical tests, including prothrombin time and serum
bilirubin. Any clinical or biological sign of general or liverrelated complication is documented in the patient’spostoperative record and promptly addressed.
20.5 Conclusion and future
perspectives
Laparoscopic right liver hepatectomy and left liver
hepatectomy with the middle hepatic vein for adult
living-related transplantation are still at the developmental stage but may be a promising approach in the
future for living donor liver transplantation [16]. Laparoscopic living donor left liver hepatectomy will continue to be an important option in liver transplantation.
However, aside from the risk for the donor, this procedure is challe nging laparoscopically because of an oblique transection pl ane which can prevent an optimal
view onto the operative site. Optimizing trocar
positioning, e.g. further to the right of the abdomen
than for standard left and left lateral hepatectomy, and
some mobilization of the right liver could aid in performing laparoscopic left liver living donation. While
mobilization of the right liver would allow better exposure, it has the potential to jeopardize donor liver
integrity. A future development may be to perform
the operation in a supine rather than left lateral position. Tilting the table could optimize the operative field,
an approach that is performed for tumor left lateral liver
resection by some centers today.
To conclude, laparoscopic left lateral sectionectomy is a
safe and reproducible procedure for living donor liver
transplantation; however, donor safety is critical and
therefore this approach requires experienced surgeons.
A steep learning curve exists and should be flattened
through the close collaboration between two experienced
liver transplant surgeons.
Laparoscopic right and left liver hepatectomy (including the middle hepatic vein) may increase graft volume
and function for adult living-related transplantation, but
before this can be performed routinely, the technique has
to be standardized and all possible measures taken to
ensure donor safety.
Liver transplant surgeons should always keep in mind
that donor safety is paramount, since the donors are, prior
to the donation, disease-free volunteers.
Key points and technical tips
KEY POINTS
• Appropriate patient selection is key.
• Perform the steps of the hepatectomy alternating between the two experienced liver surgeons (one performing the pedicle
dissection, the other the parenchymal transection).
• As a team, define preoperatively the criteria for conversion.
• As a team, define a “checklist” of key maneuvers to be validated step by step by both surgeons during the intervention (the most
important steps being the left bile duct section and the left vessels stapling).
TECHNICAL TIPS
• At the level of the hilar plate, pull downwards on the portal vein using the tape in order to avoid vascular injury and to obtain an
optimal exposure.
• Avoid thermal injuries close to the bile ducts.
• Locking clips rather than titanium clips minimize the risk of a bile duct stump leak.
• Anticipate the very last step of graft harvest to shorten warm ischemia time: open the endoscopic retrieval bag in the peritoneal
cavity beforehand and confirm team readiness to receive the graft before staple dividing inflow.
• Anticoagulation should be discussed before vessel division. Today there is no consensus on an optimal regimen.
286 Chapter 20
References
1 Raia S, Nery J, Mies S. Liver transplantation from live donors.
Lancet 1989; 2:497.
2 Strong RW, Lynch SV, Ong TH, Matsunami H, Koido Y,
Balderson GA. Successful liver transplantation from a living
donor to her son. N Engl J Med 1990; 322:1505–1507.
3 Lo CM. Complications and long-term outcome of living liver
donors: a survey of 1,508 cases in five Asian centers. Transplantation 2003; 75(3 suppl):S12–15.
4 Iida T, Ogura Y, Oike F, et al. Surgery-related morbidity in
living donors for liver transplantation. Transplantation 2010;
89(10):1276–1282.
5 Cheah YL, Simpson MA, Pomposelli JJ, Pomfret EA. The
incidence of death and potentially life-threatening “near
miss” events in living donor hepatic lobectomy: a worldwide
survey. Liver Transplant 2013; 19:499–506.
6 Cherqui D, Soubrane O, Husson E, et al. Laparoscopic living
donor hepatectomy for liver transplantation in children.
Lancet 2002; 359(9304):392–396.
7 Soubrane O, Cherqui D, Scatton O, et al. Laparoscopic left
lateral sectionectomy in living donors: safety and reproducibility of the technique in a single center. Ann Surg 2006; 244
(5):815–820.
8 Chang S, Laurent A, Tayar C, Karoui M, Cherqui D. Laparos-
copy as a routine approach for left lateral sectionectomy. Br J
Surg 2007; 94(1):58–63.
9 Kim KH, Jung DH, Park KM, et al. Comparison of open and
laparoscopic live donor left lateral sectionectomy. Br J Surg
2011; 98(9):1302–1308.
10 Carswell KA, Sagias FG, Murgatroyd B, Rela M, Heaton N,
Patel AG. Laparoscopic versus open left lateral segmentectomy. BMC Surg 2009; 9:14.
11 Scatton O, Katsanos G, Boillot O, et al. Pure laparoscopic
left lateral sectionectomy in living donor: from innovation
to development in France. Ann Surg 2015; 261(3):
506–512.
12 Redvanly RD, Nelson RC, Stieber AC, Dodd GD 3rd. Imaging
in the preoperative evaluation of adult liver transplant candidates: goals, merits of various procedures, and recommendations. Am J Roentgenol 2995; 164:611–617.
13 Lo CM, Fan ST, Liu CL, et al. Minimum graft size for sucessful
living donor liver tranplantation. Transplantation 1999;
68:1112–1116.
14 Kiuchi T, Kasahara M, Uryuhara K, et al. Impact of graft size
mismatching on graft prognosis in liver transplantation from
living donors. Transplantation 1999; 67:321–327.
15 Sakamoto S, Uemoto S, Uryuhara K, et al. Graft size assess-
ment and analysis of donors for living donor liver transplantation using right lobe. Transplantation 2001; 71:1407–1413.
16 Soubrane O, Perdigao Cotta F, Scatton O. Pure laparoscopic
right hepatectomy in a living donor. Am J Transplant 2013;
13(9):2467–2471.
Video 19 will be of interest to readers of this chapter.
the companion website at:
Visit
www.wiley.com\go\conrad\liver-pancreas-biliary-laparoscopic-surgery
SECTION 3 Advanced laparoscopic pancreas surgery
CHAPTER 21
Pancreatic anatomy in the era of extensive
and less invasive surgery
Yoshihiro Sakamoto, Yoshihiro Mise, and Norihiro Kokudo
Hepatobiliary Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
EDITOR COMMENT
This chapter is critical for achieving an advanced understanding of pancreatic anatomy, which is fundamental to performing safe and
oncological laparoscopic pancreatic resections. Expert pancreatic surgeons and anatomists detail the arterial as well as venous anatomy
of the pancreas and expand on the importance of the celiac and superior mesenteric artery plexus in oncological pancreatic surgery.
The authors highlight relevant peripancreatic lymph node stations and describe the key anatomy for an Appleby’s procedure.
Additionally, pancreatic embryological development is clearly outlined, providing a basis for understanding organ-preserving resections
such as duodenum-preserving pancreatic head resection, pancreatic head-preserving duodenectomy, and segmental pancreas
resection. The educational pictures of the intricate pancreatic anatomy will help the reader minimize the morbidity of pancreatic
surgery and perform complete oncological resections. Ultimately, a detailed anatomical understanding is the basis for advanced
laparoscopic pancreatic surgery.
Keywords: Appleby’s procedure, arterial pancreatic anatomy, celiac and superior artery nerve plexus, duodenum-preserving pancreatic
head resection, pancreatic embryology, pancreatic head-preserving duodenectomy, pancreatic lymph node station, pancreatic
segmental resection, venous pancreatic anatomy
21.1 Introduction
Increasing numbers of laparoscopic and robotic pancreatic surgeries are being performed all over the world.
Distal pancreatectomy (DP) is the most frequently performed pancreatic resection and recommended for resection of borderline malignancies or well-selected ductal
adenocarcinomas located in the body or tail of the pancreas. A recent meta-analysis comparing laparoscopic
with open pancreatectomy showed that laparoscopic
distal pancreatectomy was associated with better shortterm outcomes; that is, earlier oral intake, lower
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
incidence of operative morbidity, and shorter hospital
stay [1].
In contrast to the more widespread laparoscopic DP,
laparoscopic pancreaticoduodenectomy (PD) is still technically very demanding. The challenging nature of a
laparoscopic PD stems in part from the complex anatomy
of the pancreatic head. An excellent understanding of the
anatomy is required to safely perform a laparoscopic
approach to pancreatic surgery in general and particularly
in the treatment of invasive pancreatic cancer. Pancreatic
cancer resection often entails extensive resections of
peripancreatic tissue that includes lymph nodes, nerve
287
288 Chapter 21
plexus, portal vein, and sometimes even arteries. Despite
advances in our knowledge of pancreatic anatomy, critical anatomical concepts for extensive pancreatic surgery
are still at a developmental stage.
Minimally invasive or less invasive pancreatic surgery
has also shown considerable promise in the quest for
“organ-preserving surgery.” PD is one of the most invasive surgeries in the epigastrium, and a variety of organpreserving surgeries have been reported, aiming to preserve the pancreas or the duodenum. An even more
detailed anatomical knowledge is required to safely
accomplish these organ-preserving surgeries.
In this chapter, we provide important information on
the pancreatic anatomy required for both extensive and
minimally invasive pancreatic surgery.
21.2 Basic vascular anatomy for
pancreatectomy (see Videos
20–26)
21.2.1 Arterial anatomy
The superior mesenteric artery (SMA) and celiac artery
(CeA) are the two major branches from the aorta. These,
in turn, give off important branches to the pancreatic
head. The branches off the SMA and CeA form the
anterior and posterior pancreatic arterial arcades.
21.2.1.1 Superior mesenteric artery
The SMA has several important branches that are critical
for surgery at the level of the pancreatic head. These
include the inferior pancreaticoduodenal artery (IPDA),
jejunal arteries, transverse pancreatic artery, and aberrant hepatic arteries. Among these, the key arteries
affected during pancreatectomy will be the IPDA, some
of the aberrant hepatic arteries, and the transverse pancreatic artery, as we will demonstrate below.
Inferior pancreaticoduodenal artery
Understanding the branching of the IPDA and its specific
anatomical location is important not only for safe resection of the pancreatic head but also for oncological reasons. In advanced cases, invasive pancreatic head cancer
may spread to nodal stations along the route of the
IPDA [2]. It is vital to remember that transsection of
the pancreatic head along the SMA involves dissection
of the nerve plexus around the SMA, as well as division of
the IPDA. The communication between the IPDA and
Figure 21.1 The branches off the superior mesenteric artery.
Type I (58%). (Ia) The inferior pancreaticoduodenal artery
(IPDA) has a common trunk with the first jejunal artery (JA) at
the left side of the superior mesenteric artery (SMA). This type
accounts for 51% including minor variations. (Ib) The anterior
IPDA (AIPDA: A) and the posterior IPDA (PIPDA: P) branch off
from the JA independently at the right side of the SMA. This
type accounts for 6%. Type II (24%). The IPDA and JA run
independently off the SMA. Type III (18%). The anterior and
posterior IPDA run independently off the JA behind the SMA.
the first jejunal artery (JA) has several variations
(Figure 21.1). The most frequent variation is that the
IPDA has a common trunk with the JA. In this case, the
root of the common trunk may be located at the left dorsal
aspect of the SMA (type Ia, 51.2%) or at the right side of
the SMA (type Ib, 6%) [3]. A frequent variation is
the individual branching of the IPDA and the JA off
the SMA.
A second type of IPDA anatomy is where the IPDA has
two dominant branches: (i) the anterior–inferior pancreaticoduodenal artery (AIPDA) and (ii) the posterior–
inferior pancreaticoduodenal artery (PIPDA) (type II,
24%). A third variation of the IPDA is when the JA
runs by itself behind the SMA (type III, 18.44%). The
AIPDA often runs along the anterior aspect of the duodenum behind the inferior portion of the pancreatic head
(Figure 21.2a), toward the major papilla. In most of these
cases, the PIPDA runs behind the pancreatic head, giving
off small branches toward the pancreas and duodenum
(Figure 21.2b).
It is possible to identify the JA, IPDA, AIPIDA, and
PIPDA intraoperatively (Figure 21.3), and early ligation of
the inflow artery to the pancreatic head, i.e. the “artery
first” approach, is reported to reduce blood loss during
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