Langenbecks Arch Surg (2010) 395:1161–1164
DOI 10.1007/s00423-010-0663-9
HOW TO DO IT
Uncinate process first—a novel approach for pancreatic
head resection
Thilo Hackert & Jens Werner & Jürgen Weitz &
Jan Schmidt & Markus W. Büchler
Received: 20 March 2010 / Accepted: 10 June 2010 / Published online: 27 June 2010
# Springer-Verlag 2010
Abstract
Purpose Partial pancreatico-duodenectomy is the standard
treatment for malignancies of the pancreatic head. We
describe a technical modification with a retrograde dissec-
tion of the pancreatic head as a novel surgical approach.
Methods Retrograde resection of the pancreatic head is
performed starting with the uncinate process after division
of the first jejunal loop and transection of the pancreas as
the last operative step of the resection. Technical aspects
and possible advantages for this procedure are discussed.
Results The retrograde resection can be safely performed
and offers a comfortable and innovative approach for
pancreatico-duodenectomy.
Conclusions The “uncinate process first” approach can
serve as an additional approach in modern pancreatic
surgery. Further studies are required to evaluate this
procedure regarding operative parameters and postoperative
outcome compared to the standard resection.
Keywords Pancreatico-duodenectomy . Technique .
Retrograde resection
Background
Partial pancreatico-duodenectomy is the standard treatment
for malignancies of the pancreatic head and selected
patients with chronic pancreatitis when preservation of the
duodenum is not possible [1–4]. The first description of this
operative procedure appertains to Walter Kausch back in
T. Hackert : J. Werner : J. Weitz : J. Schmidt : M. W. Büchler (*)
Department of Surgery, University of Heidelberg,
Im Neuenheimer Feld 110,
69120 Heidelberg, Germany
e-mail: markus_buechler@med.uni-heidelberg.de
1909 [5]; however, the introduction into clinical practice is
the merit of Allen Whipple during the 1930s [6]. Since then
the so-called Whipple operation has been established as a
one-stage procedure and has—especially during the last
four decades—become routine in visceral surgery. Due to
technical modifications and a high grade of standardization,
low surgical morbidity and mortality rates can be achieved
in experienced centers today [7, 8]. Among these mod-
ifications, preservation of the pylorus as described by
Traverso [9] and antecolic reconstruction of the duodeno-
jejunal passage have been the most important developments
in recent times [10, 11]. With regard to the surgical
procedures, standard resection is usually performed in a
cranio-caudal direction [12]. Several other approaches have
been described which aim at special anatomically or
technically challenging situations [13–17]. We describe a
technical modification of partial pancreatico-duodenectomy
with a “retrograde” dissection of the pancreatic head in a
caudo-cranial direction, starting with the uncinate process
after division of the proximal jejunum and translocation of
the first jejunal loop to the right side of the mesenteric root.
Transection of the pancreas is performed as the last step of
the resection.
Technique
Beginning with laparoscopy or laparotomy, the abdominal
cavity is explored to exclude liver and peritoneal metasta-
ses. The lesser sack is opened to explore the anterior aspect
of the pancreas and define the extent of the pancreatic head
tumor towards the body of the gland as well as the possible
attachment to the distal stomach to decide whether the
pylorus can be preserved. This is followed by a Kocher
maneuver with wide mobilization of the duodenum and the
1162 Langenbecks Arch Surg (2010) 395:1161–1164

pancreatic head from the retroperitoneal adhesions. During

this step, the ligament of Treitz is opened on the right side
of the mesenteric root, and the superior mesenteric artery
and vein are visualized to ensure respectability of the
tumorous process.
Afterwards, the hepato-duodenal ligament is prepared
including lymphadenectomy and exposure of the common
and proper hepatic arteries as well as the gastroduodenal
artery which can be cut at this point of time as well as the
common bile duct after removal of the gallbladder. The
next step of the preparation is the division of the proximal
jejunum left of the mesenteric root which can be performed
by a stapling device to safely close the lumen of the small
bowel and avoid contamination during the operative Fig. 2 Mobilization of the uncinate process (black arrow) in a caudo-
procedure (Fig. 1). After transection and mobilization, the cranial direction. The uncinate process is mobilized along the ileocolic
distal end of the small bowel can be transposed towards the vein towards the superior mesenteric vein (white arrow). Superior
mesenteric artery (dotted white arrow).The pancreas has not been
right aspect of the upper abdomen and can—together with tunneled above the portal vein
the uncinate process and the pancreatic head—be grasped
and controlled by the surgeon’s left hand.
The specimen is now mobilized from the retroperitoneal Transection of the pancreas above the portal vein does
soft tissue under clear visualization of the superior not require tunneling before, as the specimen is usually
mesenteric vein and artery (Figs. 2 and 3). This is already mobilized extensively at this point of time and can
performed in a caudo-cranial direction under clipping and therefore be resected as far towards the body as possible
thermocoagulation of the contributaries to the uncinate without preceding mobilization at an earlier point of time.
process and the pancreatic head such as the posterior After removal of the specimen, frozen sections from the cut
inferior pancreatico-duodenal vessels (Fig. 4). The artery end of the bile duct and the pancreatic margin should be
and vein are approached from the right caudo-peripheral examined to ensure an R0 situation, and bleeding control of
direction. This preparation offers a clear visualization of the the pancreatic margin can immediately be performed by
vessels towards their origin and thereby minimizes the risk single atraumatic stitches using thin monofilament sutures.
of accidental injury and bleeding. In the next operative step, the transected proximal
After completion of the dissection along the vessels, the jejunal loop is transposed to the upper abdomen through
specimen is attached to the gastroduodenal junction and the an incision of the transverse mesocolon. Reconstruction can
pancreatic body itself. These structures are dissected and afterwards be carried out as described in detail before with
cut stepwise, starting with the postpyloric duodenum or if an end-to-side pancreatico- and hepatico-jejunostomy fol-
necessary the stomach and finally the pancreatic body lowed by an antecolic duodeno- or gastro-jejunostomy.
(Fig. 5).

Fig. 3 The transected jejunal loop (white arrow) is translocated to the

right side of the mesenteric root and dissection between uncinate
Fig. 1 Beginning of the dissection after transection of the first jejunal process and mesenteric root along the vessels (black arrow: superior
loop (white arrow) distal of the ligament of Treitz (black arrow) mesenteric vein) proceeds towards the portal vein
Langenbecks Arch Surg (2010) 395:1161–1164
Fig. 4 Dissection along the portal vein (white arrow) to mobilize the
pancreatic head and corpus (black arrow). Superior mesenteric artery
(right dotted white arrow)
Discussion
The technique described above differs from the classical
resection technique of the duodenum and the pancreatic
head, as the resection is performed in a retrograde way
starting with the division of the proximal jejunum, which is
pulled through behind the mesenteric axis to the right
aspect of the mesenteric root. This offers the opportunity to
completely lateralize the uncinate process to the right side
and dissect it from the retroperitoneum and the superior
mesenteric vein under visual control of the vein and the
artery. The respectability of the tumor has to be ensured
during the Kocher maneuver before to avoid technical
problems resulting in an incomplete resection afterwards
[18, 19]. In case of suspected tumor infiltration of the
artery, definite evaluation can be done by the “artery first”
approach [20]. In case of a tumor infiltration of the portal
Fig. 5 Completed mobilization. The pancreatic body (black arrow) is
dissected from the portal vein (white arrow) and transection of the
pancreas can then be carried out as the last step of the resection.
Superior mesenteric artery (dotted white arrow) and cut end of the
common bile duct (dotted black arrow)
1163
vein, the retrograde approach can be performed without
technical problems and offers a good exposition of the
situs. The perspective after lateralizing the first jejunal loop
to the right side is rather uncommon, as usually the
specimen is fixed tightly in the distal retroperitoneal and
mesenteric tissue during the conventional resection proce-
dure until this area is reached from the cranial direction.
The initial mobilization and dissection of the duodeno-
jejunal junction and transposition to the right side allows a
wide mobility with the advantage of an excellent overview
of all small vessels and attached structures in combination
with a manual control of the pancreatic head to create
tension on the surrounding tissue which facilitates the
preparation. The artery can be controlled accurately to
avoid any accidental injury as it is approached from the
distal aspect. In addition, the tissue margin separating the
uncinate process from the retroperitoneum can be accurate-
ly seen due to the mobility of the specimen which ensures a
complete resection of all pancreatic tissue in this position.
This preparatory step may be more difficult during the
conventional “antegrade” resection due to bleeding or the
size of the specimen already mobilized. Nevertheless,
complete removal of pancreatic tissue is essential to ensure
a microscopically radical R0 resection as especially the
medial resection margin is often the site of R1 situations
[19]. Therefore, resection may be more radical when the
retrograde procedure is used. Step by step, the dissection
proceeds under clip ligation of small vessels and careful
bipolar coagulation along the portal vein. This offers very
accurate bleeding control and minimizes blood loss,
especially when the gastroduodenal artery has been ligated
before. From our experience, the retrograde approach is not
only superior due to bleeding control, but also much more
comfortable as the resection margins are clearly viewed
throughout the whole preparation with both superior
mesenteric vessels, artery and vein. All contributaries are
approached from the distal and peripheral aspect with the
chance to selectively clip or ligate them.
In case of clear resection margins towards the venous
vessels, the pancreas can be completely mobilized from
the superior mesenteric vein (SMV), portal vein, and the
confluens. The pancreas is transected above or left of the
portal vein as the last step of the preparation, which
minimizes blood loss, as bleeding control on the cut end
tissue surface can be immediately done by fine atraumatic
sutures. Any intermediate bleeding control, e.g., by pan-
creatic tissue compression with the consecutive risk of
irritating the pancreatic remnant can be avoided, the
pancreas is already definitely mobilized and prepared for
the following anastomosis. Furthermore, the retrograde
procedure can be used in total pancreatectomies for a
complete removal of the organ without transecting the
gland.
1164
In case of suspected tumor infiltration along the SMV or
the portal vein, the preparation can be carried out
retrogradely up to the point of tumor adherence and must
then be forwarded from the side of the hepato-duodenal
ligament to control both portal vein and SMV. The splenic
vein needs to be controlled to enable safe venous resection
with the enable safe venous resection en bloc with the
specimen and direct reconstruction or graft insertion [20, 21].
Besides tumor infiltration, also peritumoral inflammation
can alter the pancreatico-venous tissue margin which makes
tunneling above the portal vein difficult. Any traumatic
manipulation with the risk of vessel injury during this
maneuver can be avoided by starting dissection caudally
along the SMV. Especially in these cases, we have
experienced the retrograde dissection as a convenient
technique with a very low risk of uncontrolled injury of
the SMV or portal vein.
In conclusion, the retrograde dissection technique is a
safe surgical procedure which offers a comfortable, accu-
rate, and controlled resection of the pancreatic head or the
complete gland. We have not observed any major intra-
operative complications. The technique can be used in all
indications for partial pancreatico-duodenectomy and is not
limited to any special anatomic situations or defined tumor
entities like many other special approaches that have been
described in the past. Therefore, it can be recommended as
an additional approach in modern pancreatic surgery to
supplement the standard technique. Further studies are
required to evaluate its possible advantages in comparison
to the classical dissection techniques especially with regard
to operative parameters such as time of preparation, blood
loss, need for transfusion, and postoperative outcome in
terms of R1 frequency and local recurrence rates.
References
1. Wagner M, Redaelli C, Lietz M et al (2005) Curative resection is
the single most important factor determining outcome in patients
with pancreatic adenocarcinoma. Br J Surg 91:586–594
2. Schnelldorfer T, Ware AL, Sarr MG et al (2008) Long-term
survival after pancreatoduodenectomy for pancreatic adenocarci-
noma: is cure possible? Ann Surg 247:456–462
3. Seiler CA, Wagner M, Bachmann T et al (2005) Randomized
clinical trial of pylorus-preserving duodenopancreatectomy versus
classical Whipple resection-long term results. Br J Surg 92:547–556
Langenbecks Arch Surg (2010) 395:1161–1164
4. Sakorafas GH, Farnell MB, Nagorney DM et al (2000) Pancrea-
toduodenectomy for chronic pancreatitis: long-term results in 105
patients. Arch Surg 135:517–523
5. Das KW (1912) Carcinom der Papilla duodeni und seine radikale
Entfernung. Beitr Klin Chir 78:439–486
6. Whipple AO, Parsons WB, Mullins CR (1935) Treatment of
carcinoma of the ampulla of Vater. Ann Surg 102:763–779
7. Birkmeyer JD, Siewers AE, Finlayson EV et al (2002) Hospital
volume and surgical mortality in the United States. N Engl J Med
346:1128–1137
8. McPhee JT, Hill JS, Whalen GF et al (2007) Perioperative
mortality for pancreatectomy: a national perspective. Ann Surg
246:246–253
9. Traverso LW, Longmire WP Jr (1978) Preservation of the
pylorus in pancreaticoduodenectomy. Surg Gynecol Obstet
146:959–962
10. Hartel M, Wente MN, Hinz U et al (2005) Effect of antecolic
reconstruction on delayed gastric emptying after the pylorus-
preserving Whipple procedure. Arch Surg 140:1094–1099
11. Tani M, Terasawa H, Kawai M et al (2006) Improvement of
delayed gastric emptying in pylorus-preserving pancreaticoduode-
nectomy: results of a prospective, randomized, controlled trial.
Ann Surg 243:316–320
12. Weitz J, Koch M, Kleeff J, Müller MW, Schmidt J, Friess H,
Büchler MW (2004) Kausch-Whipple pancreaticoduodenectomy.
Technique and results. Chirurg 75(11):1113–1119
13. Nakao A, Takagi H (1993) Isolated pancreatectomy for pancreatic
head carcinoma using catheter bypass of the portal vein.
Hepatogastroenterology 40(5):426–429
14. Nakao A, Fernández-Cruz L (2007) Pancreatic head resection
with segmental duodenectomy: safety and long-term results. Ann
Surg 246(6):923–928
15. Samra JS, Gananadha S, Gill A, Smith RC, Hugh TJ (2006)
Modified extended pancreatoduodenectomy: en bloc resection of
the peripancreatic retroperitoneal tissue and the head of pancreas.
ANZ J Surg 76(11):1017–1020
16. Sharma MS, Brams DM, Birkett DH, Munson JL (2006)
Uncinatectomy: a novel surgical option for the management of
intraductal papillary mucinous tumors of the pancreas. Dig Surg
23(1–2):121–124
17. Weitz J, Rahbari N, Koch M, Buchler MW (2010) The “artery
first” approach for resection of pancreatic head cancer. J Am Coll
Surg 210:e1–e4
18. Köninger J, Wente MN, Müller-Stich BP, di Mola FF, Gutt CN,
Hinz U, Müller MW, Friess H, Büchler MW (2008) R2 resection
in pancreatic cancer—does it make sense? Langenbecks Arch
Surg 393(6):929–934
19. Esposito I, Kleeff J, Bergmann F et al (2008) Most pancreatic
cancer resections are R1 resections. Ann Surg Oncol 15:1651–
1660
20. Weitz J, Kienle P, Schmidt J et al (2007) Portal vein resection for
advanced pancreatic head cancer. J Am Coll Surg 204:712–716
21. Harrison LE, Klimstra DS, Brennan MF (1996) Isolated portal
vein involvement in pancreatic adenocarcinoma. A contraindica-
tion for resection? Ann Surg 224:342–347