Organs to be resected are the bile duct, gastroduodenal segment, and pancreas. The level of bile duct cutting can be customized according to the tumor origin and location (Fig. 23.4). For pancreatic head cancer, common hepatic duct just proximal to the cystic duct insertion site is recommended. Common bile duct level transaction (distal to the cystic duct) is not recommended because sometimes cystic duct lumen and long redundant common duct make anastomosis complicated, even though its radicality is acceptable for pancreatic cancer. It would be oncologically safer to remove the whole extrahepatic common duct for common bile duct cancer.

There are some options for gastroduodenal transaction level (Fig. 23.5). In addition to conventional pancreatoduodenectomy and pylorus-preserving pancreatoduodenectomy (PPPD), pylorus-resecting or near total gastric-preserving pancreatoduodenectomy has been introduced recently as another option, mainly for preventing delayed gastric emptying after PPPD [2, 3]. If the pylorus is thought to have a significant physiologic function, it could be the surgeon’s choice whether they preserve the pylorus for preventing delayed gastric emptying. In author’s institution, PPPD is considered first unless there is any reason to do PD, and then the level of transaction can be customized between PD and PPPD according to various factors. For instance, PD is recommended for the tumor at anterior superior portion of the pancreas, and PPPD is recommended for tumors at inferior portion of the head of the pancreas (Fig. 23.6). If the duodenal perfusion condition is not good enough, other options can be tried, such as pylorus-transecting PD.

Pancreatic neck transaction line should be customized according to the tumor location. A safe length of gross tumor-free segment has not been clearly defined. It would be difficult to define because of infiltrating nature of pancreatic cancer and associated inflammation of the pancreas, especially distal side of the tumor. In order to get free margin, 1 cm margin at least is recommended, so transaction line should be customized according to the tumor location.

Transection line can also be customized for technical reason. Pancreatic duct runs very close to the posterior surface of the pancreatic neck, so that anastomosis is sometimes very difficult. Transection at a little left side of the neck is recommended to get more centrally located duct for easier anastomosis (Fig. 23.7).

Separation of uncinate process from SMA as the first procedure (SMA-first approach) is what many surgeons stress nowadays [4]. Mesenteric approach is the most commonly adopted artery-first approach (Fig. 23.8). Most surgeons are used to conventional right side approach (SMA-last approach), but the mesenteric approach has advantages for the tumors involving uncinate process, especially in the cases of SMV/PV invasion or suspicious SMA invasion. It is considered to make early determination of respectability possible, to be better for complete peri-SMA lymph nodes dissection, and to cause less operative bleeding despite longer operation time. Other options for approach to SMA have been introduced with potential indications, but any good evidences are not available yet [4].

SMA-last approach is a conventional approach that is more familiar to most surgeons because it is simpler and easier compared to SMA-first approach and it has been working well for most of the periampullary cancers including pancreatic head cancer. So unless pancreatic cancer is located, uncinate process or major vascular invasion – at least abutting – is suspected, and SMA-last approach can be chosen.

If PV/SMV invasion is suspicious and combined vein resection is expected, vein resection should be the last procedure for en bloc removal of the specimen. To make it possible, uncinate process should be divided from SMA first before vein resection (Fig. 23.9).

Surgeons should design portal vein resection for those who have suspicious portal vein invasion. Whether wedge resection or segmental resection with or without different types of graft is chosen should be determined according to the site and the extent of invasion. And the order of vessel dissection should be customized as described above. For instance, if there is no vein invasion, SMV can be separated from pancreatic head first, and if invasion is suspected, SMA first with SMV last is recommended for en bloc removal of specimen. Graft that could be used is diverse, autograft, allograft, or xenograft. There are different sources of autograft such as the left renal vein, jugular vein, external iliac vein, saphenous vein, etc. Frozen vessels from organ donor can be used and bovine patch grafts are used.

All the reconstruction procedures are to aim preserving portal blood flow as much as possible. Splenic vein and inferior mesenteric vein are recommended to be preserved unless vascular invasion is suspected. Some surgeons prefer splenic vein cutting for better exposure of the superior mesenteric artery and retroperitoneum (more for vascular resection and reconstruction is covered in other chapters).

Lymph node metastasis has been known strong prognostic factor of pancreatic cancer, and extensive dissection of regional lymph nodes has been considered to bring some survival benefit. To investigate whether extensive lymph node dissection has any beneficial effect on survival in pancreatic head cancer, five randomized controlled trials have been tried to compare between limited LN dissection and extended LN dissection [5–9]. Although there were slight differences in the extent of LN resection (Fig. 23.10 and Table 23.1), all the studies failed to show any survival benefit of extended dissection. Therefore, it has been documented that standard or limited LN dissection is recommended (more for extent of surgery is discussed in other chapters). However, the results of these RCTs have not made most surgeons routinely perform standard limited LN dissection for pancreatic head cancer. Actually in most institutions, the extent of PD is customized between standard PD and extended PD.

For customizing LN dissection, several points should be considered. For R0, LN site of frequent metastasis and recurrence should be considered. There should not be additional morbidity. LN dissection can be done for biopsy purpose. Prognosis of cases with direct LN invasion has been reported better than that of cases with typical LN metastasis [10]. So LN dissection can be customized according to the tumor location.