Background : Recent studies have evaluated utility and safefy of arterial divestment procedures in borderline resectable and locally advanced pancreatic cancers after neoadjuvant therapy. In this video vignette, we endeavor to demonstrate the technique of divesting the superior mesenteric artery for a pancreatic head cancer.

Methods : Surgery was performed at Tata Memorial Hospital, Mumbai. Patient was a 56-year-old lady with preserved performance status, diagnosed with a non-metastatic adenocarcinoma of the pancreatic head (borderline-resectable since the abutment of Superior Mesenteric Artery (SMA) was <180degress). She received neoadjuvant chemotherapy with stereotactic body radiation therapy (SBRT). Stability of the disease was documented on serial imaging. She underwent a Pylorus-Preserving Pancreaticoduodenectomy (PPPD) with periarterial divestment and triangle clearance.

Results : Operative blood loss was 1500ml. Frozen section for margins was negative especially at the SMA divestment plane. Postoperative chylous ascites was managed conservatively. She was discharged on the 15th postoperative day. Final histopathology confirmed moderately-differentiated adenocarcinoma of the pancreatic head with tumour-free margins and 5/30 nodes positive. (AJCC TNM 8th ypT1c N2 M0) She received adjuvant chemotherapy and is on regular follow-up.

Conclusions : Periadventitial divestment is an important advancement in contemporary pancreatic cancer surgery. It affords an alternative to the more morbid arterial resection, without compromising on oncological clearance.