Background : The most common reason of R1 resection in pancreatic head cancer is involvement of the retroperitoneal margin. The concepts of mesopancreas (Gockel, 2007) and mesopancreatoduodenum (Kawabata, 2012) were asserted to secure the retroperitoneal margin. Unlike the mesorectum, there is a counterargument that the boundary of mesopancreas is ambiguous, but it is argued that the mesopancreas excision raises the rate of R0 resections. We’d like to show a video introducing total mesopancreatoduodenum excision with left side approach to inferior PD vein in total pancreatectomy.

Methods : A 64 years old female presented with synchronous pancreatic head and body cancers. The head lesion was 2.7cm in diameter and abutting the gastroduodenal artery and gastrocolic trunk. The body/tail mass was 1.3cm in diameter. There was no evidence of lymph node or distant metastasis. CA 19-9 level was 273 U/ml and total bilirubin 0.4 mg/dl. She had diabetes mellitus for 10 years and was on oral hypoglycemic agent. She also had hypertension and dyslipidemia. She underwent hysterectomy 30 years ago. BMI was 25.15.

Results : The operative time was 435 minutes and intraoperative estimated blood loss was 200 ml. She took soft diet since 4 days after the operation. She was discharged 17 days after the operation without complication. The hospital stay was prolonged for education of diabetic control.

Conclusions : Through the left side approach to SMA and PDJV in total pancreatectomy, branches of PDJV from the uncinate process or duodenojejunal junction were easily controllable without tearing under direct vision by the operator as well as the assistants. By doing so, total mesopancreatoduodenum excision can be done safely and anatomically.