Background : Anatomical variation of the hepatic arterial anatomy increases the technical challenge of the laparoscopic Whipple’s procedure. The incidence of a replaced right hepatic artery is 9-24% and 14.5% for a replaced left hepatic artery. Tips and tricks for performing a laparoscopic Whipple’s procedure in a patient with both replaced left and right hepatic artery is presented.

Methods : A 74-year-old man with a prior laparoscopic cholecystectomy for cholecystitis, presented with obstructive jaundice and loss of weight/appetite. Staging CT revealed an upfront resectable localised poorly delineated 2.3cm uncinate tumour with biliary obstruction without distant metastases. Endoscopic ultrasound (EUS) was performed and biopsy of the tumour returned as pancreatic adenocarcinoma. Prior to operation, he also underwent endoscopic retrograde cholangiopancreatography (ERCP) and biliary stenting.

Results : Laparoscopic Whipple’s procedure was done with careful dissection of both the right and left replaced hepatic artery, both of which were preserved. Pancreas was soft with pancreatic duct 3mm. Bile duct was dilated with stent in situ and moderate adhesions was encountered at the porta hepatis from previous laparoscopic cholecystectomy. Post operatively, patient recovered well without grade B/C post-operative pancreatic fistula, liver failure or bleeding. He resumed full diet on POD 4 and was taken over by rehabilitation team on POD 7 with eventual discharge home POD 10. Final histology revealed a 3.5cm pT2N2 (13/25) LVI/PNI + moderately differentiated pancreatic adenocarcinoma with clear margins.

Conclusions : Minimally invasive Whipple’s procedure is a feasible and safe option in pancreatic uncinate carcinoma the presence of dual replaced hepatic arteries in well selected patients.