Precision anatomy required for minimally invasive surgery for biliary diseases: Focus on pancreaticoduodenectomy

Abstract

Minimally invasive pancreatoduodenectomy (MIPD) has emerged as a feasible option for selected biliary tract malignancies, such as ampullary carcinoma and distal cholangiocarcinoma. These tumors often present with limited tissue inflammation and relatively horizontal tumor spread, making them more amenable to minimally invasive techniques than pancreatic ductal adenocarcinoma. However, the anatomical complexity surrounding the pancreatic head requires meticulous dissection and advanced surgical skills.

The concept of "precision anatomy" has become essential for safe MIPD. It refers to the detailed, three-dimensional understanding of key vascular structures that vary significantly between individuals. This review highlights three critical anatomical considerations for MIPD in biliary diseases: (1) anomalies in the right hepatic artery, (2) branching patterns of the inferior pancreaticoduodenal artery, and (3) confluence patterns of the first jejunal vein and the inferior pancreaticoduodenal vein. Additionally, we describe the "three-layer dissection" technique developed in our institution, which facilitates systematic and safe dissection around the superior mesenteric artery via a right-sided approach.

A thorough understanding of precision anatomy allows for safer surgery, improved oncologic outcomes, and broader adoption of minimally invasive techniques in complex hepatopancreatobiliary procedures.