Ann Hepatobiliary Pancreat Surg.  2021 Aug;25(3):376-385. 10.14701/ahbps.2021.25.3.376.

“Mesopancreas-first” radical resection of pancreatic head cancer following the Cattell–Braasch–Valdoni maneuver: Appreciating the legacy of pioneers in visceral surgery

• Vasiliadis KD

• KMID: 2519295
• DOI: http://doi.org/10.14701/ahbps.2021.25.3.376

Abstract

The “artery-first” approach pancreaticoduodenectomy, with maximal mesopancreas excision and central vascular ligation, represents the current principal determinants of radicality in pancreatic head cancer resection. However, these modifications at the resection stage of pancreaticoduodenectomy constitute extremely demanding and technically complicated procedures. Among the most critical contributing factors in the difficulty of artery-first approaches is the spiral configuration of the mesoduodenum and proximal mesojejunum around the superior mesenteric artery axis. This creates complicated tridimensional anatomy, making surgical dissection in the inferior peripancreatic anatomic area extremely challenging and demanding. The Cattell–Braasch–Valdoni maneuver (right-sided medial visceral mobilization and intestinal derotation maneuver) restores the embryological twist of the duodenojejunal junction, which demystifies the distorted peripancreatic vascular anatomy and facilitates a safe and radical “mesopancreas-first” pancreatic head cancer resection. The aim of this paper was to present the advantages, efficacy, and safety of the Cattell–Braasch–Valdoni maneuver in artery-first approach radical pancreaticoduodenectomy and provide a detailed description of its surgical technique.

Keyword

Pancreaticoduodenectomy; Mesenteric artery; superior; Pancreas; Pancreatic carcinoma; Dissection

Figure

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  Fig. 1 Usual pattern of the vascular anatomy around the pancreatic head. The torsional arrangement between the pancreaticoduodenal complex and the uppermost jejunum around the superior mesenteric artery creates complicated tridimensional vascular anatomy. Additionally, there is a great chance of possible variations, making the inferior peripancreatic vascular anatomy consistently inconsistent. IMV, inferior mesenteric vein; IPDA, inferior pancreaticoduodenal artery; JB1, first jejunal branch; IPDV, inferior pancreaticoduodenal vein; JV1, first jejunal vein; SMV, superior mesenteric vein, SMA, superior mesenteric artery.

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  Fig. 2 The Cattell–Braasch–Valdoni maneuver. Derotation in a 270-degree clockwise direction of the primary umbilical loop. It restores the embryologically twisted duodenojejunal junction by transposing the duodenum and uppermost jejunum to the right of the SMV-SMA axis in a two-dimensional horizontal plane. CA, celiac artery; SMA, superior mesenteric artery; IVC, inferior vena cava SMV, superior mesenteric vein.

• 

  Fig. 3 Restoration of the torsional arrangement between the pancreaticoduodenal complex and uppermost jejunum around the SMA axis following the Cattell–Braasch–Valdoni maneuver. The IPDA and first jejunal artery origins are shifted to the right aspect of the SMA. The inferior pancreatic veins flow into the right aspect of the SMV or the first jejunopancreatic vein (FJPV), coursing from right to left in a two-dimensional horizontal plane. IMV, inferior mesenteric vein; IPDV, inferior pancreaticoduodenal vein; IPDA, inferior pancreaticoduodenal artery; JV, jejunal vein; SMV, superior mesenteric vein; SMA, superior mesenteric artery.

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