Background : The unfavorable anatomical variations, especially in hepatic arterial system, are occasionally the serious obstacles in patients that should receive pancreaticoduodenectomy (PD). Laparoscopic PD, which has advantages of minimal invasive surgery and shorter hospital stay, is widely and increasingly performed. However, laparoscopic PD can be limited in anatomical variations because of operative complexity and patient’s morbidities. We hope to present laparoscopic pylorus preserving pancreaticoduodenectomy (PPPD) in patient with unfavorable hepatic artery variation.

Methods : A 60-year-old female with diabetes mellitus transferred to resect surgically a pancreas neck and head mass. A pancreas lesion was identified on CT and MRI imaging, and the remaining pancreatic duct in pancreas body and tail was also dilated. Her diabetes was not controllable and serum amylase/lipase was also high despite of medications.

Results : Laparoscopic PPPD was tried, and meticulous dissection was performed under magnified laparoscopic view. Gastroduodenal artery and the branches of hepatic artery from the firm pancreatic inflammatory tissues were fully isolated after sharp and careful dissection with laparoscopic skills. Laparoscopic PPPD was completed without special events.

Conclusions : Laparoscopic PPPD has been accepted as a feasible and safe procedure in periampullar malignant diseases. But, the anatomical variation can be a significant operative risk factor in laparoscopic PPPD. Well-developed laparoscopic system, various energy devices, and skilled laparoscopic techniques allows meticulous dissection in complex laparoscopic PPPD. Conclusively, we performed the successful laparoscopic PPPD with careful pre-operative and surgical preparations without any complications.