Total non-division technique of pancreaticoduodenectomy: A strategic integration of superior mesenteric artery-first approach and total mesopancreas excision

Pancreaticoduodenectomy remains the only curative intervention for periampullary and pancreatic head cancers, with R0 resection being essential for long-term survival. Nonetheless, the predictive value of preoperative imaging, particularly following neoadjuvant therapy, often remains inadequate. Committing to irreversible surgical steps too early can lead to futile procedures associated with significant morbidity. Here, we introduce the innovative "Total Non-Division Technique," which strategically combines the superior mesenteric artery (SMA)-first approach and total mesopancreas excision (TMpE) to ensure resectability prior to performing any irreversible maneuvers. The procedure initiates with the Cattell Braasch Valdoni manoeuvre, Kocherisation and division of the ligament of Treitz which facilitates a 270-degree duodenal-jejunal derotation, clarifying the SMA and SMV anatomical relationship. Employing a combined posterior and right medial SMA-first approach allows for early vascular control while safeguarding aberrant hepatic arteries. TMpE (type 2 or 3) is achieved en bloc, providing radical clearance within pl-Ph-II between the SMA and celiac axis. Irreversible surgical actions are intentionally deferred until R0 resectability is established, supporting intraoperative decision-making and allowing for procedure abandonment should oncological criteria not be fulfilled. This surgical method enhances rates of R0 resection and reduces morbidity linked to non-curative operations. By avoiding early bile duct transection, contamination risk is minimized, and delayed pancreatic division optimizes margin status and haemostasis. This innovative approach is safe and follows established principles of oncologic surgery, while introducing an intraoperative "path of escape," analogous to Sun Tzu's doctrine of strategic flexibility, ensuring that irreversible commitments are undertaken only upon clear oncological justification.