Laparoscopic Assisted Duodenopancreatectomy for Vaterian Ampulloma in an Obese Patient

We present a case of laparoscopic assisted duodenopancreatectomy for vaterian ampulloma in an obese patient. A 58 year old obese (BMI=36.5) male patient presented for sclerotegumentary jaundice associated with moderate upper abdominal pain and nausea. Biochemical test results showed an important syndrome of cholestasis: total bilirubin was 10.2 mg/dl while direct bilirubin was 5.8 mg/dl, alkaline phosphatase = 202 U/L, GamaGT = 125 U/L. A computed tomography was realized and revealed a 3 cm vaterian ampulloma also confirmed by MRI and ERCP. Three 5 mm trocars, were inserted - two on the right flank and one in the upper left quadrant. (B) One 12 mm scope trocar was inserted towards the left of the umbilicus. (C) Another 12 mm trocar, was inserted toward the left flank on midclaviculary line. A laparoscopic assisted duodenopancreatectomy associated with wide lymph node dissection was performed, including hepatic arteries, superior mesenteric artery, retroportal and interaortocaval lymph dissection. Following removal of the laparoscopically resected specimen through a minilaparotomy in epigastrum, the reconstruction phase of the operation was initiated through this incision. A pancreaticogastrostomy (through a gastrotomy performed on the anterior wall of the stomach) was performed. Next, a precolic end-to-side hepaticojejunostomy was created with the first loop of the jejunum. The last anastomosis was a side-to-side two layer gastrojejunostomy, 30 cm distal to the hepaticojejunal anastomosis. The patient had a favourable postoperative evolution, resuming a normal food transit, normalisation of bilirubin blood levels, he was discharged in the 10-th postoperative day. The total blood loss was 300 ml. Although is still controversial, laparoscopy may represent a feaseable solution for Whipple procedures.