Posterior enucleation of the pancreatic head: an alternative route of access for parenchyma-sparing pancreatic resection

  • Michael S. Pärli
  • Philip C. Müller
  • Sascha A. Müller
  • Claudio M. Ruzza
  • Kaspar Z’graggenEmail author
How-I-Do-It articles



Enucleation has become an alternative treatment in benign or low-malignant cystic tumors, including intraductal papillary mucinous neoplasms (IPMN). For enucleation to be a safe alternative to the standard procedures, there must be good access to the resection area. In this report, we present such a route for dorsally situated IPMNs.


The head of the pancreas was exposed by an extended Kocher maneuver to the left lateral edge of the aorta. Stay sutures were placed along the second part of the duodenum to allow maximal rotation of the pancreatic head to the left, which exposed the posterior aspect of the pancreatic head. The cystic lesion was then enucleated followed by a protective pancreaticojejunostomy on the resection cavity.


Two consecutive patients with IPMNs of the dorsal pancreatic head successfully underwent dorsal enucleation. The postoperative course was uneventful in the first patient, while the course of the second patient was complicated by a clinically relevant pancreatic fistula, delayed gastric emptying, and hospital discharge on day 35.


This study shows the feasibility of a dorsal approach to the pancreatic head for enucleation as well as reconstruction by means of posterior Roux-en-Y pancreaticojejunostomy. In very selected cases in specialized centers, cystic lesions in the posterior aspect of the pancreatic head will become amenable to enucleation with preservation of pancreatic functionality. However, more research is needed to clarify postoperative outcomes of this approach.


Pancreatic resection Enucleation Cystic pancreatic lesion IPMN Surgical technique 


Authors’ contributions

Study conception and design: Müller SA, Müller PC, and Z’graggen K. Acquisition of data: Z’graggen K, Müller SA, and Pärli MS, Razza C. Analysis and interpretation of data: Pärli MS, Müller PC, and Ruzza C. Drafting of manuscript: Pärli MS, Müller SA, and Müller PC. Critical revision: Ruzza C and Z’graggen K.

Funding information

The study was funded by institutional means.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

423_2019_1835_MOESM1_ESM.mp4 (316.7 mb)
Video 1 (MP4 324056 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of SurgeryKlinik Beau-SiteBernSwitzerland
  2. 2.Department of Visceral and Transplant SurgeryUniversity Hospital ZurichZurichSwitzerland

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