The duodenal window approach to pancreatoduodenectomy.

The pancreatoduodenectomy (PD) technique is yet to be standardized. One of the most difficult passages in PD is the mobilization of the second, third, and fourth parts of the duodenum. This maneuver is classically performed from the supramesocolic space after the division of the gastrocolic ligament, but traction on the transverse mesocolon and the superior mesenteric pedicle can cause bleeding from the venous and arterial branches of the pancreatic head and uncinate process. We hereby describe a technique to access and mobilize the distal duodenum and proximal jejunum (D2 to J1) through the duodenal window and the Treitz's foramen, performing an almost complete Kocher's maneuver before opening the gastrocolic ligament and mobilizing the hepatic flexure. The anatomical basis and the surgical technique of the duodenal-window-first PD are discussed. The duodenal-window-first approach is a standardizable step of PD that allows an easy and safe mobilization of D2 to J1. This technique has been applied to 15 cases of PD, both open and robotic, with no specific morbidity. Therefore, we propose the adoption of the duodenal-window-first technique as a routine standardized step of PD.