title: Classification and techniques of en bloc venous reconstruction for pancreaticoduodenectomy.
abstract: Surgical resection is the only cure for hepato-pancreato-biliary (HPB) malignancy. In the era of multidisciplinary approaches and neoadjuvant therapies for locally advanced, borderline resectable tumors, the feasibility and efficacy of en bloc vascular resection has been validated across multiple studies. However, the variability of venous anatomy within the perihepatic and peri-portal regions necessitates familiarity with alternative resection and reconstruction techniques appropriate to the specific region of tumor invasion.
  
  
  
  To organize these paradigms, the venous system has been divided into five zones: 1) hepatic hilum; 2) hepatoduodenal ligament; 3) portal vein/splenic vein confluence, which is further subdivided into right (3a) and left (3b); 4) infra-confluence; and 5) splenic vein.
  
  
  
  This study systematically analyzes the anatomic considerations and clinical scenarios specific to each zone to organize the necessary preparative maneuvers, surgical procedures, and vascular reconstruction techniques to achieve an R0 resection. The anatomic and tumor-specific factors which deem a specimen unresectable are also explored. Surgical videos demonstrating these techniques are presented.
  
  
  
  Preparation and familiarity with venous reconstruction maneuvers is essential for an oncologically effective operation, and can be safely achieved by utilizing this logical anatomic and procedural framework.
authors: Department of Surgery, University of Missouri, Kansas City, Kansas City, MO, USA.
authors: Farzad
authors: F
authors: Alemi
authors: Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA.
authors: Flavio G
authors: FG
authors: Rocha
authors: Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA.
authors: William S
authors: WS
authors: Helton
authors: Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA.
authors: Thomas
authors: T
authors: Biehl
authors: Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA. Electronic address: Adnan.alseidi@virginiamason.org.
authors: Adnan
authors: A
authors: Alseidi
mesh_terms: D000072226:Computed Tomography Angiography; D004067:Digestive System Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D006503:Hepatic Veins / Q000002:abnormalities / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008022:Ligaments / Q000002:abnormalities / Q000000981:diagnostic imaging / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000379:methods*; D010690:Phlebography / Q000379:methods; D011169:Portal Vein / Q000002:abnormalities / Q000000981:diagnostic imaging / Q000601:surgery*; D011237:Predictive Value of Tests; D012307:Risk Factors; D013162:Splenic Vein / Q000002:abnormalities / Q000000981:diagnostic imaging / Q000601:surgery*; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000379:methods*