The ‘TRIANGLE Operation’ by Laparoscopy: Radical Pancreaticoduodenectomy with Major Vascular Resection for Borderline Resectable Pancreatic Head Cancer

  • Edoardo RossoEmail author
  • Giuseppe Zimmitti
  • Antonio Iannelli
  • Marco Garatti
Pancreatic Tumors



It has recently been shown that the ‘triangle operation’1 may be associated with margin-free resection in selected patients with borderline resectable pancreatic cancer after neoadjuvant chemotherapy. Such a procedure consists of en bloc removal, following the adventitial plane of the whole mesopancreas from the triangular space delimited by the superior mesenteric artery, hepatic artery, and portal vein.2, 3, 4, 5, 6, 7, 8, 9, 10, 11 In this video, we show how to safely perform this procedure by laparoscopy.


A 70-year-old male with persistent back pain and significant loss of weight underwent a computed tomography that showed a 3 cm mass of the uncinate process of the pancreas with involvement of the superior mesenteric artery and venous axis. The biopsy, performed at the time of endoscopic retrograde cholangiopancreatography, showed an adenocarcinoma of the pancreas. Cancer antigen (CA) 19-9 was in the normal range. The patient received eight cycles of neoadjuvant chemotherapy (FOLFIRINOX). The chemotherapy induced a major tumoral radiological response with tumoral shrinkage, however the preoperative computed tomography showed persistent infiltration of the mesopancreas behind the superior mesenteric artery and venous axis. A radical laparoscopic pancreaticoduodenectomy with portal vein resection was performed, including the complete clearing of the superior mesenteric artery and the right side of the celiac trunk, as in the ‘triangle operation’. Venous reconstruction was achieved with an end-to-end 5/0 polypropylene running suture with growth factor, while intestinal reconstruction was achieved with an end-to-side hepaticojejunal anastomosis, a double purse-string pancreaticogastrostomy, and side-to-side mechanical linear gastrojejunostomy. The specimen was removed via a short Pfannenstiel incision.


Operative time was 7 h and 15 min, and blood loss was 150. Frozen sections of the superior mesenteric artery margins were negative for tumoral cells. On postoperative day 5, the patient had a hematemesis with bleeding from the pancreaticogastrostomy, which was treated endoscopically. Hospital stay was 16 days. Histopathological examination showed a well-differentiated adenocarcinoma of the pancreas [ypT3 N1 (3/36) R0].


The ‘triangle operation’ for borderline resectable pancreatic head cancer can be achieved safely by laparoscopy in carefully selected patients.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 Proven experience in both open and laparoscopic pancreatic surgery is mandatory.





Edoardo Rosso, Giuseppe Zimmitti, Antonio Iannelli, and Marco Garatti have no disclosures to declare.

Supplementary material

10434_2019_8101_MOESM1_ESM.mp4 (249.3 mb)
Supplementary material 1 (MP4 255324 kb)


  1. 1.
    Hackert T, Strobel O, Michalski CW, et al. The TRIANGLE operation – radical surgery after neoadjuvant treatment for advanced pancreatic cancer: a single arm observational study. HPB (Oxford) 2017;19:1001–7. CrossRefGoogle Scholar
  2. 2.
    Morales E, Zimmitti G, Codignola C, et al. Follow “the superior mesenteric artery”: laparoscopic approach for total mesopancreas excision during pancreaticoduodenectomy. Surg Endosc 2019;33(12):4186–91.CrossRefGoogle Scholar
  3. 3.
    Klompmaker S, van Hilst J, Wellner UF, et al.; European consortium on Minimally Invasive Pancreatic Surgery (E-MIPS). Outcomes After Minimally-invasive Versus Open Pancreatoduodenectomy: A Pan-European Propensity Score Matched Study. Ann Surg. Epub 1 Jun 2018.
  4. 4.
    Zimmitti G, Manzoni A, Addeo P, et al. Laparoscopic pancreatoduodenectomy with superior mesenteric artery-first approach and pancreatogastrostomy assisted by mini-laparotomy. Surg Endosc 2016;30:1670–1.CrossRefGoogle Scholar
  5. 5.
    Addeo P, Rosso E, Fuchshuber P, et al. Resection of Borderline Resectable and Locally Advanced Pancreatic Adenocarcinomas after Neoadjuvant Chemotherapy. Oncology 2015;89:37–46.CrossRefGoogle Scholar
  6. 6.
    Makino I, Kitagawa H, Ohta T, et al. Nerve plexus invasion in pancreatic cancer: spread patterns on histopathologic and embryological analyses. Pancreas 2008;37:358–65.CrossRefGoogle Scholar
  7. 7.
    Butler JR, Ahmad SA, Katz MH, Cioffi JL, Zyromski NJ. A systematic review of the role of periadventitial dissection of the superior mesenteric artery in affecting margin status after pancreatoduodenectomy for pancreatic adenocarcinoma. HPB (Oxford) 2016;18:305–11.CrossRefGoogle Scholar
  8. 8.
    Noto M, Miwa K, Kitagawa H, et al. Pancreas head carcinoma: frequency of invasion to soft tissue adherent to the superior mesenteric artery. Am J Surg Pathol 2005;29:1056–61.PubMedGoogle Scholar
  9. 9.
    Hirono S, Kawai M, Okada KI, et al. MAPLE-PD trial (Mesenteric Approach vs. Conventional Approach for Pancreatic Cancer during Pancreaticoduodenectomy): study protocol for a multicenter randomized controlled trial of 354 patients with pancreatic ductal adenocarcinoma. Trials 2018 8;19:613.Google Scholar
  10. 10.
    Ironside N, Barreto SG, Loveday B, Shrikhande SV, Windsor JA, Pandanaboyana S. Meta-analysis of an artery-first approach versus standard pancreatoduodenectomy on perioperative outcomes and survival. Br J Surg 2018;105:628–36.CrossRefGoogle Scholar
  11. 11.
    Cai Y, Gao P, Li Y, Wang X, Peng B. Laparoscopic pancreaticoduodenectomy with major venous resection and reconstruction: anterior superior mesenteric artery first approach. Surg Endosc 2018;32:4209–15.CrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Edoardo Rosso
    • 1
    Email author
  • Giuseppe Zimmitti
    • 1
  • Antonio Iannelli
    • 2
    • 3
    • 4
  • Marco Garatti
    • 1
  1. 1.Department of SurgeryIstituto Fondazione PoliambulanzaBresciaItaly
  2. 2.Université Côte d’AzurNiceFrance
  3. 3.Digestive Surgery and Liver Transplantation UnitCentre Hospitalier Universitaire de NiceNice Cedex 3France
  4. 4.Inserm, U1065, Team 8 “Hepatic Complications of Obesity and Alcohol”NiceFrance

Personalised recommendations