Pancreaticoduodenal + right nephrectomy by retrograde approach in right lower abdomen (with pictures) Wang Gangcheng, Department of General Surgery, Henan Cancer Hospital Wang Gangcheng, Department of General Surgery, Henan Cancer Hospital I. Case data: male, 63 years old, huge tumor in the right upper abdomen, abdominal enhanced CT suggested that the tumor invaded the head of pancreas, duodenum and right kidney. There was no metastasis in distant organs. II. Surgical approach: pancreaticoduodenum + right nephrectomy III. Surgical procedure was smooth, bleeding was about 600 ml. operative time was 5 hours. IV. Surgical experience: difficulties: exploration is the most difficult point. 1. The tumor was large in size, located in the right upper abdomen, and closely related to the portal vein, superior mesenteric artery, and inferior vena cava. In particular, the inferior vena cava could not be demonstrated on several abdominal CT levels, and whether the tumor invaded the wall of the inferior vena cava could not be easily explored by the traditional method (Kocher’s incision) because the tumor invaded the right kidney at the same time. 2. The tumor invades the right kidney at the same time, and the right renal artery and vein cannot be explored. The pancreaticoduodenum is integrated with the right kidney below, and it is difficult to perform pancreaticoduodenectomy or right nephrectomy by the traditional method alone. 3. Because it is impossible to perform pancreaticoduodenectomy or right nephrectomy alone, there is an uncontrollable risk of intraoperative hemorrhage. In particular, left-handed control of portal and superior mesenteric vein bleeding is not possible when dealing with the pancreatic leptomeninges. The right kidney must be resected after pancreaticoduodenectomy and resection, and the tumor as a whole must be separated outward before there is a possibility of complete visualization of the inferior vena cava and visualization of the arterial veins of the right kidney. Determination of resectability: 1. Because the inferior vena cava could not be explored normally, the right lower abdominal approach could be performed, lifting the right hemicolon, along the course of the inferior vena cava, and separating the tumor from the wall of the inferior vena cava from the bottom upwards. 2. Below the hepaticoduodenal ligament along the wall of the inferior vena cava to the distal course, separating the adhesions from the top downwards, and using the left forefinger with the right index finger below to meet, it was found that the tumor and the anterior wall of the inferior vena cava could be separated. 3. Although the relationship between the tumor and the lateral wall of the inferior vena cava was not fully explored, the nature of the tumor was relatively soft and elastic, and it was judged that most of the tumor could be separated, and even if the local adhesions were tight, the possibility of resection was also possible. 4. The portal vein and the superior mesenteric vein could be separated even though they had a close relationship with the tumor. Resection process: change the traditional order of exploration and resection, retrograde approach exploration, retrograde pancreaticoduodenal resection (from the bottom up, from the surface to the inside). Intraoperatively, it was confirmed that the tumor invaded part of the lateral wall of the inferior vena cava, which was resected and repaired. Preoperative abdominal CT Figure 1 Preoperative abdominal CT Intraoperative resection result: pancreaticoduodenum combined with the right kidney and tumor was completely resected.