accordingly , the number of reports of laparoscopic pancreaticoduodenectomy ( lap pd ) has gradually increased . although the feasibility and safety of lap pd have been established in institutes particularly experienced in the skilled performance of this technique ( hereafter referred to as  experienced institutes  ) , the benefit of lap pd beyond conventional surgery has not yet been shown . the management of concomitant abdominal aortic aneurysm ( aaa ) and intra - abdominal malignancy is controversial . three issues must be considered in the development of a treatment technique in such cases . the first is mutual interference because of operative fields that are in close vicinity to one another , resulting in adhesions or collateral injuries . the last is postoperative complications , especially intra - abdominal abscessation with graft infection . in particular , the pancreas is the organ that is most resistant to resolution of these issues because of its anatomical proximity to the aorta and severity of pancreatic fistulae as a postoperative complication . the feasibility and safety of endovascular repair ( evar ) for aaa have been established . in addition , laparoscopic colectomy and evar for aaa were successfully performed in a patient . similarly , lap pd and evar for aaa could have some benefits for patients . however , to the best of our knowledge , concomitant treatment by lap pd and evar has never been reported . a 70-year - old japanese man was referred from vascular surgery for investigation of a pancreatic tumor , which was identified as a cystic tumor of the pancreas head by computed tomography ( ct ) . within 1.5 years he had a previous history of percutaneous coronary intervention for acute myocardial infarction when he was 66 years old and aortic stent grafting for an aaa when he was 68 years old . the aaa was located on the infrarenal aorta with a thrombus of 52  mm ( fig . the height , weight , and body mass index of the patient were 163  cm , 67.3  kg , and 25.3 , respectively . a ct scan showed a cystic tumor of 31-mm diameter in the pancreas head without dilatation of the main pancreatic duct ( fig . 2 ) , but contrast - enhanced endoscopic sonography revealed a nodule among the cyst mucus ( fig . thus , we diagnosed the enlarging tumor as a branched - type ipmn with a nodule and planned to perform a resection . to avoid disturbing the aaa or stimulating a residual aaa , we intended to perform lap pd . open laparoscopy was performed at the umbilicus , and an additional five ports were placed ( fig . the patient had severe visceral steatosis , and the abdominal cavity was filled with omental fat . for mobilization around the ligament of treitz and the fourth portion of the duodenum , an additional port was placed at the middle of the inferior abdomen ( fig . 3 ) . during this procedure , neither duodenal adhesion to the aorta nor other inflammatory changes due to the previously placed stent graft were observed . after mobilization , an upper - middle incision of 15  cm was made , and the pancreas head was excised and removed . a pancreato - jejunal anastomosis was created by hand - suturing between the pancreatic duct and the jejunal mucosa . although the patient required medical therapy for pancreatic fistulae ( grade b according to the international study group on pancreatic fistula [ isgpf ] ) , his postoperative recovery was uneventful . the pathological diagnosis was intraductal papillary mucinous adenoma with small foci of carcinoma in situ ( fig . lap pd after evar for aaa was safely performed with both rigorous preoperative planning and a meticulous operation . although lap pd is one of the most complicated procedures in laparoscopic surgery , its safety and feasibility have been reported in experienced institutions . pancreatic cancer , as a representation of pancreas head tumors , has a poor prognosis . thus , the indications for lap pd in patients with pancreatic cancer are very limited . this case involved an ipmn , and the patient was thus a good candidate for lap pd . there are few operative indications for this type of neoplasia , and reported cases have shown a poor prognosis . when pancreatic cancer and aaa are simultaneously present , pancreatectomy is first recommended , including determination of the stage of the cancer . second , mutual interference between the two conditions is undeniable because of the proximity of the pancreas to the aorta . deiparine advocated division of the retroperitoneal dissection procedure : right - sided dissection for pd and left - sided dissection for abdominal aortic bypass . the last is the severity of the postoperative complications after pancreatectomy . in the present case , laparoscopic dissection of the pancreas head was safely performed without interference of the residual aaa because the axis of the laparoscopic procedure was located apart from the aaa ( fig . moreover , laparoscopic procedures require smaller operative fields using magnified visualization . these are benefits of the laparoscopic approach for patients with aaa . after the resection , an upper abdominal incision was made and reconstruction of the pancreas stump was performed through the incision . this reconstruction involved wirsung anastomosis , which represents the usual manner of standard pd in our institute . total lap pd has been reported in experienced institutes ; however , other reconstruction methods and no reconstruction have also been reported . thus , we performed reconstruction by hand as usual because laparoscopic reconstruction had not replaced hand sewing at that time in our institute . the additional upper incision is adequately located apart from the aaa ; therefore , the reconstruction procedure is safely performed without interference by the aaa . the isgpf grade b pancreatic fistulae healed with medical therapy and without graft infection . the pancreatic tumor was detected during follow - up of the aaa after evar . increased performance of evar for written informed consent was obtained from the patient for publication of this case report and accompanying images . a copy of the written consent is available for review by the editor - in - chief of this journal on request . norihiko ishikawa , mari shimada , and hideki moriyama performed the lap pd with the corresponding author .
introductionmost gastroenterological surgeries , even pancreatic surgery , can now be performed laparoscopically . however , the management of concomitant abdominal aortic aneurysm ( aaa ) and intra - abdominal malignancy is controversial . 
 the performance of endovascular repair ( evar ) for aaa has been increasing ; however , there is no report of laparoscopic pancreaticoduodenectomy after evar.presentation of casea pancreatic tumor was detected during follow - up after evar for aaa . 
 the enlarging tumor was diagnosed as an intraductal papillary mucinous tumor with a nodule . 
 laparoscopic pancreaticoduodenectomy was safely performed . 
 after laparoscopic dissection around the pancreas head , an additional incision was made in the upper abdomen , and pancreatic reconstruction was performed through the incision . in spite of grade 
 b pancreatic fistulae , the patient recovered with medical therapy . 
 the pathological diagnosis was intraductal papillary mucinous adenoma with small foci of carcinoma in situ . 
 the patient has been well with neither recurrence of the tumor nor any cardiovascular events for 18 months.discussionthe management of concomitant malignancy and aaa is challenging , especially in patients with a pancreatic tumor . 
 the reasons for the rarity of treatment include prognosis , anatomical vicinity , and postoperative complications . 
 evar reduces retroperitoneal adhesions . 
 a laparoscopic approach provides a small operative field and decreases mutual interference with aaa . 
 moreover , reconstruction is performed through an upper abdominal incision apart from the aaa . 
 hand - sewing provides more reliable stability of the anastomosis.conclusionthe increasing frequency of performance of evar for aaa and subsequent computed tomography may help to detect malignancy . 
 laparoscopic surgery appears to be a valid approach to malignancy after evar .