Objective: Pathologies in the third and fourth part of the duodenum are rare, it represent a significant challenge for diagnosis and treatment. Management of such conditions requires extensive knowledge of the anatomy and careful pre-operative assessment of the relation with to the root of the mesentery to avoid more morbid extensive operations.

Methods: In this video we describe our experience with the laparoscopic inframesocolic approach for three challenging pathologies in D3/D4 parts of the duodenum. This includes laparoscopic inframesocolic side to side duodenojejunostomy for Superior Mesenteric Artery Syndrome in a 23 yo female patient, Laparoscopic resection of GIST tumor at the D3/D4 junction with side to side Right inframesocolic duodeno-jejunal anastomosis for reconstruction in a 57 you female patient, and laparoscopic resection of bleeding Neurofibromas at the fourth part of the duodenum in a 54 yo female patient with side to side Left inframesocolic duodeno-jejunal anastomosis for reconstruction. Results: Patients had uneventful recovery with discharge on day one after surgery, operative time was 60, 110, and 120 minutes respectively.

Conclusions: laparoscopic inframesocolic approach provide an excellent way to manage pathologies in the D3/D4 region, careful pre-operative evaluation to assess the relation to the room of the mesentery and extensive intra-operative mobilization of the duodenum is essential for successful outcomes.