A 58-year-old male patient, without any history of trauma or important previous symptoms, was admitted to the emergency department of Medical Park Gaziantep Hospital on September 2009 with the complaint of sudden onset of severe abdominal pain. Physical examination revealed signs of an acute abdomen. Laboratory tests showed leukocytosis, but the renal and liver function tests, and serum amylase and lipase levels were normal. Chest and abdominal X-ray revealed no free air in the abdomen. An ultrasound examination revealed large amounts of free fluid in the abdomen, and gallbladder hydrops was identified. However, a finding of a gallbladder and common bile duct stone was not reported. Because of these findings, the patient underwent diagnostic laparoscopy with the prediagnosis of hollow organ perforation. However, exploration revealed bile peritonitis, and approximately 1 l of bile was aspirated. The gallbladder, pylorus, duodenum and common bile duct, the possible regions of bile leakage, were investigated, but there was no perforation. Continuous accumulation of bile in the left subphrenic region focused the exploration on this region. Interestingly, bile leakage was detected at the left-end part of the triangular ligament. It was understood that the bile peritonitis was associated with spontaneous perforation of an aberrant bile duct in the appendix fibrosa hepatis. Leakage was controlled with a few intracorporeal sutures (Additional file: Video 1). The postoperative period was uneventful. However, close examination of the patient during follow-up revealed obstructive jaundice. MRCP detected a 1-cm tumor mass in the region of the ampulla of Vater and common bile duct dilatation. However, there were no biliary tract stones (Additional file: Video 2). These findings revealed aberrant bile duct perforation developed secondarily to ampullary tumor mass effect. ERCP was performed, and a plastic stent was inserted for drainage. The biopsy, taken during the procedure, was reported as adenocarcinoma. Curative surgery was planned within 1 month after the improvement of the peritoneal findings. Operability and tumor stage were assessed according to the preoperative radiological imaging tests, which demonstrated a tumor limited to the ampulla of Vater with no any evidence of regional lymph node enlargement or distant metastasis. According to the currently accepted American Joint Committee on Cancer staging system for ampullary carcinoma, the preoperative tumor stage was T1N0M0 and stage I. Among different options for curative surgery, TLPD was preferred. The reasons and criteria for choosing laparoscopic instead of conventional open surgery were as follows: (1) the early stage of the tumor, (2) the absence of a systemic disease that contraindicated long-term general anesthesia, (3) the absence of a pathology that absolutely required avoiding laparoscopic surgery, (4) the patient had a very suitable body mass index of 24 kg/m2 for laparoscopic surgery, (5) the presence of a surgeon who had sufficient experience in laparoscopy, having carried out more than 100 intracorporeal gastrointestinal and biliary anastomoses (both in humans and swine) and more than 500 advanced laparoscopic surgeries including distal pancreatic resections, enucleations and extrahepatic biliary tract surgeries, and (6) the preference of the patient. This patient was the first in whom a TLPD was attempted. Therefore, the possible advantages and complications of this new surgical procedure and, at any stage, the possibility of conversion to traditional open surgery were described in detail to the patient. Thereafter, the patient gave his written informed consent, choosing this method instead of conventional surgery. The local ethics review board approved the procedure. In the second surgery, the patient underwent complete laparoscopic pyloric protective pancreaticoduodenectomy. A total of five trocars were used. According to the nature of the tissue, the combination of an ultrasonic dissector, vessel sealing device, and monopolar hook coagulator was used in all dissections. The duodenum and jejunum were transected with an endo-GIA stapler. The neck of the pancreas was divided using an ultrasonic dissector. All anastomoses were performed intracorporeally, and in all of them single-filament absorbable 4/0 polydioxanone sutures were used. Because of the technical ease, pancreaticogastrostomy was preferred for pancreatic reconstruction. Then, a single-layer hepaticojejunostomy and finally a double-layer duodenojejunostomy anastomosis was performed on the same jejunal loop. The specimen was removed through the 6-cm suprapubic incision in accordance with oncological principles (Additional file: Video 3, Additional file: Video 4, Additional file: Video 5 and Additional file: Video 6). There were no complications and no need for blood transfusions. Operative time was 510 min. Pathological evaluation revealed an exposed protruding-type and well-differentiated adenocarcinoma macroscopically and microscopically, respectively, with negative surgical margins, with 14 lymph nodes retrieved and no tumor invasion. The patient was started on oral nutrition on day 5 and discharged on postoperative day 7. On follow-up examination after 6, 12, and 24 months, there was no evidence of recurrence or metastasis of the tumor on abdominal and thoracic CT, and the blood test showed only mild hyperglycemia.