We thank the anaesthesiologists and operating room nurses who assisted with the operation.

This protocol follows the guidelines of the human research ethics committee of the Sixth Affiliated Hospital, Sun Yat-sen University. Written informed consent was obtained from the patients for performing this study.
NOTE: A 48-year-old female patient presented with an incidental finding of a 3.0 cm x 2.5 cm asymptomatic mass in the head of the pancreas. The patient&#39;s clinical history showed a healthy status. Endoscopic ultrasound (EUS) showed a cystic lesion of the pancreatic head.
1. Preoperative workup
<ol>
	<li>Determine the surgical approach based on the computed tomography (CT) scan to determine the extent of the tumor and any abnormal vasculature, see Figure 1.</li>
	<li>Check for contraindications carefully. 
	NOTE: There are relative contraindications to LDPPHR, including tumors in the portal vein or superior mesenteric vein that need vascular reconstruction, as well as previous major abdominal surgery with possible complications. It depends on preoperative imaging diagnosis and intraoperative diagnosis of vascular invasion. The preoperative enhanced CT and MR imaging are valuable.</li>
</ol>
2. Anesthesia
<ol>
	<li>Apply the antibiotic (2 g of Ceftriaxone sodium) 30 min before the surgery to prevent infection. Puncture and catheterize the radial artery (catheter size, 20 G) and a central venous (catheter size, 8 Fr) under ultrasound guidance. 
	NOTE: The amount of anesthesia administered differs greatly among patients, primarily dependent on individual characteristics such as age and other medical factors.</li>
</ol>
3. Surgical technique
<ol>
	<li>Operation setting
	<ol>
		<li>Position the patient in a reverse Trendelenburg position with the head elevated 30&#176; and legs split apart, see Figure 2.</li>
		<li>Set the standing position as depicted in Figure 2. Use a 5-port technique to perform the procedure. 
		NOTE: The first surgeon is on the right side, the second surgeon is on the left side, and the first assistant stands between the patient&#39;s legs, respectively.</li>
		<li>Place the sub-umbilical 10 mm trocar and then four trocars along a semi-circular plane after creating the pneumoperitoneum. Place two 10 mm trocars to the left and right of the umbilicus and two 10 mm trocars four fingers subcostal to the left and right in the anterior axillary line, see Figure 2.</li>
	</ol>
	</li>
	<li>Exploration phase
	<ol>
		<li>Exclude peritoneal and liver metastases using diagnostic laparoscopy as a routine step. Explore the anterior abdominal wall, the surface of abdominal viscera, pelvic cavity, and the surface of abdominal viscera, the mesentery and the small intestine and stomach and adjacent structures, and the omental bursa in order.
		<ol>
			<li>Ensure that the exploration follows a specific sequence, usually from top to bottom, first examining solid organs before hollow ones, starting with the abdominal cavity followed by the pelvic cavity.</li>
			<li>Conduct a comprehensive examination of all abdominal organs, such as the liver, spleen, stomach, intestines, mesentery, peritoneum, uterus, and adnexa. Simultaneously, perform a focused examination on suspicious areas of pathology.</li>
			<li>Utilize non-traumatic graspers to gradually inspect the intestinal tract, progressing in approximately 5 cm segments per examination from the duodenal suspensory ligament to the ileocecal region and repeating the process in the opposite direction. Ensure that the examination encompasses both the intestinal tract and mesentery.</li>
		</ol>
		</li>
		<li>Retract the ligament to the ventral abdominal wall by placing a straight needle transcutaneously in the epigastric region around the Teres ligament.</li>
	</ol>
	</li>
	<li>Dissection phase
	<ol>
		<li>Suspend the transverse colon enteric fat over the liver falciform ligament to expose the infracolic compartment (see Figure 3A).</li>
		<li>Make an incision in front of the duodenum&#39;s transverse mesocolon to expose the pancreatic head using an ultrasonic scalpel (see Figure 3B).</li>
		<li>Expose the infracolic compartment between the transverse colon and the pancreatic head, fully free the superior mesenteric vein (SMV) from the uncinate process of the pancreas, and transect its tributary using clips (see Figure 3C).</li>
		<li>Dissect the inferior margin of the uncinate process of the pancreas using an ultrasonic scalpel, and pull up the margin of the uncinate process of the pancreas to expose the sub pancreaticoduodenal vessels branch into the uncinate process of the pancreas and transect them using clips (see Figure 3D).</li>
		<li>Restore the transverse colon position and section the gastrocolic ligament to expose the pancreas behind the stomach. Position the patient&#39;s head low and right upside. Suspend the stomach body over the liver falciform ligament to set free it from the pancreas using a red urine catheter and a clip (see Figure 3E).</li>
		<li>Expose the common hepatic artery (CHA) and gastroduodenal artery (GDA) (see Figure 3F). Removed the pancreas from the medial side of the duodenal ring and anterior superior pancreaticoduodenal artery (ASPDA), and ligate and detach the branches of ASPDA into the uncinate process of the pancreas using a clip.</li>
		<li>Cut off the peritoneum at the lower margin of the pancreatic head, ligate, and detach the right gastroepiploic vein. Flip the uncinate process of the pancreas to the head side to expose the SMV to transect the pancreatic neck with Harmonic scissors in front of the SMV. 
		NOTE: The cystic tumor was found behind the uncinate process of the pancreas (see Figure 3G).</li>
		<li>Detach the pancreatic head from the right and dorsal edges of the SMV. Then, detach the upper part to expose the distal CBD.</li>
		<li>Perform dissection along the left and dorsal margins of the common bile duct (CBD) to expose and safeguard the posterior superior pancreatic duodenal artery (PSPDA) (see Figure 3H). This artery originates from the GDA and extends its branches into the distal CBD and the ampulla of Vater. Severe the anterior superior pancreatic duodenal artery (ASPDA) to facilitate deeper dissection.</li>
		<li>Dissect, ligate, and cut off the main pancreatic duct to the ampulla finally using an ultrasonic scalpel (see Figure 3I).</li>
	</ol>
	</li>
	<li>Reconstruction phase
	<ol>
		<li>Transect the jejunum at a distance of 20 cm from the distal Treinz ligament for pancreatojejunal anastomosis and jejunal anastomosis.</li>
		<li>Insert an external ventricular drainage catheter after identifying the main pancreatic duct. Perform an end-to-side pancreaticojejunostomy (duct-to-mucosa) (see Figure 3J) and side-to-side jejunojejunostomy.</li>
		<li>Place the specimen inside a bag and remove it through a 5 cm incision on the lower abdomen. Place two drainage catheters near the pancreaticojejunostomy and the CBD and bring them out through two trocar port sites. 
		NOTE: The texture at the pancreatic stump is quite tough, so we perform an end-to-side pancreaticojejunostomy to reduce the risk of pancreatic fistula. The diameter of drainage catheters with side holes is 1.5 cm.</li>
	</ol>
	</li>
</ol>

<ol><li>Mihaljevic, A. L., Kleeff, J., Friess, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Beger%27s+operation+and+the+Berne+modification%3A+Origin+and+current+results%5BTitle%5D)+AND+%22J+Hepatobiliary+Pancreat+Sci%22%5BJournal%5D)">Beger's operation and the Berne modification: Origin and current results.</a> J Hepatobiliary Pancreat Sci. 17 (6), 735-744 (2010).</li>
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<li>Huang, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Real-time+fluorescence+imaging+with+indocyanine+green+during+laparoscopic+duodenum-preserving+pancreatic+head+resection%5BTitle%5D)+AND+%22Pancreatology%22%5BJournal%5D)">Real-time fluorescence imaging with indocyanine green during laparoscopic duodenum-preserving pancreatic head resection.</a> Pancreatology. , (2023).</li>
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<li>Zhou, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+duodenum-preserving+pancreatic+head+resection%3A+A+case+report%5BTitle%5D)+AND+%22Medicine+%28Baltimore%29%22%5BJournal%5D)">Laparoscopic duodenum-preserving pancreatic head resection: A case report.</a> Medicine (Baltimore). 95 (32), 4442(2016).</li>
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<li>Chen, X., Chen, W., Zhang, Y., An, Y., Zhang, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Short-term+outcomes+of+laparoscopic+duodenum-preserving+total+pancreatic+head+resection+compared+with+laparoscopic+pancreaticoduodenectomy+for+the+management+of+pancreatic-head+benign+or+low-grade+malignant+lesions%5BTitle%5D)+AND+%22Med+Sci+Monit%22%5BJournal%5D)">Short-term outcomes of laparoscopic duodenum-preserving total pancreatic head resection compared with laparoscopic pancreaticoduodenectomy for the management of pancreatic-head benign or low-grade malignant lesions.</a> Med Sci Monit. 26, e927248(2020).</li>
<li>Takada, T., Yasuda, H., Amano, H., Yoshida, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+duodenum-preserving+and+bile+duct-preserving+total+pancreatic+head+resection+with+associated+pancreatic+duct-to-duct+anastomosis%5BTitle%5D)+AND+%22J+Gastrointest+Surg%22%5BJournal%5D)">A duodenum-preserving and bile duct-preserving total pancreatic head resection with associated pancreatic duct-to-duct anastomosis.</a> J Gastrointest Surg. 8 (2), 220-224 (2004).</li>
<li>Li, X. L., Gong, L. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Preoperative+3d+reconstruction+and+fluorescent+indocyanine+green+for+laparoscopic+duodenum+preserving+pancreatic+head+resection%3A+A+case+report%5BTitle%5D)+AND+%22World+J+Clin+Cases%22%5BJournal%5D)">Preoperative 3d reconstruction and fluorescent indocyanine green for laparoscopic duodenum preserving pancreatic head resection: A case report.</a> World J Clin Cases. 11 (4), 903-908 (2023).</li>
<li>Vlek, S. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Biliary+tract+visualization+using+near-infrared+imaging+with+indocyanine+green+during+laparoscopic+cholecystectomy%3A+Results+of+a+systematic+review%5BTitle%5D)+AND+%22Surg+Endosc%22%5BJournal%5D)">Biliary tract visualization using near-infrared imaging with indocyanine green during laparoscopic cholecystectomy: Results of a systematic review.</a> Surg Endosc. 31 (7), 2731-2742 (2017).</li>
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</ol>

The authors report no conflict of interest.

LDPPHR only removes the diseased pancreatic head while preserving the duodenum, stomach, jejunum, common bile duct, and gallbladder that need to be removed in Whipple surgery. Compared to pancreaticoduodenectomy (PD) and pylorus-preserving pancreaticoduodenectomy (PPPD), LDPPHR showed enhancements in mid- and long-term results encompassing hospital stay duration, quality of life, post-surgery recovery, and maintenance of exocrine function5,14. DPPHR only removes the diseased pancreatic head, which reduces the extent of pancreatic resection and protects the physiological and anatomical integrity. This may explain why DPPHR has a better preservation of the exocrine function compared to PD15. It is still a challenging surgery due to the need to maintain the integrity of the duodenum and biliary system and preserve the complex blood supply. Classically, some pancreatic tissues are left on the duodenum side and in the distal CBD in Beger&#39;s procedure to preserve the pancreatic duodenal arterial arcade. It can provide adequate blood supply to the duodenum, distal CBD, and ampulla of Vater16.
By taking advantage of the amplification of the enhanced 3D laparoscopy, the pancreatic duodenal arterial arcade to the duodenum, distal CBD, and ampulla of Vater will be better preserved due to the clearer 3D vision. In addition, under clearer 3D vision, it is feasible that pancreas tissue would be removed from the lateral wall of the CBD and the medial side of the duodenal ring.
Just the same with open abdominal surgery, the key surgical points of LDPPHR are to ensure the blood supply in the duodenum and bile duct. It is reported that an important factor in avoiding ischemia is the preservation of the posterosuperior pancreatoduodenal artery17. In this case, we preserved the retropancreatic fascia along the CBD to ensure the blood supply and avoid injury to the CBD. Reliable pancreaticojejunostomy is an important factor in decreasing the pancreatic fistula rate.
To enhance the procedure of LDPPHR, the utilization of intravenous indocyanine green fluorescent can be implemented. This approach enables real-time navigation with fluorescent display, facilitating the guidance of surgical dissection and mitigating the risk of injury to the biliary tract9,11,18,19,20. However, in cases of swelling of the pancreatic head, the fluorescence laparoscope remains less than satisfactory in protecting the lower segment of the common bile duct. By contrast, with a 3D laparoscopic imaging system, important structures can be preserved more easily, resulting in a faster continence recovery. There is no standardized approach for LDPPHR. LDPPHR is demanding with respect to surgical experience, proficiency in anatomy, and suturing skills. Also, it requires precise planning that relies on preoperative imaging. Due to the two limitations, it is not possible to perform this procedure at relatively low-level centers. Which approach will be chosen for LDPPHR likely depends on the local anatomy of the lesions of the pancreatic head. In our opinion, the inferior infracolic approach is more suitable for patients with a thin mesenteric fat layer since it is more convenient to dissect the inferior pancreaticoduodenal artery via the inferior infracolic approach.
The LDPPHR method is both safe and feasible for the treatment of benign lesions of the pancreatic head. However, further studies are needed in surgical methods, minimally invasive surgery, and preoperative patient selection to improve long-term outcomes.

In 1972, Prof. Berger first proposed the duodenum-preserving pancreatic head resection (DPPHR) and Roux-en-Y pancreatic-enteral reconstruction as a treatment for chronic pancreatitis1. DPPHR has become the primary surgical treatment for benign lesions of the pancreatic head due to its low incidence of postoperative complications and mortality, as well as its ability to maintain the endocrine and exocrine functions of the pancreas and high remission rate of abdominal pain2,3,4. DPPHR only removes the diseased pancreatic head while preserving the duodenum, stomach, jejunum, common bile duct, and gallbladder that need to be removed in Whipple surgery, resulting in minimal damage and high postoperative quality of life3,5.
Laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has made significant progress in the last decade and is gradually replacing duodenum-preserving pancreatic head resection (DPPHR)6,7. The key to this surgical procedure is to ensure the blood supply of the duodenum and bile duct in order to avoid damage to the duodenum and bile duct, as well as duodenal necrosis and stenosis or atresia of the bile duct caused by ischemia7,8.&#160;A few experienced medical centers have reported LDPPHR9,10,11. As maintaining the integrity of the duodenum and biliary system and preserving complex blood supplies are necessary, the surgical procedure is challenging. It is essential to be very familiar with the special anatomical relationship between the pancreatic head and the duodenum while implementing LDPPHR, which is a difficult surgery that requires stronger surgical skills and psychological qualities.
Previous studies have proved that preserving the integrity of both anterior and posterior pancreaticoduodenal arterial arcades, as well as only preserving the posterior collateral branches of the arteries, will not cause duodenal ischemic necrosis11,12. Some surgeons preserve a thin layer of pancreatic tissue adhering to the common bile duct to avoid ischemia of the bile duct and duodenum but increase the incidence of pancreatic fistula13. In this study, the inferior infracolic approach was chosen for LDPPHR due to the patient with a thin mesenteric fat layer. By taking advantage of the amplification of the 3D laparoscopy, we successfully removed the pancreas from the lateral wall of the common bile duct (CBD) and the medial side of the duodenal ring without intraoperative fluorescence image guidance. This approach ensured the integrity of the vascular arch and reduced intraoperative blood loss, thereby minimizing the risk of pancreatic fistula.

<table><tbody><tr><td>3D Laparoscope</td><td>STORZ</td><td>TC200,TC302</td><td></td></tr><tr><td>Cisatracurium Besylate Injection</td><td>Hengrui Pharma</td><td>H20183042</td><td></td></tr><tr><td>Drainage catheters</td><td>Jiangsu YUBANG MED-DEVICE</td><td>YB-B-III</td><td></td></tr><tr><td>Harmonic ACE Ultrasonic Surgical Devices</td><td>Ethicon Endo-Surgery</td><td>HAR36</td><td></td></tr><tr><td>Ligating Clips</td><td>Teleflex Medical</td><td></td><td></td></tr><tr><td>Nacrotrend anaesthesia monitoring system</td><td>Monitor Technik</td><td>Bad Bramsted</td><td></td></tr><tr><td>Trocar</td><td>Ethicon Endo-Surgery</td><td>10 mm</td><td></td></tr></tbody></table>

laparoscopic duodenum-preserving pancreatic head resection via inferior infracolic approach: a surgical approach for benign lesions

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct.
This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms.
LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.

The patient&#39;s total pancreatic head, including the cystic tumor, was removed in 3 h with 100 mL of blood loss. The pancreatojejunal (PJ) anastomosis and jejunal anastomosis were completed in 60 min after the pancreatic head was removed from the body. The entire recovery period after surgery went smoothly, with no signs of postoperative pancreatic fistula. The amylase levels in both drains on postoperative day 3 were 1373 U/L and 804 U/L, respectively, but decreased to normal levels by day 5 when the drains were removed. The patient was discharged on the 6th postoperative day.
Postoperative pathology revealed a 2.5 x 1.5 cm intraductal papillary mucinous neoplasm (IPMN) (see Figure 4A-D). Microscopically, the resection margins were radical (R0), and no lymph nodes had tumor cells. The patient&#39;s first postoperative imaging at approximately 1 month is shown in Figure 4E,F.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/66251/66251fig01.jpg" /> 
Figure 1: CT images. (A-D) showed low-density multiple intercommunicating cystic lesions within the uncinate process of the pancreas. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66251/66251fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/66251/66251fig02.jpg" /> 
Figure 2: Surgical position setting and trocar placement. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66251/66251fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/66251/66251fig03.jpg" /> 
Figure 3: Dissection phase of the surgery. (A) Suspend the transverse colon enteric fat over the liver falciform ligament to expose the infracolic compartment. (B) Dissect the anterior peritoneum of the duodenum horizontal part to expose the pancreatic head. (C) Transect SMV tributary using clips. (D) Transect the sub pancreaticoduodenal vessels branch into the uncinate process of the pancreas. (E) Suspend the stomach body over the liver falciform ligament to set free it from the pancreas using a red urine catheter and a clip. (F) Expose the common hepatic artery (CHA) and gastroduodenal artery (GDA). (G) The cystic tumor was circled with a blacked dashed line. (H) Expose and protect PSPDA. (I) The main pancreatic duct to the ampulla. (J) Set-up for the P-J anastomosis. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66251/66251fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/66251/66251fig04.jpg" /> 
Figure 4: Tumor sample. (A,B) Images of tumor sample, scale bars=1 cm.(C,D) The H&#38;E staining of tumor sample, scale bars=100 &#181;m. (E,F) Postoperative CT images. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66251/66251fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Duration of surgery</td>
			<td>180 min</td>
		</tr>
		<tr>
			<td>Blood loss</td>
			<td>100 mL</td>
		</tr>
		<tr>
			<td>Day of discharge</td>
			<td>6 days</td>
		</tr>
		<tr>
			<td>Rmovement of drainage tube</td>
			<td>5 days</td>
		</tr>
		<tr>
			<td>Tumor size</td>
			<td>2.5 cm &#215; 1.5 cm</td>
		</tr>
		<tr>
			<td>Pathological type</td>
			<td>intraductal papillary mucinous neoplasms (IPMN)</td>
		</tr>
		<tr>
			<td>Lymphnodes metastasis</td>
			<td>negative</td>
		</tr>
		<tr>
			<td>First post-operative CT</td>
			<td>1 month after operation</td>
		</tr>
	</tbody>
</table>
Table 1: Surgical outcomes and postoperative details of the patient.

Read this Scientific Article Protocol about Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions at JoVE.com

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

This article provides a whole technical process of laparoscopic duodenum-preserving pancreatic head resection via an inferior infracolic approach. This is a surgical approach for benign tumors without intraoperative fluorescence image guidance.

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic ...

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Nanyang Technological University

Research

JoVE Journal

Medicine

339 Views.  The Sixth Affiliated Hospital of Sun Yat-sen University. Voer om te beginnen een abdominaal laparoscopisch onderzoek uit en hang het enterische vet van de transversale dikke darm op over het falciforme ligament van de lever om het infrasone compartiment bloot te leggen. Maak met een ultrasoon scalpel een incisie aan de voorkant van de twaalfvingerige darm transversale mesocolon om de pancreaskop bloot te leggen. Leg vervolgens het infracolische compartiment tussen de transversale dikke darm en de pancreaskop bloot en bevrijd de superieure mesenteri...

Video: Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis.
The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index &#62;35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers.
The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy.
The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

Laparoscopic pancreatoduodenctomy (LPD) may offer advantages over open pancreatoduodenectomy, including early postoperative mobilization, less delayed gastric emptying and a shorter hospital stay. However, LPD is technically challenging and not well-standardized, especially regarding the pancreatic anastomosis. We describe a standardized technique for the pancreatic anastomosis during LPD: modified Blumgart pancreaticojejunostomy.

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal ...

Cancer Research

Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several studies have described the safety of RPD in case of a replaced or aberrant right hepatic artery, but detailed video descriptions of the approach are lacking. This case report describes a step-&#173;by-&#173;step technical video in case of a replaced right hepatic artery. A 58-year-old woman presented with an incidental finding of a 1.7 cm pancreatic head mass. RPD was performed using the da Vinci Xi system and involves a robotic-assisted pancreatico- and hepatico-jejunostomy and open gastro-jejunostomy at the specimen extraction site. The operation time was 410 min with 220 mL of blood loss. The patient had an uncomplicated postoperative course and was discharged after 5 days. Pathology revealed a pancreatic head cancer. RPD is a feasible and safe procedure in case of a replaced hepatic artery when performed in selected patients in high-volume centers by experienced surgeons.

Robotic pancreatoduodenctomy (RPD) has been highly standardized in recent years and may be used in selected patients with pancreatic head cancer, including those with a replaced right hepatic artery. This case report describes a standardized and reproducible technique for RPD, which includes the approach of the Dutch LAELAPS-3 training program to an aberrant vasculature.

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several ...

Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic remnants to reduce the severity of postoperative pancreatic fistulas and moreover the overall postoperative morbidity. This reconstruction technique is characterized by an extra-long jejunal loop for the construction of the pancreaticojejunostomy and hepaticojejunostomy. The longer distance between these anastomoses and an additional jejuno-jejunostomy between the afferent and efferent limb of the hepaticojejunostomy separate the fluids and prevent backflow of bile towards the pancreaticojejunostomy. Thus, the secretions cannot activate each other and aggravate an existing anastomotic leakage. We observed a reduced rate of severe postoperative pancreatic fistulas after modified single-loop reconstruction compared to conventional single loop reconstruction. The technique is easy to perform, safe, and less time-consuming than a traditional double-loop reconstruction.

The technique of modified single-loop reconstruction following pancreaticoduodenectomy separates pancreatic secretion from bile, thus reducing the severity of POPF without prolonging the duration of surgery.

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic ...

Robotic Enucleation of an Intra-Pancreatic Insulinoma in the Pancreatic Head

Pancreatic parenchyma sparing surgery for insulinomas avoids the risk of endocrine and exocrine insufficiency, and potential high-risk anastomoses associated with pancreatic resection. Robotic surgery may be used as an alternative for open pancreatic enucleation without compromising dexterity and 3D-vision.
We present the case of a 42-year old woman who presented with sweating, tremor and episodes of hypoglycemia. A fasting test confirmed endogenic insulin overproduction. After inconclusive CT- and MRI imaging, endoscopic ultrasonography showed a hypoechoic lesion, which was fully within the pancreatic head. Although consent was obtained for pancreatoduodenectomy, robotic enucleation seemed feasible. After mobilization, intraoperative ultrasonography was used to identify the lesion and its relation with the pancreatic duct. Dissection was performed using a traction suture, hot shears and bipolar diathermia. A sealant patch was applied for hemostasis and a drain placed. The patient developed a grade B pancreatic fistula for which endoscopic sphincterotomy was performed; the surgical drain could be removed in the outpatient clinic after 20 days. Prospective studies should confirm the short- and long-term benefits of robotic enucleation of insulinomas.

Here, we present a robotic approach to enucleate an insulinoma in the pancreatic head.

Pancreatic parenchyma sparing surgery for insulinomas avoids the risk of endocrine and exocrine insufficiency, and potential high-risk anastomoses ...

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.
The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who ...

Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy

Laparoscopic pancreatoduodenectomy (LPD) is a demanding abdominal operation that necessitates meticulous surgical skills and teamwork. The management of the pancreatic uncinate process is one of the most important and difficult processes in LPD because of its deep anatomical location and difficult exposure. Complete resection of the uncinate process and mesopancreas has become the cornerstone of LPD. In particular, it is even more difficult to avoid positive surgical margins and incomplete lymph node dissection when the tumor is located in the uncinate process. No-touch LPD, which is an ideal oncological operation process fitting the "tumor-free" principle, has been reported by our group previously. This article introduces the management of the uncinate process in no-touch LPD. Based on the multi-angle arterial approach, in this protocol, the median-anterior and left-posterior approaches to the SMA are used to correctly deal with the important vascular structure, the inferior pancreaticoduodenal artery (IPDA), in order to ensure the safe and complete excision of the uncinate process and mesopancreas. For the achievement of the no-touch isolation technique in LPD, the pancreatic head and the blood supply to the duodenal region must be severed at the very early stage of the operation; after that, the tumor can be isolated intact, resection can be performed in situ, and finally, the tissue can be removed en bloc. This paper aims to show the distinctive ways to manage the uncinate process in no-touch LPD and investigate the viability and safety of this approach. Moreover, the technique may increase the R0 resection rate.

Complete resection of the uncinate process and mesopancreas is one of the most important and difficult processes in laparoscopic pancreatoduodenectomy (LPD). This article presents a method for managing the uncinate process in no-touch LPD using the median-anterior and left-posterior approaches to the superior mesenteric artery (SMA).

Laparoscopic pancreatoduodenectomy (LPD) is a demanding abdominal operation that necessitates meticulous surgical skills and teamwork. The management of ...

Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or extrinsic, such as pancreatic pseudocyst, superior mesenteric artery syndrome, and foreign bodies. Current treatments range from endoscopic approaches, such as endoscopic resection and stent placement, to surgical approaches, including duodenal resection, pancreaticoduodenectomy, and gastrointestinal bypass. Minimally invasive robot-assisted surgery is gaining importance due to its potential to decrease surgical stress, intraoperative blood loss, and postoperative pain, while its instruments and 3D-vision facilitate fine dissection and intra-abdominal suturing, all leading to a reduced time to functional recovery and shorter hospital stay. We present a case of a 75-year-old female who underwent robotic D3 partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis for a 5 cm adenoma with focal high-grade dysplasia.

This protocol presents a case of a robotic partial duodenal resection with primary side-to-side duodeno-jejunal reconstruction in a patient with a 5 cm duodenal stenosis. This is done at the third duodenal segment (D3) after an endoscopic mucosal resection (EMR) for a duodenal polyp.

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or ...

Application of Mid-Pancreatectomy with End-to-End Anastomosis in Pancreatic Benign Tumors

Mid-pancreatectomy combined with end-to-end anastomosis is a surgical procedure used to treat benign pancreatic tumors. It involves removing the tumor from the middle section of the pancreas and connecting the proximal and distal ends through an anastomosis. The traditional surgical approach for resecting the middle segment of the pancreas involves closing the proximal pancreas and creating a Roux-en-Y anastomosis with the jejunum. However, this approach carries a double risk of pancreatic stump fistula and pancreatico enteric anastomotic leak postoperatively. In this paper, a new procedure is described where stent tubes were placed into the proximal and distal sides of the pancreatic ducts after ensuring sufficient freedom from the proximal distal pancreas. The pancreatic parenchyma was then sutured continuously under direct vision to achieve pancreatic end-to-end anastomosis. This procedure helps preserve pancreatic function, reducing the risk of postoperative pancreatic insufficiency. However, due to the complexity and risks involved, thorough evaluation and preparation are necessary before surgery. We carefully assess the patient's history, serology, and imaging results to determine the feasibility and effectiveness of the procedure. During surgery, we consider the use of a suitable pancreatic duct stent to ensure the flow of pancreatic juice into the intestine through physiological pathways. Our goal is to remove the tumor while preserving as much normal pancreatic tissue as possible for the anastomosis. After the operation, it is crucial to monitor the patient's pancreatic function, paying close attention to blood glucose levels, drainage fluid volume, and amylase value of the pancreatic anastomosis. During the postoperative follow-up visit, the patient's pancreatic function was assessed, and there was no significant change in quality of life compared to before the surgery. This indicates that mid-pancreatectomy combined with end-to-end anastomosis is a safe and effective procedure for treating pancreatic benign neoplasms.

The present protocol describes the application of mid-pancreatectomy combined with end-to-end anastomosis in the surgical treatment of pancreatic benign tumors, which presents a feasible solution for managing such tumors while concurrently preserving pancreatic function.

Mid-pancreatectomy combined with end-to-end anastomosis is a surgical procedure used to treat benign pancreatic tumors. It involves removing the tumor ...

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

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