The authors have no acknowledgements. The described technique is used in both institutions of the authors.

No specific ethics approval is required since this operation was performed in routine clinical care. The patient is a 67-year-old female with a 1 cm ampullary tumor, presenting with obstructive jaundice, pale colored stools, dark colored urine, itching and 10 kg weight loss in 1 year. Patient&#39;s clinical history shows hypertension and type II diabetes mellitus. Endoscopic ultrasound (EUS) shows a large pedunculated polypoid lesion of the ampulla.
1. Patient Selection
<ol>
	<li>Select patients on the basis of a pancreatic or peri-ampullary tumor without any signs of involvement of major vessels on a recent (max 4 weeks old) contrast enhanced CT-scan.</li>
	<li>Examine the CT for any vascular abnormalities such as aberrant course of the right hepatic artery.</li>
	<li>During training, exclude patients with a body mass index &#62;35 kg/m2, recurrent acute or chronic pancreatitis, previous major abdominal surgery, pancreas-targeted radiotherapy, mid-cholangiocarcinomas, and large duodenal cancers, due to expected technical difficulties. Once extensive experience with LPD has been obtained, vascular resections are also feasible during LPD20.</li>
</ol>
2. Patient Preparation
<ol>
	<li>Perform a preoperative endoscopic retrograde cholangiopancreatography (ERCP) to relieve the obstructive jaundice.</li>
	<li>Place a 7Fr plastic biliary stent and take biopsies. Pathology shows a tubulovillous adenoma of common bile duct (CBD) with focal high-grade dysplasia. Figure 1 illustrates the appearance of the lesion on CT scan.</li>
</ol>
3. Surgical Technique
<ol>
	<li>Operation setting
	<ol>
		<li>Place the patient in French position with a heating device on a short grain mattress with the right arm in and left arm abducted to 90&#176;.</li>
		<li>During sterile exposition, remember to keep the suprapubic region free for a Pfannenstiel incision to remove the specimen. The first surgeon stands between the patient&#39;s legs, the 1st and the 2nd assistant are on the left and right side, respectively. Use a 6-port technique to perform the procedure, see Figure 2.</li>
		<li>After creation of pneumoperitoneum, place the sub-umbilical 12 mm trocar and then 4 trocars along a semi-circular plane (two 12 mm trocars left and right of the umbilicus, two 5 mm trocars four fingers subcostal left and right in the anterior axillary line).</li>
		<li>Place the 6th trocar just sub-xiphoidal (Figure 2) for liver retraction.</li>
		<li>Choose an appropriated (articulating) sealing device, along with laparoscopic monopolar hook and laparoscopic bipolar clamp diathermy.</li>
	</ol>
	</li>
	<li>Exploration Phase
	<ol>
		<li>Perform a diagnostic laparoscopy to exclude peritoneal and liver metastases. Place a straight needle transcutaneously in the epigastric region, around the Teres ligament to retract the ligament to the ventral abdominal wall.</li>
		<li>Dissect the gallbladder hilum and the cystic artery and then divide the duct between clips and suture Hartmann&#39;s pouch to the ventral abdominal wall for further liver retraction and exposure of the hepato-duodenal ligament.</li>
	</ol>
	</li>
	<li>Dissection Phase
	<ol>
		<li>Open the lesser sac by dividing the gastrocolic ligament 2 cm distal from the gastroepiploic vessels. Free the stomach from the pancreas and let the assistant retract the stomach anteriorly. Mobilize the hepatic flexure. Thereafter, the left assistant retracts the duodenum to the patient&#39;s left side, while the right assistant pushes the colon caudo-medially with a gauze.</li>
		<li>Kocher Maneuver
		<ol>
			<li>Perform a wide Kocher maneuver, exposing the inferior caval vein, the origin of the superior mesenteric artery (SMA) and the ligament of Treitz. Expose also the superior mesenteric vein (SMV) and its confluence with the gastroepiploic vein. Dissect the latter and transect it using clips and articulating sealer.</li>
		</ol>
		</li>
		<li>Pancreatic Tunnel
		<ol>
			<li>Now, create the beginning of a wide pancreatic tunnel.</li>
			<li>Next, free the distal part of the stomach, just 1 cm proximal to the pylorus, and transect it using an endostapler after the nasogastric tube is pulled back. On the cranial side of the pancreas, dissect the hepatic artery lymph node station (number 8a) and send it for pathology. Hereafter, identify the hepatic artery, portal vein and gastroduodenal artery.</li>
			<li>Encircle the gastroduodenal artery with a vessel loop and divide it, leaving 2 locking clips on the patient&#39;s side and 1 on the specimen&#39;s side. Complete the pancreatic tunnel by blunt dissection using the articulating sealer and sling the pancreas with a quarter length vessel loop, securing it with a plastic self-locking clip.</li>
		</ol>
		</li>
		<li>Ligament of Treitz resection
		<ol>
			<li>Mobilize the duodenojejunal flexure (ligament of Treitz), and divide the first jejunal loop with an endostapler using a vascular cartridge. Now complete the mobilization of the first loop up to the mesenteric root. Hereafter, suture the two free ends of the jejunum to each other and pass both under the mesenteric root to the patient&#39;s right side.</li>
		</ol>
		</li>
		<li>Pancreatic resection
		<ol>
			<li>For the pancreatic head dissection, move the camera to the right sided 12-mm trocar as this offers a better view of the SMA and SMV. Dissect the uncinate process with the articulating sealer from the lateral aspect of the SMV and first jejunal branch. Work in layers from ventral to dorsal, while retracting the SMV medially to expose the SMA.</li>
			<li>Transect the pancreas using monopolar diathermy, manage bleeding with bipolar diathermy.</li>
			<li>Transect the pancreatic duct with scissors to avoid sealing of the duct. Dissect all retroperitoneal nodes, while visualizing the SMA.</li>
		</ol>
		</li>
		<li>Bile duct resection
		<ol>
			<li>Follow up the common hepatic artery to the right hepatic artery and take care in case of aberrant vascular anatomy. Hereafter, encircle the hepatic duct with a vessel loop and divide it between a laparoscopic bulldog on the proximal hepatic duct, and a plastic locking clip (or second bulldog) on the distal hepatic duct.</li>
			<li>Next, place the specimen in a plastic retrieval bag and temporarily leave it in the lower abdomen. Remove the specimen later simultaneously with the gallbladder. Take a short pause before start of the reconstruction phase.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Reconstruction Phase
	<ol>
		<li>Pancreatic anastomosis
		<ol>
			<li>With 3D laparoscopy, start the reconstruction phase performing the PJ, according to the modified Blumgart technique, with 4 barbed sutures (large blunt needle, 3/0, 23cm length) (Figure 3).</li>
			<li>Pass the sutures through the pancreas approximately 1 cm from the cut edge, then pass them dorsally through the bowel and back through the pancreas. After passing, drive the needle through its own loop, tighten and place it far from the pancreas.</li>
			<li>Repeat this procedure for each suture, taking care not to obstruct the pancreatic duct (Figure 3.1). The 3D laparoscopy facilitates easy needle placement and suturing.</li>
		</ol>
		</li>
		<li>Duct-to-mucosa anastomosis
		<ol>
			<li>Create a 2 mm enterotomy in the jejunum using the diathermy hook (about 5 mm from the pancreatic duct).</li>
			<li>Subsequently, place 4-6 duct-to-mucosa sutures using a small blunt needle (5/0). In case of four sutures, place them at 8, 5, 11 and 2 o&#39;clock. Choose the position in order to overcome more difficult suturing of the typical 9 and 3 o&#39;clock sutures in small pancreatic ducts.</li>
			<li>First, place the 8 and 5 o&#39;clock sutures with the knot inside. Place a 12 cm 6 or 8 Fr pediatric nasogastric tube as internal pancreatic stent (Figure 3.2).</li>
			<li>Next, place the 11 and 2 o&#39;clock sutures with the knot outside. Complete the anastomosis picking up the ventral side of the jejunum with the original four barbed sutures, inserting them first anteriorly through the jejunal wall and then back through the ventral side of the pancreas, and retracting toward the spleen to prevent tearing of the pancreas.</li>
			<li>Secure each suture with a clip on the pancreatic surface before cutting (Figure 3.3 and 3.4).</li>
		</ol>
		</li>
		<li>Biliary anastomosis
		<ol>
			<li>Approximately 5-7 cm further on the jejunal loop, create a 2-4mm antimesenterial enterotomy with the diathermy hook.</li>
			<li>Perform an end-to-side hepaticojejunostomy (HJ) with interrupted absorbable threaded (5/0) sutures, starting with a suture between 6 o&#39;clock on the bile duct to 12 o&#39;clock in the enterotomy.</li>
			<li>Continue it from caudal to cranial alternating between the left and right sides of the HJ. A tension-releasing suture may be placed between the jejunal loop and the gallbladder bed. In case of a wide, thick-walled bile duct use a running suture with the surgeon standing on the patient&#39;s left or right side.</li>
			<li>Place a surgical drain from the right subcostal space through the foramen of Winslow ending at the superior border of the PJ. Complete the cholecystectomy and place the gallbladder in a second retrieval bag. Pull up the first jejunal loop to the stomach.</li>
		</ol>
		</li>
		<li>Gastric anastomosis
		<ol>
			<li>After a small enterotomy and small gastrostomy just ventral from the staple line perform a stapled side-to-side antecolic gastrojejunostomy (GJ). Close the remaining opening with a single suture with a barbed 3/0 suture.</li>
			<li>Create a Pfannenstiel incision of 5 cm to extract the pancreatoduodenectomy specimen and the gallbladder. Close this incision in layers and insufflate the abdomen to place a second drain through the most right sided 5 mm trocar at the inferior border of the PJ, with the tip under the GJ.</li>
			<li>Cover the PJ and the stump of the GDA with the greater omentum. Close the fascia of the three 12 mm trocars. Close all incisions by intracutaneous sutures (4/0) (Figure 4).</li>
		</ol>
		</li>
	</ol>
	</li>
</ol>

<ol>
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Results of an All-inclusive National Observational Study.</a> Ann Surg. , (2016).</li><li>de Rooij, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pan-European+survey+on+the+implementation+of+minimally+invasive+pancreatic+surgery+with+emphasis+on+cancer.">Pan-European survey on the implementation of minimally invasive pancreatic surgery with emphasis on cancer.</a> HPB (Oxford). 18 (2), 170-176 (2016).</li><li>Hogg, M. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Training+in+Minimally+Invasive+Pancreatic+Resections:+a+paradigm+shift+away+from+&amp;#34;See+one,+Do+one,+Teach+one&amp;#34;.">Training in Minimally Invasive Pancreatic Resections: a paradigm shift away from &amp;#34;See one, Do one, Teach one&amp;#34;.</a> HPB (Oxford). 19 (3), 234-245 (2017).</li><li>Magge, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+effectiveness+of+minimally+invasive+and+open+distal+pancreatectomy+for+ductal+adenocarcinoma.">Comparative effectiveness of minimally invasive and open distal pancreatectomy for ductal adenocarcinoma.</a> JAMA Surg. 148 (6), 525-531 (2013).</li><li>Venkat, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+distal+pancreatectomy+is+associated+with+significantly+less+overall+morbidity+compared+to+the+open+technique:+a+systematic+review+and+meta-analysis.">Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis.</a> Ann Surg. 255 (6), 1048-1059 (2012).</li><li>Gagner, M., Pomp, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+pylorus-preserving+pancreatoduodenectomy.">Laparoscopic pylorus-preserving pancreatoduodenectomy.</a> Surg Endosc. 8 (5), 408-410 (1994).</li><li>Boggi, U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+pancreaticoduodenectomy:+a+systematic+literature+review.">Laparoscopic pancreaticoduodenectomy: a systematic literature review.</a> Surg Endosc. 29 (1), 9-23 (2015).</li><li>Mendoza, A. 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The authors have nothing to disclose.

LPD is a technically challenging but well standardized, safe and reproducible procedure. LPD may offer the advantages of minimally invasive approaches, including early mobilization, early return of bowel function and short hospital stay21. It is widely recognized that laparoscopy offers a better quality of the visualization, enlarging all the details of the surgical field and minimal manipulation of the tissue22. The pathological outcomes are also comparable between the LPD and the open technique. Particularly, the same R0 resection and lymph node harvest rates have been reported10.
The use of the French position, the 6-port technique, 3D laparoscopy (especially during the anastomotic phase) and the appropriate laparoscopic devices can reduce the obstacles of the minimal invasive approach. We suggest also some technical tips, previously described by Palanivelu et al.23 such as the transcutaneous needle in the epigastric region to retract the Teres&#39; ligament or the suture of the Hartmann&#39;s pouch to the ventral abdominal wall, to improve the exposure of the hepatoduodeneal ligament.
Unfortunately, there is a price to be paid; this complex operation must be performed at high volume centers where surgeons have extensive experience in both open pancreatic resections and advanced laparoscopic procedures15. Although the modified Blumgart pancreaticojejunostomy is a reproducible technique to perform the pancreatic anastomosis, careful surgery is required. The surgeon needs to take care to not obstruct the pancreatic duct with the barbed sutures. The duct-to-mucosa sutures also needs to be placed meticulously. Each suture is placed under direct visualization, but does not need to be tightened immediately and could be kept initially for traction. When initially cutting the pancreatic duct, it may be kept somewhat longer to facilitate these sutures.
Laparoscopic pancreaticoduodenectomy requires advanced laparoscopic skills and extensive experience with open pancreatic surgery. Further studies need to investigate the oncological results of this technique. Whether the minimal invasive approach is safe and beneficial for these patients has to be establish in a randomized setting. In the Netherlands, the LEOPARD-2 (trial registry NTR5689) multicenter trial is currently randomizing patients between minimally invasive and open pancreatoduodenectomy using the described technique24.

Laparoscopic surgery has a fast evolution during the last decades and is being performed for increasingly complex surgical procedures. Despite increasing recognition of the benefits of this approach, the majority of pancreatic surgeons remain uncertain about the advantages of this technique1,2,3,4,5. Laparoscopic distal pancreatectomy is now proven to be safe and readily available, although its use in the treatment of adenocarcinoma is still debated2,4,6,7. Since the first report on laparoscopic pancreatoduodenectomy (LPD) in 19948, few studies have described the technique9,10,11,12. Non-randomized studies reported a reduction in delayed gastric emptying and in the estimated intraoperative blood loss has been reported for LPD, as compared to open pancreatoduodenectomy13,14. One randomized trial and a systematic review reported that LPD could reduce a hospital stay, without increasing the overall costs15,16. Unfortunately, LPD seems to be associated with higher rates of postoperative pancreatic fistula and readmission, especially in low volume centers17. The best pancreatic anastomosis technique is still open for debate. The most common anastomoses performed during open pancreatoduodenectomy are being reproduced in LPD. However, as for open pancreatic surgery, the results obtained with LPD are controversial. Safety, feasibility, reproducibility and simplicity of the pancreatic anastomosis have a crucial role in the diffusion of this technique and in its surgical results.
The Blumgart pancreatic anastomosis is a simple and effective technique that combines the principle of duct-to-mucosa anastomosis with jejunal covering over the raw surface of the pancreas18. The Blumgart anastomosis has been associated with lower pancreatic fistula rate to than the other techniques19.
This article aims to demonstrate the safety and feasibility of LPD and specifically the pancreaticojejunostomy (PJ) with a modified Blumgart anastomosis and its surgical oncologic outcome in a patient with an ampullary tumor.

<table><tbody><tr><td>Bair Hugger</td><td>3M COMPANY</td><td>79500</td><td>Patient Warming Unit, Model 795, 120V-ENG-E, Refurbished 79500</td></tr><tr><td>ENSEAL</td><td>Ethicon Endo-Surgery, Cincinnati, OH, USA</td><td>NSLG2C45</td><td>articulating sealing device&amp;nbsp;</td></tr><tr><td>Weck Hem-o-lok Polymer Ligation System - Automatic</td><td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td><td>543965</td><td>The Weck Hem-o-lok Auto Endo5 delivers 15 true Medium-Large clips on a 5mm platform. The Medium-Large clip is designed for 3-10 mm size vessels. Designed for security, the non-absorbable locking polymer clip is inert, nonconductive, radiolucent, and does not interfere with CT or X-ray diagnostics.</td></tr><tr><td>ECHELON FLEX Powered Plus Stapler</td><td>Ethicon Endo-Surgery, Cincinnati, OH, USA</td><td>PLEE60A</td><td>The ECHELON FLEX GST System controls tissue movement</td></tr><tr><td>Echelon black</td><td>Ethicon Endo-Surgery, Cincinnati, OH, USA</td><td>GST60T</td><td>Black reload intended for use in very thick tissue</td></tr><tr><td>Echelon blue</td><td>Ethicon Endo-Surgery, Cincinnati, OH, USA</td><td>GST60B</td><td>Blue reload intended for use in regular tissue</td></tr><tr><td>V-Loc</td><td>Covidien</td><td>VLOCM1824&amp;nbsp;</td><td>The V-Loc wound closure device is a revolutionary technology that supports optimal patient outcomes by closing wounds securely without the need to tie knots.&amp;nbsp;</td></tr><tr><td>VICRYL Suture</td><td>ETHICON&amp;nbsp;</td><td>J303H</td><td>Suture USP: 5-0 Brand: Coated Vicryl Suture Color: Violet Strands per Pack: 1 Suture Length (Inches): 27 Needle Type: RB-1</td></tr></tbody></table>

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.

The operation time was 6 hours with 150 mL of blood loss. The patient's postoperative course was uncomplicated. No postoperative pancreatic fistula was detected. The postoperative day 3 amylase level in both drains were 1373 U/L and 804 U/L, which had normalized by day 5 where after the drains were removed. The patient was discharged on the 6th postoperative day. Pathology assessment revealed a 1.5 cm tubulovillous adenoma of the papilla of Vater with low grade dysplasia. Resection margins were microscopically radical (R0) and none of the thirteen lymph nodes harvested were involved by tumor cells.
<img alt="CT scan images of abdominal cross-sections, used for medical diagnosis and analysis." class="xfigimg" src="/files/ftp_upload/56819/56819fig1.jpg" data-altupdatedat="1747911167000" data-alt="Figure 1"> 
Figure 1 Preoperative CT scan 
The images show the ampullary tumor, causing obstructive jaundice. <a href="/files/ftp_upload/56819/56819fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Laparoscopic surgery diagram with trocar placement and surgical team positioning, abdominal procedure." class="xfigimg" src="/files/ftp_upload/56819/56819fig2.jpg" data-altupdatedat="1747911167000" data-alt="Figure 2"> 
Figure 2 Setting of the patient 
The operator is between the legs, the 1st and the 2nd assistant on the left and right, respectively. The procedure is performed by a 6-port technique. <a href="/files/ftp_upload/56819/56819fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Pancreatic islet isolation diagram, showing injection and microsurgery steps for cell extraction." class="xfigimg" src="/files/ftp_upload/56819/56819fig3.jpg" data-altupdatedat="1747911167000" data-alt="Figure 3"> 
Figure 3 Pancreaticojejunostomy according to the modified Blumgart technique 
The modified Blumgart pancreaticojejunostomy is performed with four barbed sutures (3/0), large needle, for the transpancreatic U-sutures (3.1). An 12cm internal 6 or 8 Fr pancreatic stent is placed and the duct-to-mucosa anastomosis is performed using 4-6 absorbable threaded 5/0 sutured with a small blunt needle (3.2). The anastomosis is completed by picking up the ventral side of the jejunum with the original four barbed sutures (3.3, 3.4). Lateral view of the final result (3.5).
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/56819/56819fig4.jpg"> 
Figure 4 Postoperative Result 
This is the final result after laparoscopic pancreatoduodenectomy with modified Blumgart pancreaticojejunostomy.

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Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

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 ...

laparoscopic-pancreatoduodenectomy-with-modified-blumgart

Research

JoVE Journal

Cancer Research

14.8K Views.  Academic Medical Center. Laparoscopische pancreatoduodenctomy (LPD) kan bieden voordelen ten opzichte van de open pancreatoduodenectomy, met inbegrip van vroege postoperatieve mobilisatie, minder vertraagde lediging van de maag en een korter verblijf in het ziekenhuis. LPD is echter technisch uitdagende en niet goed gestandaardiseerd, met name wat betreft de alvleesklier anastomose. We beschrijven een gestandaardiseerde techniek voor de alvleesklier wapendrager tijdens LPD: Blumgart pancreaticoje...

Video: Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

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 ...

Colonial Wig Pancreaticojejunostomy

Postoperative pancreatic fistula (POPF) is one of the most problematic complications after pancreaticoduodenectomy (PD). We describe a series of 48 pancreatic-head resections from our institution, in which we compare a new technique to create the pancreaticojejunostomy (PJ) reconstruction with standard techniques. The goal is to achieve a lower rate of POPF. This new PJ is termed the &#34;Colonial Wig&#34; (CW) PJ due to the novel appearance of the jejunum wrapping around the pancreas, resembling a Colonial wig wrapping around the head of a Colonial Whig (e.g.,&#160;George Washington). In our consecutive series, 22 cases were performed using the new CW technique to perform the PJ and were compared to 26 traditional PDs with traditional reconstruction. There was an incidence of clinically relevant POPF of 0% in the CW group, compared to 15% in 26 conventional PJs. Our proposed CW PJ reconstruction is&#160;associated with a lower the incidence of POPF following PD, and hence may be a way to improve outcomes after PD.

We describe a new technique for pancreaticojejunostomy reconstruction after pancreaticoduodenectomy that is associated with a very low rate of postoperative pancreatic fistula.

Postoperative pancreatic fistula (POPF) is one of the most problematic complications after pancreaticoduodenectomy (PD). We describe a series of 48 ...

Medicine

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 ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

Robotic lateral pancreaticojejunostomy (RLPJ) may be used in patients with painful, morphine dependent, chronic pancreatitis and a dilated main pancreatic duct. We describe a standardized and reproducible technique for RLPJ, which includes transection of the gastroduodenal artery.

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of the pancreas. The aim of central pancreatectomy is to prevent postoperative life-long endocrine and exocrine insufficiency. The downside of central pancreatectomy is the high rate of postoperative pancreatic fistula, which is the main reason that many surgeons do not routinely use central pancreatectomy in eligible patients. Most studies report open or laparoscopic central pancreatectomy with a pancreatico-gastrostomy anastomosis in adults. This is the first description of a standardized approach to robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy reconstruction in an adolescent (16-year-old boy) with a pseudopapillary tumor in the body of the pancreas. The operation time was 248 min with 20 mL of blood loss. The postoperative course was uneventful except for the short-term medical treatment for a grade B pancreatic fistula. Robotic central pancreatectomy can be safely applied in selected patients in experienced centers.

Robotic central pancreatectomy may be used in selected patients in experienced centers. This protocol presents all steps and the feasibility of a robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy in a 16-year-old adolescent patient.

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of ...

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 ...

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 ...

Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic capsule to infiltrate surrounding tissues. In conventional distal pancreatosplenectomy (DPS), tumor cells are prone to spread along the direction of blood and lymphatic reflux due to surgical compression. Additionally, inflammation makes it challenging to achieve R0 resection, leading to a lower patient survival rate. To address these limitations, radical antegrade modular pancreatosplenectomy (RAMPS) was developed, emphasizing deeper excision, including the left anterior renal fascia, the left anterior renal adipose sac, and even the left adrenal gland, to improve the R0 resection rate. With the advancement of minimally invasive surgical techniques, laparoscopic RAMPS (L-RAMPS) is being considered technically safe and feasible in oncology. However, due to technical difficulties and a lack of supporting evidence for clinical application, only a few institutions are currently conducting L-RAMPS. In this context, this article presents detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy (L-pRAMPS), offering promise for future clinical applications.

Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) is currently considered technically safe and feasible. However, due to technical challenges and a lack of supporting evidence for widespread clinical applications, only a limited number of institutions are currently conducting L-RAMPS. This article aims to provide detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy.

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic ...

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.

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.

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

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