Not applicable.

This protocol focuses on the reconstruction phase of PD using mSLR and follows the guidelines of the ethics committee of the Ruhr-University Bochum, Germany.
NOTE: Patients with a resectable tumor of the pancreatic head, the papillary region or severe refractory chronic calcifying pancreatitis underwent PD. Resectability was present if the tumor had less than 50 % contact to the peripancreatic arteries and did not infiltrate the portal vein or the superior mesenteric vein. Distant metastases in cases of adenocarcinomas were also contraindications for PD. The resection technique in PD is standardized and described in detail elsewhere11,12. It does not affect the type of reconstruction itself.
1. Patient preparation
<ol>
	<li>After the patient has been brought to the operation theatre by the nurses, have the anesthesiologist start the anesthesia. Monitor the depth of anesthesia throughout the operation by the anesthesiologist including continuous check of the vital signs.</li>
</ol>
2. Establishing the indication for mSLR
<ol>
	<li>Confirm the indication for a mSLR after the resection phase in PD. Construct a mSLR in cases of a high-risk pancreatic remnant characterized by soft and fragile pancreatic tissue and/or a tiny main pancreatic duct with a diameter of 1-2 mm.</li>
	<li>Palpate the pancreas to determine subjectively whether the pancreatic texture is soft or hard. Use a Shore durometer to measure the pancreatic texture. Shore units &#60; 40 are characteristic for soft pancreata.</li>
</ol>
3. Reconstruction phase: mobilization of the jejunal loop
<ol>
	<li>Resect the first 10 inches of the jejunum to provide enough length of the mesentery. The jejunum follows the duodenum and begins after the ligament of Treitz.</li>
	<li>Advance the loop into the right upper abdominal quadrant through a wide slit in the transverse mesocolon distal to the right colic artery.</li>
	<li>Close the slit with an interrupted polypropylene 4 &#8211; 0 suture.</li>
	<li>Oversew the stapled line with a continuous PDS 5-0 suture.</li>
</ol>
4. Reconstruction phase: pancreaticojejunostomy
<ol>
	<li>Position the jejunal loop as demonstrated in Figure 1 (&#8220;modified single-loop reconstruction&#8221;) to construct an end-to-side pancreaticojejunostomy.</li>
	<li>Create a double-layer, end-to-side, duct-to-mucosa PJ using an interrupted polydioxanone (PDS) 5-0 suture for the outer layer and interrupted polypropylene 5-0 suture for the inner layer.</li>
	<li>Use interrupted sutures between the pancreatic duct and the jejunal mucosa for the inner layer. Construct the outer layer with single sutures between the pancreatic parenchyma/capsule and the seromuscular layer of the jejunal loop.</li>
</ol>
5. Preparation of the long jejunal limb and jejunojejunostomy
<ol>
	<li>Choose a jejunal segment between the PJ and HJ (which will be constructed afterwards), which measures 25&#8211;35 cm instead of 10 cm as in conventional single-loop reconstruction. Create the jejuno-jejunostomy before or after construction of the HJ.</li>
	<li>Now construct an additional side-to-side jejunojejunal anastomosis at the lowest point between the afferent and efferent limbs of the HJ. Begin by placing marking sutures at the sites of the jejuno-jejunostomy with single PDS 5-0 stitches.</li>
	<li>Perform the intestinal anastomosis in a continuous double-layer PDS 5-0 suture technique. Construct the outer layer of the backwall with a continuous seromuscular suture. Perform the inner layer of the backwall with a continuous suture with stitching of all jejunal layers on both sides. Construct the inner layer and the outer layer of the front wall in the same way.</li>
	<li>Ensure that the anastomosis is sufficiently wide &#8211; about 1 inch. This allows good flow of bile and pancreatic secretions even in the early postoperative period when themucosa is edematous and may obstruct a narrow anastomosis. Close the slit around the jejunal loop using interrupted polypropylene 5-0 sutures.</li>
</ol>
6. Reconstruction phase: hepaticojejunostomy
<ol>
	<li>Use a single-layer interrupted or continuous PDS 5-0 suture for construction of the HJ. Use interrupted sutures especially for tiny ducts. Ensure that the stitches enclose all jejunal layers and all layers of the common bile duct.</li>
	<li>Splint thin-walled and tiny common bile ducts with an externally diverted T-tube.</li>
</ol>
7. Reconstruction phase: duodenojejunostomy
<ol>
	<li>Reconstruct the intestinal passage with an end-to-side, double-layer duodeno(pyloro-)jejunostomy using continuous PDS 4-0 sutures.</li>
	<li>Construct continuous seromusculary sutures for the outer layer of the back- and front wall as described in step 5.3. Use continuous sutures with stitching of all duodenojejunal layers for the inner layers of the anastomosis.</li>
</ol>
8. Management of drainages, postoperative medical treatment and POPF - monitoring
<ol>
	<li>At the end of the surgery, place 2 intraabdominal soft silicone drains in the vicinity of the HJ and PJ. Channel them separately through the skin of the right and left middle abdomen.</li>
	<li>Apply subcutaneous octreotide 100 &#181;g three times a day for 7 days after surgery. Use pasireotide as an alternative.</li>
	<li>Determine pancreatic amylase and lipase activity in the drain fluid every 48 h beginning on postoperative day 3.</li>
	<li>Discharge the patient once they have recovered from surgery &#8211; usually around postoperative day 21. Ensure that the drainages have been removed, the patient is fully mobile and able to eat regularly.</li>
	<li>Perform follow-up investigations including computed-tomography of the abdomen, magnet-resonance-cholangiopancreatography and esophagogastroscopy at least 6, 12 and 24 months after surgery to rule out tumor recurrence, metastases and anastomotic ulcers. The tumor marker carbohydrate antigen 19 &#8211; 9 must be determined as well.</li>
</ol>

<ol><li>Cameron, J. L., He, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Two+thousand+consecutive+pancreaticoduodenectomies%5BTitle%5D)+AND+%22Journal+of+American+College+of+Surgeons%22%5BJournal%5D)">Two thousand consecutive pancreaticoduodenectomies.</a> Journal of American College of Surgeons. 220 (4), 530-536 (2015).</li>
<li>Keck, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pancreatogastrostomy+Versus+Pancreatojejunostomy+for+RECOnstruction+After+PANCreatoduodenectomy+%28RECOPANC%2C+DRKS+00000767%29%3A+Perioperative+and+Long-term+Results+of+a+Multicenter+Randomized+Controlled+Trial%5BTitle%5D)+AND+%22Annals+of+Surgery%22%5BJournal%5D)">Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and Long-term Results of a Multicenter Randomized Controlled Trial.</a> Annals of Surgery. 263 (3), 440-449 (2016).</li>
<li>Deng, L. H., Xiong, J. J., Xia, Q. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Isolated+Roux-en-Y+pancreaticojejunostomy+versus+conventional+pancreaticojejunostomy+after+pancreaticoduodenectomy%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Journal+of+Evidence+Based+Medicine%22%5BJournal%5D)">Isolated Roux-en-Y pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a systematic review and meta-analysis.</a> Journal of Evidence Based Medicine. 10 (1), 37-45 (2017).</li>
<li>Klaiber, U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Meta-analysis+of+complication+rates+for+single-loop+versus+dual-loop+%28Roux-en-Y%29+with+isolated+pancreaticojejunostomy+reconstruction+after+pancreaticoduodenectomy%5BTitle%5D)+AND+%22British+Journal+of+Surgery%22%5BJournal%5D)">Meta-analysis of complication rates for single-loop versus dual-loop (Roux-en-Y) with isolated pancreaticojejunostomy reconstruction after pancreaticoduodenectomy.</a> British Journal of Surgery. 102 (4), 331-340 (2015).</li>
<li>Eshmuminov, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Systematic+review+and+meta-analysis+of+postoperative+pancreatic+fistula+rates+using+the+updated+2016+International+Study+Group+Pancreatic+Fistula+definition+in+patients+undergoing+pancreatic+resection+with+soft+and+hard+pancreatic+texture%5BTitle%5D)+AND+%22HPB+%28Oxford%29%22%5BJournal%5D)">Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture.</a> HPB (Oxford). 20 (11), 992-1003 (2018).</li>
<li>Ke, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+prospective%2C+randomized+trial+of+Roux-en-Y+reconstruction+with+isolated+pancreatic+drainage+versus+conventional+loop+reconstruction+after+pancreaticoduodenectomy%5BTitle%5D)+AND+%22Surgery%22%5BJournal%5D)">A prospective, randomized trial of Roux-en-Y reconstruction with isolated pancreatic drainage versus conventional loop reconstruction after pancreaticoduodenectomy.</a> Surgery. 153 (6), 743-752 (2013).</li>
<li>El Nakeeb, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Isolated+Roux+loop+pancreaticojejunostomy+versus+pancreaticogastrostomy+after+pancreaticoduodenectomy%3A+a+prospective+randomized+study%5BTitle%5D)+AND+%22HPB+%28Oxford%29%22%5BJournal%5D)">Isolated Roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a prospective randomized study.</a> HPB (Oxford). 16 (8), 713-722 (2014).</li>
<li>Tani, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Randomized+clinical+trial+of+isolated+Roux-en-Y+versus+conventional+reconstruction+after+pancreaticoduodenectomy%5BTitle%5D)+AND+%22British+Journal+of+Surgery%22%5BJournal%5D)">Randomized clinical trial of isolated Roux-en-Y versus conventional reconstruction after pancreaticoduodenectomy.</a> British Journal of Surgery. 101 (9), 1084-1091 (2014).</li>
<li>Machado, M. C., da Cunha, J. E., Bacchella, T., Bove, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+modified+technique+for+the+reconstruction+of+the+alimentary+tract+after+pancreatoduodenectomy%5BTitle%5D)+AND+%22Surgery+Gynecology+Obstetrics%22%5BJournal%5D)">A modified technique for the reconstruction of the alimentary tract after pancreatoduodenectomy.</a> Surgery Gynecology Obstetrics. 143 (2), 271-272 (1976).</li>
<li>Aghalarov, I., Herzog, T., Uhl, W., Belyaev, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+modified+single-loop+reconstruction+after+pancreaticoduodenectomy+reduces+severity+of+postoperative+pancreatic+fistula+in+high-risk+patients%5BTitle%5D)+AND+%22HPB+%28Oxford%29%22%5BJournal%5D)">A modified single-loop reconstruction after pancreaticoduodenectomy reduces severity of postoperative pancreatic fistula in high-risk patients.</a> HPB (Oxford). 20 (7), 676-683 (2018).</li>
<li>Marangoni, G., Morris-Stiff, G., Deshmukh, S., Hakeem, A., Smith, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+modern+approach+to+teaching+pancreatic+surgery%3A+stepwise+pancreatoduodenectomy+for+trainees%5BTitle%5D)+AND+%22Journal+of+Gastrointestinal+Surgery%22%5BJournal%5D)">A modern approach to teaching pancreatic surgery: stepwise pancreatoduodenectomy for trainees.</a> Journal of Gastrointestinal Surgery. 16 (8), 1597-1604 (2012).</li>
<li>Sülberg, D. U. W. Pyloruserhaltende Duodenohemipankreatektomie nach Traverso-Longmire mit T-Drainage (pp-Whipple). , Available from: 
 <a target="_blank" href="https://www.webop.de/Allgemein-und-Viszeralchirurgie/Pankreas-und-Milz/Pyloruserhaltende-Duodenohemipankreatektomie-nach-Traverso-Longmire-mit-T-Drainage-pp-Whipple">https://www.webop.de/Allgemein-und-Viszeralchirurgie/Pankreas-und-Milz/Pyloruserhaltende-Duodenohemipankreatektomie-nach-Traverso-Longmire-mit-T-Drainage-pp-Whipple</a> (2019).</li>
<li>Machado, M. C., Machado, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Systematic+use+of+isolated+pancreatic+anastomosis+after+pancreatoduodenectomy%3A+Five+years+of+experience+with+zero+mortality%5BTitle%5D)+AND+%22European+Journal+of+Surgical+Oncology%22%5BJournal%5D)">Systematic use of isolated pancreatic anastomosis after pancreatoduodenectomy: Five years of experience with zero mortality.</a> European Journal of Surgical Oncology. 42 (10), 1584-1590 (2016).</li>
<li>Pescio, G., Cariati, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+new+reconstructive+method+after+pancreaticoduodenectomy%3A+the+triple+Roux+on+a+%22P%22+loop.+Rationale+and+radionuclide+scanning+evaluation%5BTitle%5D)+AND+%22HPB+Surgery%22%5BJournal%5D)">A new reconstructive method after pancreaticoduodenectomy: the triple Roux on a "P" loop. Rationale and radionuclide scanning evaluation.</a> HPB Surgery. 9 (4), 223-227 (1996).</li>
<li>Kingsnorth, A. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Safety+and+function+of+isolated+Roux+loop+pancreaticojejunostomy+after+Whipple%27s+pancreaticoduodenectomy%5BTitle%5D)+AND+%22Annals+of+the+Royal+College+of+Surgeons+of+England%22%5BJournal%5D)">Safety and function of isolated Roux loop pancreaticojejunostomy after Whipple's pancreaticoduodenectomy.</a> Annals of the Royal College of Surgeons of England. 76 (3), 175-179 (1994).</li>
<li>Jester, A. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+Impact+of+Hepaticojejunostomy+Leaks+After+Pancreatoduodenectomy%3A+a+Devastating+Source+of+Morbidity+and+Mortality%5BTitle%5D)+AND+%22Journal+of+Gastrointestinal+Surgery%22%5BJournal%5D)">The Impact of Hepaticojejunostomy Leaks After Pancreatoduodenectomy: a Devastating Source of Morbidity and Mortality.</a> Journal of Gastrointestinal Surgery. 21 (6), 1017-1024 (2017).</li>
<li>Funovics, J. M., Zoch, G., Wenzl, E., Schulz, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Progress+in+reconstruction+after+resection+of+the+head+of+the+pancreas%5BTitle%5D)+AND+%22Surgery+Gynecology+Obstetrics%22%5BJournal%5D)">Progress in reconstruction after resection of the head of the pancreas.</a> Surgery Gynecology Obstetrics. 164 (6), 545-548 (1987).</li>
<li>Jover, J. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Results+of+defunctionalized+jejunal+loop+after+pancreaticoduodenectomy%5BTitle%5D)+AND+%22Cirurgia+Espanola%22%5BJournal%5D)">Results of defunctionalized jejunal loop after pancreaticoduodenectomy.</a> Cirurgia Espanola. 80 (6), 373-377 (2006).</li>
<li>Albertson, D. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pancreaticoduodenectomy+with+reconstruction+by+Roux-en-Y+pancreaticojejunostomy%3A+no+operative+mortality+in+a+series+of+25+cases%5BTitle%5D)+AND+%22The+Southern+Medical+Journal%22%5BJournal%5D)">Pancreaticoduodenectomy with reconstruction by Roux-en-Y pancreaticojejunostomy: no operative mortality in a series of 25 cases.</a> The Southern Medical Journal. 87 (2), 197-201 (1994).</li>
</ol>

The authors have nothing to disclose.

To date, POPF contributes significantly to the postoperative morbidity following PD1.
A mixture of bile and pancreatic juice can lead to mutual activation of both secretions, increasing their adverse effects on the PJ or the HJ9,13,14,15,16. Cytotoxic activity of activated phospholipase A2, which converts bil...

Pancreaticoduodenectomy (PD) is considered a sophisticated surgical procedure. While mortality has decreased over the last decades, morbidity still remains high1. The most frequent and feared complication is the postoperative pancreatic fistula (POPF), which occurs in over 20% of operations2,3,4,5. POPF can lead to subsequent complications such as postpancreatectomy hemorrhage, delayed gastric emptying, intraabdominal abscess and sepsis. Increased hospital costs, prolonged hospital stay, and delayed initiation of chemotherapy in cancer patients have a dramatic socioeconomic impact2,3,4.
Different surgical approaches have been introduced in the last decades to decrease the frequency and severity of POPF. One of those is the double-loop reconstruction (DLR) with isolated Roux-en-Y loops for the biliary and pancreatic anastomoses. Separating pancreatic juice from bile is thought to decrease the detrimental effects of mutually activated secretions on the pancreaticojejunostomy (PJ). Results in the literature have been encouraging6,7,8. However, operative time is significantly prolonged with DLR4,9.
We here introduce the technique of modified single-loop reconstruction (mSLR) during PD to separate pancreatic secretion from bile compared to the conventional single-loop reconstruction (SLR, Figure 1). In this method, a single long small-bowel loop is used for the construction of the hepaticojejunostomy (HJ) and PJ. A side-to-side anastomosis between the afferent and efferent limb of the HJ facilitates isolated flow of bile and pancreatic secretions. The first promising results confirming decreased mortality and morbidity in patients with high-risk pancreata were reported by our group in 201810.
This method reduces the severity of POPF by separating pancreatic fluid and bile without prolonging the duration of surgery significantly compared to the double-loop reconstruction.

<table><tbody><tr><td>Alexis O XXL</td><td>Applied medical</td><td>C8405</td><td></td></tr><tr><td>Bauchtuch Gr&amp;uuml;n 10x90</td><td>Nobatrast</td><td>603219</td><td>abdominal compress</td></tr><tr><td>Bauchtuch Gr&amp;uuml;n 45x45</td><td>Nobatrast</td><td>607544</td><td>abdominal compress</td></tr><tr><td>GIA 60mm-3.8mm</td><td>Covidien/Medtronic</td><td>GIA6038S</td><td></td></tr><tr><td>GIA Loading Unit</td><td>Covidien/Medtronic</td><td>GIA6038L</td><td></td></tr><tr><td>OP-Flex Yankauer</td><td>Unomedical</td><td>34094182</td><td>suction device</td></tr><tr><td>Pr&amp;auml;pariertupfer-Set</td><td>Fuhrmann</td><td>32019</td><td>sterile swab</td></tr><tr><td>Schlinggazetupfer 30x40</td><td>Fuhrmann</td><td>32016</td><td>sterile swab</td></tr><tr><td>Telescopic Smoke Pencil</td><td>LiNA Medical</td><td>SHK-TSP-CL</td><td>electro cautery</td></tr><tr><td>Thermocover ECO</td><td>PEMAX</td><td>TC43-75EC2</td><td>bowel cover</td></tr><tr><td>Whipple-Set</td><td>M&amp;ouml;lnlycke</td><td>97016042-00</td><td></td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td>&lt;strong&gt;Drainages:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Drainagebeutel</td><td>Coloplast</td><td>?</td><td>drainagebag</td></tr><tr><td>Silikon-Kapillardrainage</td><td>AsidBonz</td><td>551012</td><td>capillary drainage</td></tr><tr><td>Trichteransatz f&amp;uuml;r T-Rohr</td><td>R&amp;uuml;sch</td><td>333169-000025</td><td>2,5 mm</td></tr><tr><td>T-Rohr nach Kehr</td><td>R&amp;uuml;sch</td><td>423600-000025</td><td>t-tube 2,5 mm</td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td>&lt;strong&gt;Sutures:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Ethiloop 2mm 2x45cm</td><td>Ethicon</td><td>EH387</td><td>loop</td></tr><tr><td>Mersilene 0 FSL</td><td>Ethicon</td><td>EH7637</td><td>fixation of the drainage</td></tr><tr><td>PDS 1 CT</td><td>Ethicon</td><td>PDP9234</td><td>suturing of the fascia</td></tr><tr><td>Vicryl 2-0 , 6x45cm</td><td>Ethicon</td><td>VCP1226</td><td>for ligature</td></tr><tr><td>Vicryl 2-0 SHplus, 8x70</td><td>Ethicon</td><td>VCP7850</td><td>for ligature</td></tr><tr><td>Vicryl 3-0 MH-1plus</td><td>Ethicon</td><td>VCP245</td><td>subcutaneous suture</td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td>&lt;strong&gt;Pancreatic anastomoses:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Prolene 5-0 c1</td><td>Ethicon</td><td>8890</td><td>6 x</td></tr><tr><td>PDS 5.0 RB-1plus</td><td>Ethicon</td><td>X1153</td><td>2 x Multipack</td></tr><tr><td>Prolene 4-0 RB-1</td><td>Ethicon</td><td>8871</td><td>2 x holding sutures</td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td>&lt;strong&gt;Hepaticojejunostomy:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Prolene 5-0 c1</td><td>Ethicon</td><td>8890</td><td>2 x holding sutures</td></tr><tr><td>PDS 5-0 c1</td><td>Ethicon</td><td>PDP1013</td><td>7 x</td></tr><tr><td>PDS 6-0 c1</td><td>Ethicon</td><td>PDP1012</td><td>1 x mucosa fixation sutures</td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td>&lt;strong&gt;Gastrojejunostomy:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>PDS 4-0 SH-1 plus</td><td>Ethicon</td><td>X1154</td><td>1 x Multipack</td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td>&lt;strong&gt;Jejuno-Jejunostomy&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Ligasure</td><td>Covidien</td><td>LS1520</td><td></td></tr><tr><td>PDS 5-0 RB-1 plus</td><td>Ethicon</td><td>X1153</td><td>1 x Multipack</td></tr><tr><td>Prolene 2-0 SH</td><td>Ethicon</td><td>8833</td><td>Vessel-suture, etc.</td></tr><tr><td>Prolene 3-0 SH</td><td>Ethicon</td><td>8832</td><td>Cystic duct, cystic artery</td></tr><tr><td>Prolene 4-0 RB-1</td><td>Ethicon</td><td>8871</td><td>2 mal suturing of the slit in the meso</td></tr></tbody></table>

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.

Every patient undergoing PD underwent an investigation of the pancreatic tissue to evaluate the indication for mSLR. High-risk pancreatic remnants (i.e., soft pancreatic tissue and a tiny main pancreatic duct) were reconstructed using a modified single loop whenever possible.
We identified 50 patients with high risk pancreatic tissue and a small main pancreatic duct. All of them underwent mSLR. The mean age was 63 &#177; 13 years old. The male/female ratio was 17:33. Indications for surgery we...

Watch this Scientific Journal Video about Modified Single-Loop Reconstruction for Pancreaticoduodenectomy at JoVE.com

Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

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 ...

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7.4K Views.  Ruhr University Bochum. Scheiding van pancreasafscheiding van gal vermindert schadelijke effecten van wederzijds geactiveerde afscheidingen op de pancreaticoduodenostomie. Dit vermindert de ernst, maar niet de incidentie, van postoperatieve pancreasfistel. De single-loop reconstructie is een vaak uitgevoerde reconstructie techniek in pancreaticoduodenectomie.De dubbele lus reconstructie is voor het eerst geïntroduceerd in 1976. Het realiseert de theorie van de scheiding van pancreasvloeistof en gal. Deze pro...

Video: Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

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

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer: Surgical Planning and Technique

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), relying on collateral flow to the liver through the gastroduodenal artery (GDA). In the current manuscript, the technical conduct of robotic DP-CAR is outlined. The greater curve of the stomach is mobilized with care to avoid sacrificing the gastroepiploic vessels. The stomach and liver are retracted cephalad to facilitate dissection of the porta hepatis. The hepatic artery (HA) is dissected and encircled with a vessel loop. The gastroduodenal artery (GDA) is carefully preserved. The common HA is clamped and triphasic flow in the proper HA via the GDA is confirmed using intra-operative ultrasound. A retropancreatic tunnel is made over the superior mesenteric vein (SMV). The pancreas is divided with an endovascular stapler at the neck. The inferior mesenteric vein (IMV) and splenic vein are ligated. The HA is stapled proximal to the GDA. The entire specimen is retracted laterally with further dissection cephalad to expose the superior mesenteric artery (SMA). The SMA is then traced back to the aorta. The dissection continues cephalad along the aorta with the bipolar energy device used to divide the crural fibers and celiac nerve plexus. The specimen is mobilized from the patient's right to left until the origin of the celiac axis is identified and oriented towards the left. The trunk is circumferentially dissected and stapled. Additional dissection with hook cautery and the bipolar energy device fully mobilizes the pancreatic tail and spleen. The specimen is removed from the left lower quadrant extraction site and one drain is left in the resection bed. A final intra-operative ultrasound of the proper HA confirms pulsatile, triphasic flow in the artery and liver parenchyma. The stomach is inspected for evidence of ischemia. Robotic DP-CAR is safe, feasible and when used in conjunction with multi-modality therapy, offers potential for long-term survival in selected patients.

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection DP-CAR for Pancreatic Cancer: Surgical Planning and Technique

We present our operative approach to robot assisted distal pancreatectomy, splenectomy, and celiac axis resection (DP-CAR), demonstrating that the procedure is safe and feasible with proper planning, patient selection, and surgeon experience.

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), ...

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 ...

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body. With technological development, the robotic surgical system has shown its advantage in minimally invasive surgery and been increasingly applied in central pancreatectomy. However, reconstruction of the continuity of pancreas with end-to-end anastomosis after robotic central pancreatectomy has not been applied. In this study, we report surgical techniques for robotic central pancreatectomy with end-to-end anastomosis. The pancreas is reconstructed by duct-to-duct anastomosis of the pancreatic duct with a pancreatic stent inserted in the two stumps of pancreatic duct, and by end-to-end anastomosis of the pancreatic parenchyma. Compared with traditional central pancreatectomy with pancreaticoenteric anastomosis, this approach decreases the operative injury to the patient, and also conserves the integrity and continuity of the digestive duct and pancreatic duct. The robotic surgical system integrated with multiple instruments with flexible and precise movement is particularly suitable for the dissection and reconstruction of the pancreatic duct. We found that robotic central pancreatectomy with end-to-end anastomosis is safe and feasible, and we need more experience to evaluate its best indications and long-term outcomes.

The robotic central pancreatectomy with end-to-end anastomosis is feasible and safe for tumor in the pancreatic neck and proximal portion of pancreatic body. The operative techniques of this operation are presented.

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of ...

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 ...

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of 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 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.

Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

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