This research was not supported by any grants.

The protocol was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Meizhou People&#39;s Hospital. (MS-2023-C-95). Informed consent was obtained from patients for this study.
1. Patient selection
<ol>
	<li>Use the following inclusion criteria for patients: meet the clinical diagnosis of acute pancreatitis; age between 18 and 80 years; have a CT-enhanced scan grade D/E; and a substantial amount of necrotic tissue and fluid accumulation around the body and tail of the pancreas, as well as in the retroperitoneal area4.</li>
	<li>Use the following exclusion criteria: exclude patients with severe cardiopulmonary dysfunction or coagulation disorders and preoperative percutaneous drainage (PCD) who had digestive fluid or abdominal bleeding in cases where gastrointestinal fistulas had occurred.</li>
</ol>
2. Preoperative preparation
<ol>
	<li>Ask patients to abstain from food for 6 h and refrain from consuming any liquids for 2 h before the scheduled surgery.</li>
	<li>Prepare concentrated red blood cells and fresh frozen plasma for patients with hemoglobin (HGB) &#8804; 80 g/L. Briefly, upon obtaining a doctor&#39;s order and patient consent, collect blood samples from the patient and label them. Send this sample to the hospital&#39;s blood bank. Conduct tests to determine the patient&#39;s blood type and Rh factor, check for any antibodies, and confirm compatibility with donor blood.</li>
	<li>Administer intravenous antibiotics (such as 2.0 g of ceftriaxone) 30 min before anesthesia induction and proton pump inhibitors (such as omeprazole 40 mg).</li>
	<li>Administer general anesthesia and perform endotracheal intubation. Following required assessments, the anesthesiologist first administers sedatives and then general anesthesia. After the patient is unconscious, the anesthesiologist inserts an endotracheal tube through the mouth into the trachea, guided by a laryngoscope. The tube is then connected to a ventilator to manage the patient&#39;s breathing. Throughout this process, the anesthesiologist continuously tailors anesthesia delivery and closely monitors its depth.</li>
</ol>
3. Surgical procedure
<ol>
	<li>Review CT scans carefully to evaluate the severity of pancreatic necrosis and fluid distribution around the pancreas and retroperitoneum (Figure 1).</li>
	<li>After successful anesthesia induction, position the patient in the right lateral decubitus position, elevate the hip bridge, and perform routine draping.</li>
	<li>Arrange the three-port trocar as in laparoscopic retroperitoneal adrenal surgery8. In brief, make a 2 cm-long skin incision below the left axillary posterior line and rib margin using a scalpel. Separate the subcutaneous tissue and muscles with fingers, extend the fingers to push apart the lumbar fascia and peritoneum, and widen the retroperitoneal space.</li>
	<li>Place a 10 mm trocar, a 5 mm trocar, and another 10 mm trocar 2 cm above the iliac crest on the left midline, below the left anterior axillary line, and 2 cm above the iliac spine on the left midaxillary line, respectively. Inject CO2 gas and maintain the gas pressure at 12 mmHg. The trocar distribution is shown in Figure 2.</li>
	<li>Explore the retroperitoneal tissues laparoscopically, employing a sharp dissection method to clear perirenal fat tissue and expose the perirenal fascia with dissecting forceps and an ultrasonic scalpel.</li>
	<li>On the lateral side of the peritoneal reflection, use an ultrasonic scalpel to open the perirenal fascia. Use a suction device and blunt dissection to access the perirenal space between the descending colon and the left kidney. Due to inflammation and edema in the perirenal space, the process is prone to bleeding. Use bipolar electrocoagulation and an ultrasonic scalpel to achieve hemostasis.</li>
	<li>Incise the anterior renal fascia and extend the retroperitoneal front space of the kidney (Figure 3). Aspirate the pus and send a portion of the sample for bacterial culture. Enlarge the incision, enter the abscess cavity, and remove the black necrotic tissue carefully and repeatedly using tissue forceps (Figure 3).</li>
	<li>Rinse the abscess cavity with hydrogen peroxide-povidone-iodine-normal saline solution, in this order, until the rinsing fluid becomes relatively clear.</li>
	<li>To achieve thorough hemostasis in the surgical area, place drainage tubes below and front of the pancreas and lead the tubes through the abdominal punctures (Figure 2).</li>
	<li>After confirming that there was no bleeding at the incision site, remove the trocars, intermittently suture the incisions with 4-0 silk sutures, and terminate the surgery.</li>
</ol>
4. Postoperative management
<ol>
	<li>Considering the severity and high mortality of necrotizing pancreatitis, transfer patients to the intensive care unit (ICU) for further observation after surgery.</li>
	<li>Based on the bacterial culture results, initiate an appropriate antibiotic treatment regimen in accordance with the identified bacteria and its sensitivity profile.
	<ol>
		<li>Administer the selected antibiotic at regular intervals, as prescribed by the treating physician. During this time, periodically monitor serum procalcitonin levels, a biomarker for bacterial infection, with blood tests. Continue the antibiotic treatment until these levels return to normal, indicating resolution of the infection. All procedures were performed following established protocols and guidelines for management of bacterial infections9.</li>
		<li>Administer intravenous proton pump inhibitors (PPIs) for at least 1 week before the patients are switched to oral PPIs (single dose) for 4 weeks. If complications such as gastrointestinal or intra-abdominal bleeding occur, extend the duration of intravenous PPI usage.</li>
	</ol>
	</li>
	<li>Perform daily peritoneal lavage with 3000-6000 mL of normal saline solution with low central negative pressure suction, ensuring the drainage tubes remain unobstructed.</li>
	<li>Recover patients from a liquid diet 24 h after surgery, gradually progressing to a regular diet based on gastrointestinal function recovery. Pay careful attention to maintaining regular bowel movements.</li>
</ol>
5. Follow-up procedures
<ol>
	<li>Conduct outpatient visits and telephone interviews at 1 month, 3 months, 6 months, and 1 year after surgery.</li>
	<li>In follow-up, assess the patient&#39;s diet and weight changes and schedule examinations, including enhanced abdominal CT, complete blood count, PCT, pancreatic enzymes, and liver function.</li>
</ol>

Laparoscopic Retroperitoneal Treatment of Necrotizing Pancreatitis Complications

<ol>
	<li>Wang, S. Q., 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=The+day+when+infection+is+confirmed+is+a+better+time+point+for+mortality+prediction+in+patients+with+severe+acute+pancreatitis.">The day when infection is confirmed is a better time point for mortality prediction in patients with severe acute pancreatitis.</a> Pancreas. 41 (4), 605-610 (2012).</li><li>Zou, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Study+on+the+related+factors+of+severe+pancreatitis+complicated+with+early+infection.">A Study on the related factors of severe pancreatitis complicated with early infection.</a> Modern Chinese Doctor. 45 (20), 13-14 (2007).</li><li>Shen, Y. F., Cui, N. Q. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+observation+of+immunity+in+patients+with+secondary+infection+from+severe+acute+pancreatitis.">Clinical observation of immunity in patients with secondary infection from severe acute pancreatitis.</a> Inflammation Res. 61 (7), 743-748 (2012).</li><li>Chen, G. D., Huang, Y. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+analysis+of+ten+cases+of+severe+acute+pancreatitis+complicated+with+peripancreatic+necrosis+with+minimally+invasive+treatment+via+retroperitoneal+pathway.">Clinical analysis of ten cases of severe acute pancreatitis complicated with peripancreatic necrosis with minimally invasive treatment via retroperitoneal pathway.</a> Chinese J Pancreatol. 17 (4), 228-230 (2017).</li><li>Working Group IPA/APA Acute Pancreatitis. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Working+Group+IPA/APA+Acute+Pancreatitis+Guidelines.+IAP/APA+evidence+-+based+guidelines+for+the+management+of+acute+pancreatitis.">Working Group IPA/APA Acute Pancreatitis Guidelines. IAP/APA evidence - based guidelines for the management of acute pancreatitis.</a> Pancrcatology. 13 (4), 15 (2013).</li><li>Chen, P., Tang, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+of+severe+acute+pancreatitis+with+laparoscopic+drainage+via+posterior+approach.">Treatment of severe acute pancreatitis with laparoscopic drainage via posterior approach.</a> Chinese J Curr Adv Gen Surg. 12 (11), 928-930 (2009).</li><li>Sileikis, A., 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=Three-port+retroperitoneoscopic+necrosectomy+in+management+of+acute+necrotic+pancreatitis.">Three-port retroperitoneoscopic necrosectomy in management of acute necrotic pancreatitis.</a> Medicina. 46 (3), 176-179 (2010).</li><li>Zhang, X., 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=Technique+of+anatomical+retroperitoneoscopic+adrenalectomy+with+report+of+800+cases.">Technique of anatomical retroperitoneoscopic adrenalectomy with report of 800 cases.</a> J Urol. 177 (4), 1254-1257 (2007).</li><li>Chinese Society of Surgical Infection and Intensive Care, Chinese Society of Surgery, Chinese Medical Association, Chinese College of Gastrointestinal Fistula Surgeons, Chinese College of Surgeons, Chinese Medical Doctor Association. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Chinese+guidelines+for+the+diagnosis+and+management+of+intra-+abdominal+infection.">Chinese guidelines for the diagnosis and management of intra- abdominal infection.</a> Chinese J Pract Surg. 40 (1), 1-16 (2020).</li><li>Banks, P. A., 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=Classification+of+acute+pancreatitis-2012:+revision+of+the+Atlanta+classification+and+definitions+by+international+consensus.">Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus.</a> Gut. 62, 102-111 (2013).</li><li>Hong, C., Sun, B., Lu, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preliminary+exploration+of+basic+treatment+principles+for+severe+acute+pancreatitis.">Preliminary exploration of basic treatment principles for severe acute pancreatitis.</a> Chinese J Surg. 45 (1), 6-8 (2007).</li><li>Adler, D. G., 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=Conservative+management+of+infected+necrosis+complicating+severe+acute+pancreatitis.">Conservative management of infected necrosis complicating severe acute pancreatitis.</a> Am J Gastroenterol. 98 (1), 98-103 (2003).</li><li>Yao, J. R., Tian, Y. Z., Liu, S. Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incremental+trauma+surgical+mode+for+the+treatment+of+severe+acute+pancreatitis.">Incremental trauma surgical mode for the treatment of severe acute pancreatitis.</a> Chinese J Joint Surg. 9 (3), 213-215 (2020).</li><li>Penghao, 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=Endoscopic+versus+minimally+invasive+surgical+approach+for+infected+necrotizing+pancreatitis:+a+systematic+review+and+meta-analysis+of+randomized+controlled+trials.">Endoscopic versus minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials.</a> Ann Med. 55 (2), 1-13 (2023).</li><li>Pancreatic Surgery Group, Surgery Branch, Chinese Medical Association. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Guidelines+for+the+diagnosis+and+treatment+of+acute+pancreatitis.">Guidelines for the diagnosis and treatment of acute pancreatitis.</a> Chinese J Digest Surg. 20 (7), 730-739 (2021).</li><li>Van Santvoort, H. C., 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=A+conservative+and+minimally+invasive+approach+to+necrotizing+pancreatitis+improves+outcome.">A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome.</a> Gastroenterology. 141 (4), 1254-1263 (2011).</li></ol>

The authors declare that they have nothing to disclose.

The optimal timing of surgical intervention for SAP has been a subject of ongoing debate. In the past, surgical intervention was assumed to be performed immediately upon the occurrence of pancreatic infection-related necrosis. However, since 2000, an increasing number of experts have suggested that the timing of surgical intervention for SAP should be postponed as much as possible11,12,13. Aseptic peripancreatic necrosis may not...

The treatment of severe acute pancreatitis (SAP) complicated by peripancreatic infection and necrosis has long been a difficult problem to solve1,2. Pancreatic infection and necrosis are serious complications of severe acute pancreatitis3. Reducing abdominal and retroperitoneal pressure, removing necrotic tissue as much as possible, and reducing the absorption of toxic substances are the main surgical principles for successfully treating SAP4. Traditional open surgery and continuous postoperative lavage have saved the lives of many SAP patients. However, the transabdominal approach requires perforation of the gastrocolic ligament, entry into the minor omental sac, and subsequent invasion of all segments of the pancreas, which inevitably interferes with various abdominal organs and might introduce retroperitoneal bacteria into the abdominal cavity, increasing the risk of abdominal infection. In addition, the drainage tube is drained from the retroperitoneal cavity to the outside of the abdominal wall. Owing to poor drainage, compression of the intestinal tube may also cause intestinal fistula and abdominal bleeding. In 2013, the Evidence-based Guidelines for the Treatment of Acute Pancreatitis issued by the International Society of Pancreatology and the American Society of Pancreatology noted that minimally invasive debridement of necrotic tissue was superior to open debridement for patients with symptomatic infectious necrosis5. Chen et al.6 used peritoneal laparoscopy to reach the peritoneum, remove necrotic pancreatic tissue, and place the drainage tube, achieving satisfactory results. However, theoretically, problems such as bacterial displacement and peritoneal infection caused by communication between the peritoneum and retroperitoneum are inevitable. Sileikis et al.7 used three-hole laparoscopic retroperitoneal resection of pancreatic necrotic tissue and catheter drainage from 2007 to 2009 and cured 8 SAP patients.
Since 2016, we have adopted retroperitoneal laparoscopy to remove necrotic pancreatic tissue through a retroperitoneal approach. Compared to other minimally invasive surgeries, this method is more direct and safer. It provides direct access to the retroperitoneal space, allowing direct visualization and removal of necrotic tissue in the renal capsule. The field of view is clear, bleeding is easily controlled, and a drainage tube can be placed as needed, ensuring effective drainage. The drainage tube does not pass through the abdominal cavity, causing minimal disturbance to the cavity and reducing the risk of abdominal infection. The necrosis and infection of SAP occur mostly in the tail of the pancreas. There is often necrosis of the peripancreatic fatty tissue, which sometimes extends into the left colonic sulcus. Therefore, we utilized a left-sided approach in all patients, and typically, a single surgery was sufficient to thoroughly remove the necrotic tissue. We believe that retroperitoneal laparoscopic surgery via a left-sided approach is particularly suitable for patients with necrosis of the pancreatic body and tail combined with massive effusion.

<table><tbody><tr><td>Dissecting forceps</td><td>KANGJI</td><td>ZP485RB 330mm&amp;times;&amp;Phi;5</td><td></td></tr><tr><td>Drainage tube</td><td>Kang-Li</td><td>QH-F28</td><td></td></tr><tr><td>Grasping forceps</td><td>KANGJI</td><td>ZP531RB 330mm&amp;times;&amp;Phi;5</td><td></td></tr><tr><td>Laparoscope</td><td>STORZ</td><td>26003BA</td><td></td></tr><tr><td>Normal Saline 3000ml</td><td>Ke-Lun</td><td>3000ml:27g</td><td></td></tr><tr><td>Suction and Irrigation</td><td>KANGJI</td><td>&amp;Phi;5/&amp;Phi;10&amp;times;330mm</td><td></td></tr><tr><td>Suture</td><td>ETHICON</td><td>SA86G</td><td></td></tr><tr><td>Trocar</td><td>KANGJI</td><td>ZP015RN &amp;Phi;5.5/ ZP018RN &amp;Phi;12.5</td><td></td></tr><tr><td>Ultrasonic knife</td><td>An-He</td><td>AH-600</td><td></td></tr><tr><td>Veress needle</td><td>KANGJI</td><td>ZP001RN &amp;Phi;2.5&amp;times;100mm</td><td></td></tr></tbody></table>

retroperitoneal laparoscopic debridement and drainage for pancreatic abscess

In patients with severe necrotizing pancreatitis, pancreatic necrosis and secondary infection of surrounding tissues can quickly spread to the whole retroperitoneal space. Treatment of pancreatic abscess complicating necrotizing pancreatitis is difficult and has a high mortality rate. The well-accepted treatment strategy is early debridement of necrotic tissues, drainage, and postoperative continuous retroperitoneal lavage. However, traditional open surgery has several disadvantages, such as severe trauma, interference with abdominal organs, a high rate of postoperative infection and adhesion, and hardness with repeated debridement. The retroperitoneal laparoscopic approach has the advantages of minimal invasion, a better drainage route, convenient repeated debridement, and avoidance of the spread of retroperitoneal infection to the abdominal cavity. In addition, retroperitoneal drainage leads to fewer drainage tube problems, including miscounting, displacement, or siphon. The debridement and drainage of pancreatic abscess tissue via the retroperitoneal laparoscopic approach plays an increasingly irreplaceable role in improving patient prognosis and saving healthcare resources and costs. The main procedures described here include laying the patient on the right side, raising the lumbar bridge and then arranging the trocar; establishing the pneumoperitoneum and cleaning the pararenal fat tissues; opening the lateral pyramidal fascia and the perirenal fascia outside the peritoneal reflections; opening the anterior renal fascia and entering the anterior pararenal space from the rear; clearing the necrotic tissue and accumulating fluid; and placing drainage tubes and performing postoperative continuous retroperitoneal lavage.

A total of six patients received this surgical treatment (Table 1). Preoperatively, all patients were assessed based on PaO2/FiO2, systolic blood pressure, and creatinine levels and were assigned modified Marshall score10 and APACHE II scores (Table 2). All patients underwent surgery smoothly, and the duration of surgery ranged from 75 to 100 min, with an average of 84 &#177; 6.7 min. Preoperative bacterial cultures obtained through PCD tubes...

Read this Scientific Article Protocol about Author Spotlight: Advancements in Retroperitoneal Approach for Necrotizing Pancreatitis at JoVE.com

Author Spotlight: Advancements in Retroperitoneal Approach for Necrotizing Pancreatitis

To improve the drainage of patients with necrotizing pancreatitis complicated with peripancreatic abscess and reduce the mortality of patients with necrotizing pancreatitis, we adopted a retroperitoneal approach for peripancreatic abscess debridement and drainage by laparoscopy.

Retroperitoneal Laparoscopic Debridement and Drainage for Pancreatic Abscess

In patients with severe necrotizing pancreatitis, pancreatic necrosis and secondary infection of surrounding tissues can quickly spread to the whole ...

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356 Views.  Meizhou People’s Hospital. To improve the drainage of patients with necrotizing pancreatitis complicated with peripancreatic abscess and reduce the mortality of patients with necrotizing pancreatitis, we adopted a retroperitoneal approach for peripancreatic abscess debridement and drainage by laparoscopy.

Video: Author Spotlight: Advancements in Retroperitoneal Approach for Necrotizing Pancreatitis

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 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 ...

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 ...

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 ...

Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing pancreatitis, if it does not resolve or is accompanied with infected necrosis in the retroperitoneum. As there are rarely any visually clear separating surface in white light image between necrotic debris and adjacent inflammatory normal tissues due to extensive retroperitoneal adhesions, VARD is accompanied with the risk of vascular injury, external pancreatico-cutaneous or enterocutaneous fistulae. In view of the above disadvantages, we apply real-time intraoperative near-infrared fluorescence imaging with indocyanine green (ICG) during VARD, which enables visualization of the well-perfused adjacent normal tissues. This modified technique (ICG-guided VARD) can provide a clear separating surface during debridement and reduce the risk of vascular or enteric injury. ICG-guided VARD may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis.

This protocol presents Indocyanine Green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis.

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing ...

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 ...

Retroperitoneal Laparoscopic Debridement and Drainage for Pancreatic Abscess

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