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>
	<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=Impact+of+a+Nationwide+Training+Program+in+Minimally+Invasive+Distal+Pancreatectomy+(LAELAPS).">Impact of a Nationwide Training Program in Minimally Invasive Distal Pancreatectomy (LAELAPS).</a> Ann Surg. , (2016).</li><li>van Hilst, J., 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=Worldwide+survey+on+opinions+and+use+of+minimally+invasive+pancreatic+resection.">Worldwide survey on opinions and use of minimally invasive pancreatic resection.</a> HPB (Oxford). , (2017).</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=Laparoscopic+Distal+Pancreatectomy+for+Pancreatic+Ductal+Adenocarcinoma:+Time+for+a+Randomized+Controlled+Trial?+Results+of+an+All-inclusive+National+Observational+Study.">Laparoscopic Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma: Time for a Randomized Controlled Trial? 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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B., 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=Matched+Case-Control+Analysis+Comparing+Laparoscopic+and+Open+Pylorus-preserving+Pancreaticoduodenectomy+in+Patients+With+Periampullary+Tumors.">Matched Case-Control Analysis Comparing Laparoscopic and Open Pylorus-preserving Pancreaticoduodenectomy in Patients With Periampullary Tumors.</a> Ann Surg. 262 (1), 146-155 (2015).</li><li>Palanivelu, 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=Evolution+in+techniques+of+laparoscopic+pancreaticoduodenectomy:+a+decade+long+experience+from+a+tertiary+center.">Evolution in techniques of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center.</a> J Hepatobiliary Pancreat Surg. 16 (6), 731-740 (2009).</li></ol>

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 border="0" cellpadding="0" cellspacing="0" width="572">
	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:215px;">Bair Hugger</td>
			<td style="width:72px;">3M COMPANY</td>
			<td style="width:119px;">79500</td>
			<td style="width:167px;">Patient Warming Unit, Model 795, 120V-ENG-E, Refurbished 79500</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">ENSEAL</td>
			<td>Ethicon Endo-Surgery, Cincinnati, OH, USA</td>
			<td>NSLG2C45</td>
			<td>articulating sealing device&#160;</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">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 height="21">
			<td height="21" style="height:21px;">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 height="21">
			<td height="21" style="height:21px;">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 height="21">
			<td height="21" style="height:21px;">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 height="21">
			<td height="21" style="height:21px;width:215px;">V-Loc</td>
			<td style="width:72px;">Covidien</td>
			<td style="width:119px;">VLOCM1824&#160;</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.&#160;</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">VICRYL Suture</td>
			<td style="width:72px;">ETHICON&#160;</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&#39;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="Figure 1" class="xfigimg" src="/files/ftp_upload/56819/56819fig1.jpg" /> 
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="Figure 2" class="xfigimg" src="/files/ftp_upload/56819/56819fig2.jpg" /> 
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="Figure 3" class="xfigimg" src="/files/ftp_upload/56819/56819fig3.jpg" /> 
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.

Watch this Scientific Journal Video about Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy at JoVE.com

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. 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.

Video: Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Anticancer Efficacy of Photodynamic Therapy with Lung Cancer-Targeted Nanoparticles

Photodynamic therapy (PDT) is a non-invasive and non-surgical method representing an attractive alternative choice for lung cancer treatment. Photosensitizers selectively accumulate in tumor tissue and lead to tumor cell death in the presence of oxygen and the proper wavelength of light.
To increase the therapeutic effect of PDT, we developed both photosensitizer- and anticancer agent-loaded lung cancer-targeted nanoparticles. Both enhanced permeability and retention (EPR) effect-based passive targeting and hyaluronic-acid-CD44 interaction-based active targeting were applied. CD44 is a well-known hyaluronic acid receptor that is often introduced as a biomarker of non-small cell lung cancer. 
In addition, a combination of PDT and chemotherapy is adopted in the present study. This combination concept may increase anticancer therapeutic effects and reduce adverse reactions. 
We chose hypocrellin B (HB) as a novel photosensitizer in this study. It has been reported that HB causes higher anticancer efficacy of PDT compared to hematoporphyrin derivatives1. Paclitaxel was selected as the anticancer drug since it has proven to be a potential treatment for lung cancer2. 
The antitumor efficacies of photosensitizer (HB) solution, photosensitizer encapsulated hyaluronic acid-ceramide nanoparticles (HB-NPs), and both photosensitizer- and anticancer agent (paclitaxel)-encapsulated hyaluronic acid-ceramide nanoparticles (HB-P-NPs) after PDT were compared both in vitro and in vivo. The in vitro phototoxicity in A549 (human lung adenocarcinoma) cells and the in vivo antitumor efficacy in A549 tumor-bearing mice were evaluated.
The HB-P-NP treatment group showed the most effective anticancer effect after PDT. In conclusion, the HB-P-NPs prepared in the present study represent a potential and novel photosensitizer delivery system in treating lung cancer with PDT.

Photodynamic therapy (PDT) is an alternative choice for lung cancer treatment. To increase the therapeutic effect of PDT, lung cancer-targeted nanoparticles combined with chemotherapy were developed. Both in vitro and in vivo anticancer efficacies of PDT with prepared nanoparticles were evaluated.

Photodynamic therapy (PDT) is a non-invasive and non-surgical method representing an attractive alternative choice for lung cancer treatment. ...

Modified Terminal Restriction Fragment Analysis for Quantifying Telomere Length Using In-gel Hybridization

There are several different techniques for measuring telomere length, each with their own advantages and disadvantages. The traditional approach, Telomere Restriction Fragment (TRF) analysis, utilizes a DNA hybridization technique whereby genomic DNA samples are digested with restriction enzymes, leaving behind telomere DNA repeats and some sub-telomeric DNA. These are separated by agarose gel electrophoresis, transferred to a filter membrane and hybridized to oligonucleotide probes tagged with either chemiluminescence or radioactivity to visualize telomere restriction fragments. This approach, while requiring a larger quantity of DNA than other techniques such as PCR, can measure the telomere length distribution of a population of cells and allows measurement expressed in absolute kilobases. This manuscript demonstrates a modified DNA hybridization procedure for determining telomere length. Genomic DNA is first digested with restriction enzymes (that do not cut telomeres) and separated by agarose gel electrophoresis. The gel is then dried and the DNA is denatured and hybridized in situ to a radiolabeled oligonucleotide probe. This in situ hybridization avoids loss of telomere DNA and improves signal intensity. Following hybridization, the gels are imaged utilizing phosphor screens and the telomere length is quantified using a graphing program. This procedure was developed by the laboratories of Drs. Woodring Wright and Jerry Shay at the University of Texas Southwestern1,2. Here, we present a detailed description of this procedure, with some modifications.

In this article, a detailed protocol for quantifying telomere length using a modified terminal restriction fragment analysis is discussed that provides fast and efficient direct measurement of telomere length. This technique can be applied to a variety of cell sources of DNA for quantifying telomere length.

There are several different techniques for measuring telomere length, each with their own advantages and disadvantages. The traditional approach, Telomere ...

Counting Proteins in Single Cells with Addressable Droplet Microarrays

Often cellular behavior and cellular responses are analyzed at the population level where the responses of many cells are pooled together as an average result masking the rich single cell behavior within a complex population. Single cell protein detection and quantification technologies have made a remarkable impact in recent years. Here we describe a practical and flexible single cell analysis platform based on addressable droplet microarrays. This study describes how the absolute copy numbers of target proteins may be measured with single cell resolution. The tumor suppressor p53 is the most commonly mutated gene in human cancer, with more than 50% of total cancer cases exhibiting a non-healthy p53 expression pattern. The protocol describes steps to create 10 nL droplets within which single human cancer cells are isolated and the copy number of p53 protein is measured with single molecule resolution to precisely determine the variability in expression. The method may be applied to any cell type including primary material to determine the absolute copy number of any target proteins of interest.

Here we present addressable droplet microarrays (ADMs), a droplet array based method able to determine absolute protein abundance in single cells. We demonstrate the capability of ADMs to characterize the heterogeneity in expression of the tumor suppressor protein p53 in a human cancer cell line.

Often cellular behavior and cellular responses are analyzed at the population level where the responses of many cells are pooled together as an average ...

Generation and Isolation of Cell Cycle-arrested Cells with Complex Karyotypes

Chromosome mis-segregation leads to aneuploidy, a condition in which cells harbor an imbalanced chromosome number. Several lines of evidence strongly indicate that aneuploidy triggers genome instability, ultimately generating cells with complex karyotypes that arrest their proliferation. Isolation and characterization of cells harboring complex karyotypes are crucial to study the impact of an imbalanced chromosome number on cell physiology. To date, no methods have been established to reliably isolate such aneuploid cells. This paper provides a protocol for the enrichment and analysis of aneuploid cells with complex karyotypes utilizing standard, inexpensive tissue culture techniques. This protocol can be used to analyze several features of aneuploid cells with complex karyotypes including their induced senescence-associated secretory phenotype, pro-inflammatory properties, and ability to interact with immune cells. Because cancer cells often harbor imbalances in chromosome number, it is crucial to decipher how aneuploidy impacts cell physiology in normal cells, with the ultimate goal of uncovering both its pro- and anti-tumorigenic effects.

Aneuploidy leads to genome instability, which eventually produces cell cycle-arrested cells with complex karyotypes. This paper provides a simple and convenient method to isolate aneuploid cells with complex karyotypes that cease to divide.

Chromosome mis-segregation leads to aneuploidy, a condition in which cells harbor an imbalanced chromosome number. Several lines of evidence strongly ...

A GPC3-targeting Bispecific Antibody, GPC3-S-Fab, with Potent Cytotoxicity

This protocol describes the construction and functional studies of a bispecific antibody (bsAb), GPC3-S-Fab. bsAbs can recognize two different epitopes through their two different arms. bsAbs have been actively studied for their ability to directly recruit immune cells to kill tumor cells. Currently, the majority of bsAbs are produced in the form of recombinant proteins, either as Fc-containing bsAbs or as smaller bsAb derivatives without the Fc region. In this study, GPC3-S-Fab, an antibody fragment (Fab) based bispecific antibody, was designed by linking the Fab of anti-GPC3 antibody GC33 with an anti-CD16 single domain antibody. The GPC3-S-Fab can be expressed in Escherichia coli and purified by two affinity chromatographies. The purified GPC3-S-Fab can specifically bind to and kill GPC3 positive liver cancer cells by recruiting natural killer cells, suggesting a potential application of GPC3-S-Fab in liver cancer therapy.

Here, we present a protocol to produce a bispecific antibody GPC3-S-Fab in Escherichia coli. The purified GPC3-S-Fab has potent cytotoxicity against GPC3 positive liver cancer cells.

This protocol describes the construction and functional studies of a bispecific antibody (bsAb), GPC3-S-Fab. bsAbs can recognize two different epitopes ...

Selecting Multiple Biomarker Subsets with Similarly Effective Binary Classification Performances

Biomarker detection is one of the more important biomedical questions for high-throughput &#39;omics&#39; researchers, and almost all existing biomarker detection algorithms generate one biomarker subset with the optimized performance measurement for a given dataset. However, a recent study demonstrated the existence of multiple biomarker subsets with similarly effective or even identical classification performances. This protocol presents a simple and straightforward methodology for detecting biomarker subsets with binary classification performances, better than a user-defined cutoff. The protocol consists of data preparation and loading, baseline information summarization, parameter tuning, biomarker screening, result visualization and interpretation, biomarker gene annotations, and result and visualization exportation at publication quality. The proposed biomarker screening strategy is intuitive and demonstrates a general rule for developing biomarker detection algorithms. A user-friendly graphical user interface (GUI) was developed using the programming language Python, allowing biomedical researchers to have direct access to their results. The source code and manual of kSolutionVis can be downloaded from http://www.healthinformaticslab.org/supp/resources.php.

Existing algorithms generate one solution for a biomarker detection dataset. This protocol demonstrates the existence of multiple similarly effective solutions and presents a user-friendly software to help biomedical researchers investigate their datasets for the proposed challenge. Computer scientists may also provide this feature in their biomarker detection algorithms.

Biomarker detection is one of the more important biomedical questions for high-throughput &#39;omics&#39; researchers, and almost all existing biomarker ...

Analyzing Tumor Gene Expression Factors with the CorExplorer Web Portal

Differential gene expression analysis is an important technique for understanding disease states. The machine learning algorithm CorEx has shown utility in analyzing differential expression of groups of genes in tumor RNA-seq in a way that may be helpful for advancing precision oncology. However, CorEx produces many factors that can be challenging to analyze and connect to existing understanding. To facilitate such connections, we have built a website, CorExplorer, that allows users to interactively explore the data and answer common questions related to its analysis. We trained CorEx on RNA-seq gene expression data for four tumor types: ovarian, lung, melanoma, and colorectal. We then incorporated corresponding survival, protein-protein interactions, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichments, and heatmaps into the website for association with the factor graph visualization. Here we employ example protocols to illustrate use of the database for comprehending the significance of the learned tumor factors in the context of this external data.

We introduce the CorExplorer web portal, an resource for exploration of tumor RNA sequencing factors found by the machine learning algorithm CorEx (Correlation Explanation), and show how factors can be analyzed relative to survival, database annotations, protein-protein interactions, and one another to gain insight into tumor biology and therapeutic interventions.

Differential gene expression analysis is an important technique for understanding disease states. The machine learning algorithm CorEx has shown utility ...

Tumor Allotransplantation in Drosophila melanogaster with a Programmable Auto-Nanoliter Injector

This protocol describes the allotransplantation of tumors in Drosophila melanogaster using an auto-nanoliter injection apparatus. With the use of an autoinjector apparatus, trained operators can achieve more efficient and consistent transplantation results compared to those obtained using a manual injector. Here, we cover topics in a chronological fashion: from the crossing of Drosophila lines, to the induction and dissection of the primary tumor, transplantation of the primary tumor into a new adult host and continued generational transplantation of the tumor for extended studies. As a demonstration, here we use Notch intracellular domain (NICD) overexpression induced salivary gland imaginal ring tumors for generational transplantation. These tumors can first be reliably induced in a transition-zone microenvironment within larval salivary gland imaginal rings, then allografted and cultured in vivo to study continued tumor growth, evolution, and metastasis. This allotransplantation method can be useful in potential drug screening programs, as well as for studying tumor-host interactions.

Tumor Allotransplantation in Drosophila melanogaster with a Programmable Auto-Nanoliter Injector

This protocol provides detailed guidance for the initial and continued generational allotransplantation of Drosophila tumors into the abdomen of adult hosts for studying various aspects of neoplasia. Using an autoinjector apparatus, researchers can achieve improved efficiency and tumor yields compared to those achieved by traditional, manual methods.

This protocol describes the allotransplantation of tumors in Drosophila melanogaster using an auto-nanoliter injection apparatus. With the use of an ...

Natural Killer (NK) and CAR-NK Cell Expansion Method using Membrane Bound-IL-21-Modified B Cell Line

Chimeric antigen receptor (CAR)-modified immune cell therapy has become an emerging treatment for cancers and infectious diseases. NK-based immunotherapy, particularly CAR-NK cell, is one of the most promising 'off-the-shelf' development without severe life-threatening toxicity. However, the bottleneck for developing a successful CAR-NK therapy is achieving sufficient numbers of non-exhaustive, long-lived, 'off-the-shelf' CAR-NK cells from a third party. Here, we developed a new CAR-NK expansion method using an Epstein-Barr virus- (EBV) transformed B cell line expressing a genetically modified membrane form of interleukin-21 (IL-21). In this protocol, step-by-step procedures are provided to expand NK and CAR-NK cells from cord blood and peripheral blood, as well as solid organ tissues. This work will significantly enhance the clinical development of CAR-NK immunotherapy.

Natural Killer NK and CAR-NK Cell Expansion Method using Membrane Bound-IL-21-Modified B Cell Line

Here, we present a method to expand peripheral blood natural killer (PBNK), NK cells from liver tissues, and chimeric antigen receptor (CAR)-NK cells derived from peripheral blood mononuclear cells (PBMCs) or cord blood (CB). This protocol demonstrates the expansion of NK and CAR-NK cells using 221-mIL-21 feeder cells in addition to the optimized purity of expanded NK cells.

Chimeric antigen receptor (CAR)-modified immune cell therapy has become an emerging treatment for cancers and infectious diseases. NK-based immunotherapy, ...

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 ...

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Summary

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Chapters in this video

Anticancer Efficacy of Photodynamic Therapy with Lung Cancer-Targeted Nanoparticles

Modified Terminal Restriction Fragment Analysis for Quantifying Telomere Length Using In-gel Hybridization

Counting Proteins in Single Cells with Addressable Droplet Microarrays

Generation and Isolation of Cell Cycle-arrested Cells with Complex Karyotypes

A GPC3-targeting Bispecific Antibody, GPC3-S-Fab, with Potent Cytotoxicity

Selecting Multiple Biomarker Subsets with Similarly Effective Binary Classification Performances

Analyzing Tumor Gene Expression Factors with the CorExplorer Web Portal

Tumor Allotransplantation in Drosophila melanogaster with a Programmable Auto-Nanoliter Injector

Natural Killer (NK) and CAR-NK Cell Expansion Method using Membrane Bound-IL-21-Modified B Cell Line

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