Our article #64904 was supported by the Research project of Traditional Chinese Medicine Bureau of Guangdong Province (ID:20222077).

This study was approved by the Ethics Committee of the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, and informed written consent was obtained from the patients involved in this study.
1. Preoperative work-up
<ol>
	<li>Perform the high-resolution contrast-enhanced CT12,13 (see Table of Materials) to assess the tumor&#39;s extent and search for any abnormal vasculature.</li>
	<li>Determine the inclusion and exclusion criteria for patients.
	<ol>
		<li>Select patients meeting the following criteria: (1) a tumor located in the uncinate process that needs radical resection; (2) resectable cases.</li>
		<li>Exclude the following cases: (1) metastatic tumor; (2) patients with poor cardio-pulmonary function that may not tolerate laparoscopic surgery; (3) a tumor that has invaded the major vessels such as SMA, common hepatic artery (CHA), or celiac artery (CA).</li>
	</ol>
	</li>
</ol>
2. Anesthetization steps
<ol>
	<li>Use 0.3 &#181;g/kg sufentanil, 3 &#181;g/mL propofol, and 0.15 mg/kg cis-atracurium (see Table of Materials) for anesthesia induction.</li>
	<li>Perform endotracheal intubation14 after the muscle relaxant takes effect.</li>
	<li>Puncture and catheterize the radial artery and central vein under the guidance of ultrasound.</li>
	<li>Use target-controlled infusion (TCI) of 1-2 &#181;g/mL propofol, 1-3 ng/mL remifentanil, 1.53 &#181;g/kg/min cis-atracurium, and sevoflurane (see Table of Materials) with an inhaled concentration of 1%-2% to maintain anesthesia, and keep the depth of anesthesia between 37 and 64 on the Nacrotrend Index15. 
	NOTE: The Nacrotrend anesthesia monitoring system (see Table of Materials) is an anesthesia depth monitoring method developed in recent years. It obtains the original EEG, analyzes the changes in frequency and power in the EEG, integrates the factors of phase and harmonics, and expresses the anesthesia depth in the form of a value from 0-99.</li>
	<li>Set the ventilator parameters to volume control ventilation mode, with a tidal volume of 8 mL/kg, an inhalation oxygen saturation of 60%, a gas flow of 2 L/min, and an end-expiratory carbon dioxide range of 35-45 mmHg.</li>
</ol>
3. Installation
<ol>
	<li>Refer to our previously published8 article (Figure 1) for details on the patient position and trocar (see Table of Materials) location.</li>
	<li>Surgeon position: Ensure that the operator surgeon and the first assistant stand on the patient&#39;s right and left sides, respectively. Ensure that the holder of the laparoscope stands between the patient&#39;s legs.</li>
</ol>
4. Surgery techniques
<ol>
	<li>Inspect the peritoneal surfaces and intraperitoneal organs for any potential extrapancreatic metastases. Remove the greater omentum for better exposure, and open the lesser sac by severing the gastrocolic ligament.</li>
	<li>Dissect the gallbladder triangle with an ultrasonic knife, then resect and sever the gallbladder artery and cystic duct, and finally, remove the gallbladder, and suspend the liver to expose the hepatoduodenal ligament and hilum (Figure 2).</li>
	<li>Explore the gap between the pancreatic neck and the SMV in order to assess the surgical resectability. 
	NOTE: The preferred gap is the space between the posterior neck of the pancreas and the SMV, which is difficult to open and expose if the tumor has invaded the SMV.</li>
	<li>Suspend the transverse colon and its mesentery on the cephalic side to establish effective exposure.</li>
	<li>Using the ileocolonic artery as the marker, open the transverse mesocolon. Protect the ileocolon artery and middle colonic artery.</li>
	<li>Expose the second and third segments of the duodenum, dissect along the right side of the SMV, and separate the second and third segments of the duodenum from the transverse mesocolon.</li>
	<li>Expose the main trunk of SMV and the proximal-dorsal jejunal vein (PDJV) between the SMV and SMA (Figure 3), and then ligate and dissect the inferior pancreaticoduodenal vein (IPDV). 
	NOTE: Be careful not to apply too much pressure, as this might cause the IPDV to hemorrhage.</li>
	<li>Perform the median-anterior approach to the SMA following steps 4.8.1-4.8.4.
	<ol>
		<li>Start the median-anterior approach to the SMA from the inferior colon region.</li>
		<li>Pull the SMV just to the right, widen the operation field, and expose the SMA pulsation to determine its trajectory.</li>
		<li>Expose the right half of the SMA, and dissect outside the arterial sheath of the SMA on the anterior-right margin in order to separate the SMA from the pancreatic mesopancreas. 
		NOTE: The middle colonic artery (MCA), which runs along the side of the vascular arch of the margin of the transverse mesocolon, can be directly linked to the trunk of the SMA in cases where it is difficult to identify the SMA, such as when it is difficult to assess arterial visual pulsation in obese patients. The best place to locate and identify the trunk of the SMA is where the MCA begins in the inferior colonic region. If required, color ultrasound assistance could be used.</li>
		<li>Through the median-anterior approach to the SMA approach, expose the main branches of the IPDA or jejunal artery (JA) along the right side of the SMA, and then conduct a further follow-up to confirm them (Figure 4). 
		NOTE: The authors&#39; experience is that IPDA and JA can be effectively identified by the subsequent left-posterior approach to the SMA.</li>
	</ol>
	</li>
	<li>Perform the left-posterior approach to the SMA following steps 4.9.1-4.9.9.
	<ol>
		<li>Place the entire small bowel to the right side to facilitate space exposure between the fourth segment of the duodenum and the inferior vena cava.</li>
		<li>Dissect the fusion fascia, and expose the left renal vein (LRV) to establish the posterior space of the SMA.</li>
		<li>Use an ultrasonic scalpel to dissect the ligament of Treitz between the beginning part of the jejunum and the mesentery of the transverse colon.</li>
		<li>Use a stapler to divide the proximal jejunum.</li>
		<li>Place an Fr8 catheter for suspending the dorsal sides of the SMA and SMV.</li>
		<li>To facilitate SMA dissection on its periadventitial plane on the anterior-left border and its detachment from the mesopancreas, pull the catheter to the upper right side. Establish an effective exposure space at the left-posterior aspect of the SMA (Figure 5).</li>
		<li>Trace up the SMA to the root along the first jejunal artery (FJA).</li>
		<li>Dissect the SMA on its periadventitial plane on the anterior-left margin in order to separate it from the pancreatic mesopancreas. Circumferentially dissect the SMA.</li>
		<li>Ligate and dissect the IPDA (Figure 6). Sacrifice the FJA if it is involved in the tumor.</li>
	</ol>
	</li>
	<li>Using the median-anterior and left-posterior SMA approaches, separate the SMA and SMV from the uncinate process and mesopancreas completely (Figure 7).</li>
	<li>Return to the superior region of the colon following steps 4.11.1-4.11.16.
	<ol>
		<li>Draw the proximal jejunum from the dorsal of the SMA to the right.</li>
		<li>Reveal the right gastrointestinal vein, the collateral right colonic vein, and the SMV trunk using an ultrasonic knife (see Table of Materials).</li>
		<li>Expose Henle&#39;s gastrocolic trunk vein to disconnect its distal and proximal ends on the right side of the SMV trunk. 
		NOTE:Find Henle&#39;s gastrocolic trunk vein along the right reticular vein on the right side of the SMV.</li>
		<li>Divide the stomach 3-5 cm away from the pylorus using a stapler device (see Table of Materials).</li>
		<li>Expose the CHA at the superior margin of the pancreatic neck.</li>
		<li>Dissect along the CHA toward the first hepatic hilar to reveal the proper hepatic artery (PHA) and the right gastric artery (RGA). Ligate and sever the RGA.</li>
		<li>Use laparoscopic bulldog clamps (see Table of Materials) to temporarily occlude the common bile duct (CBD) after separating the CBD.</li>
		<li>Dissect the hepatoduodenal ligament. Execute a lymphadenectomy along the CHA, PV, and PHA.</li>
		<li>Ligate and dissect the right gastric artery.</li>
		<li>Locate the gastroduodenal artery (GDA) at the junction of the PHA with the CHA, and meticulously ligate or suture (5-0, see Table of Materials) the GDA to reduce the possibility of an ensuing erosion or hemorrhage.</li>
		<li>Explore the tunnel between the pancreatic neck and the SMV. Ligate and dissect the dorsal pancreatic artery (DPA).</li>
		<li>Place two Fr14 catheters to block the pancreatic neck blood supply in order to reduce bleeding (Figure 8).</li>
		<li>Dissect the parenchyma of the pancreatic neck using scissors. Suture (5-0, see Table of Materials) the bleeding point of the resection surface. 
		NOTE: Examine a fast-frozen pathological specimen of the pancreatic stump to prove the negative margin.</li>
		<li>Suspend the splenic vein (SV) to establish exposure after the left first branch of the SMV has been ligated and dissected (Figure 9).</li>
		<li>Ligate and dissect the uncinate process artery behind the SV. Identify and retain the alternative right hepatic artery originating from the SMA from the uncinate process artery. 
		NOTE: At this point, all the blood supplies to the tumor are completely occluded.</li>
		<li>Ligate and dissect the branches of the PV.</li>
	</ol>
	</li>
	<li>Using the Kocher maneuver, cut off the lymphatics, and dissect the duodenum from the retroperitoneum. Resect the tumor in situ, and remove it en bloc following the oncologic principles of no-touch16,17.</li>
	<li>Use Child&#39;s method for the reconstruction of the digestive tract8,18.</li>
	<li>Perform a single-layer running suture hepaticojejunostomy from end to side using 4-0 absorbable sutures. Utilize an internal stent to perform a duct-to-mucosal, end-to-side pancreaticojejunostomy.</li>
</ol>
5. Postoperative management
<ol>
	<li>If the gastric tube drainage is &#60;200 mL, remove the tube on the next day.</li>
	<li>Start appropriate physical exercise if the vital signs are stable and the patient is generally in good condition.</li>
	<li>Assess the amylase level of the drainage liquid on postoperative day 3, and review the abdominal CT on postoperative day 7. Remove the drainage tubes if there is no evidence of biochemical leakage, lymphatic fistula, or hemorrhage.</li>
</ol>

<ol>
	<li>L&#233;ger, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatic+Surgery.">Pancreatic Surgery.</a> Chugai-Igakusha. , (1984).</li><li>O'Sullivan, A. W., Heaton, N., Rela, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cancer+of+the+uncinate+process+of+the+pancreas:+Surgical+anatomy+and+clinicopathological+features.">Cancer of the uncinate process of the pancreas: Surgical anatomy and clinicopathological features.</a> Hepatobiliary and Pancreatic Diseases International. 8 (6), 569-574 (2009).</li><li>Corcione, F., 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:+Experience+of+22+cases.">Laparoscopic pancreaticoduodenectomy: Experience of 22 cases.</a> Surgery Endoscopy. 27 (6), 2131-2136 (2013).</li><li>Kuroki, T., Eguchi, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=No-touch+isolation+techniques+for+pancreatic+cancer.">No-touch isolation techniques for pancreatic cancer.</a> Surgery Today. 47 (1), 8-13 (2017).</li><li>Gall, T. M., 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=Reduced+dissemination+of+circulating+tumor+cells+with+no-touch+isolation+surgical+technique+in+patients+with+pancreatic+cancer.">Reduced dissemination of circulating tumor cells with no-touch isolation surgical technique in patients with pancreatic cancer.</a> Journal of the American Medical Association Surgery. 149 (5), 482-485 (2014).</li><li>Tien, Y. W., 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+high+circulating+tumor+cell+count+in+portal+vein+predicts+liver+metastasis+from+periampullary+or+pancreatic+cancer:+A+high+portal+venous+CTC+count+predicts+liver+metastases.">A high circulating tumor cell count in portal vein predicts liver metastasis from periampullary or pancreatic cancer: A high portal venous CTC count predicts liver metastases.</a> Medicine. 95 (16), 3407 (2016).</li><li>Hirota, M., 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=Pancreatectomy+using+the+no-touch+isolation+technique+followed+by+extensive+intraoperative+peritoneal+lavage+to+prevent+cancer+cell+dissemination:+A+pilot+study.">Pancreatectomy using the no-touch isolation technique followed by extensive intraoperative peritoneal lavage to prevent cancer cell dissemination: A pilot study.</a> Journal of the Pancreas. 6 (2), 143-151 (2005).</li><li>Shen, Z., 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+pancreatoduodenectomy+for+pancreatic+cancer+using+in-situ+no-touch+isolation+technique.">Laparoscopic pancreatoduodenectomy for pancreatic cancer using in-situ no-touch isolation technique.</a> Journal of Visualized Experiments. (180), e63450 (2022).</li><li>Tan, Z. 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=Clinical+experience+of+laparoscopic+pancreatoduodenectomy+via+orthotopic+resection.">Clinical experience of laparoscopic pancreatoduodenectomy via orthotopic resection.</a> Zhonghua Wai Ke Za Zhi. 58 (10), 782-786 (2020).</li><li>Nagakawa, Y., 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=Surgical+approaches+to+the+superior+mesenteric+artery+during+minimally+invasive+pancreaticoduodenectomy:+A+systematic+review.">Surgical approaches to the superior mesenteric artery during minimally invasive pancreaticoduodenectomy: A systematic review.</a> Journal of Hepatobiliary Pancreatic Sciences. 29 (1), 114-123 (2022).</li><li>Hermanek, P., Wittekind, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Residual+tumor+(R)+classification+and+prognosis.">Residual tumor (R) classification and prognosis.</a> Seminars in Surgical Oncology. 10 (1), 12-20 (1994).</li><li>Chu, A. 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=Dual-source+dual-energy+multidetector+CT+for+the+evaluation+of+pancreatic+tumours.">Dual-source dual-energy multidetector CT for the evaluation of pancreatic tumours.</a> The British Journal of Radiology. 85 (1018), 891-898 (2012).</li><li>Mao, G. -. 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+application+value+of+spectral+imaging+in+diagnosis+of+pancreatic+adenocarcinoma+by+dual+source+CT.">The application value of spectral imaging in diagnosis of pancreatic adenocarcinoma by dual source CT.</a> Journal of Medical Imaging. 26 (07), 1243-1246 (2016).</li><li>Higgs, 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=Guidelines+for+the+management+of+tracheal+intubation+in+critically+ill+adults.">Guidelines for the management of tracheal intubation in critically ill adults.</a> British Journal of Anaesthesia. 120 (2), 323-352 (2018).</li><li>Schultz, 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=Comparison+of+Narcotrend+Index,+Bispectral+Index,+spectral+and+entropy+parameters+during+induction+of+propofol-remifentanil+anaesthesia.">Comparison of Narcotrend Index, Bispectral Index, spectral and entropy parameters during induction of propofol-remifentanil anaesthesia.</a> Journal of Clinical Monitoring and Computing. 22 (2), 103-111 (2008).</li><li>Cole, W. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Problems+in+operability.">Problems in operability.</a> The Ulster Medical Journal. 23 (2), 102-116 (1954).</li><li>Liu, K. J., Zhao, X. X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Application+of+tumor-free+technique+in+laparoscopic+surgery+for+malignant+tumors.">Application of tumor-free technique in laparoscopic surgery for malignant tumors.</a> Chinese Journal of Laparoscopic Surgery. 11 (01), 17-19 (2018).</li><li>Osada, S., 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=Reconstruction+method+after+pancreaticoduodenectomy.+Idea+to+prevent+serious+complications.">Reconstruction method after pancreaticoduodenectomy. Idea to prevent serious complications.</a> Journal of the Pancreas. 13 (1), 1-6 (2012).</li><li>Li, M. 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+practice+guidelines+for+the+interventional+treatment+of+advanced+pancreatic+carcinoma+(on+trial)+(6th+edition).">Clinical practice guidelines for the interventional treatment of advanced pancreatic carcinoma (on trial) (6th edition).</a> Journal of Clinical Hepatology. 38 (06), 1242-1251 (2022).</li><li>Sugiyama, M., 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=Vascular+anatomy+of+mesopancreas+in+pancreatoduodenectomy+using+an+intestinal+derotation+procedure.">Vascular anatomy of mesopancreas in pancreatoduodenectomy using an intestinal derotation procedure.</a> World Journal of Surgery. 44 (10), 3441-3448 (2020).</li><li>Zhu, C. -. F., 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=Novel+morphological+classification+of+the+normal+pancreatic+uncinate+process+based+on+computed+tomography.">Novel morphological classification of the normal pancreatic uncinate process based on computed tomography.</a> Journal of International Medical Research. 48 (9), 300060520957453 (2020).</li></ol>

The authors have nothing to disclose.

With intestinal rotation, the ventral pancreas flips to the dorsal side and unites with the dorsal pancreas throughout the development of the human embryo, and the ventral pancreas also grows into the lower portion of the pancreatic head and the uncinate process1. The pancreatic uncinate process is described as the protrusion from the bottom left of the pancreatic head that is situated behind the SMA and the SMV1. 
In the meantime, the mesopancre...

The pancreatic uncinate process is the protrusion from the bottom left of the pancreatic head that is situated behind the SMA and superior mesenteric vein (SMV)1. The management of the uncinate process is a challenging area in pancreatic surgery due to its deep anatomy and challenging exposure; therefore, especially for pancreatic cancer located in the uncinate process, surgery is prone to result in a positive surgical margin, incomplete lymph node dissection, and poor prognosis2. Therefore, improved surgical techniques and strategies are urgently required.
Most resection procedures of the pancreatic head and uncinate process are performed along the right side of the SMV and SMA3. Although this approach largely works for ampullary tumors, it has drawbacks for pancreatic head cancer, particularly for large tumors in the uncinate process2. During the procedure, it is frequently required to spin and pull the SMV and SMA in order to expose them. The IPDA cannot be dissected clearly with such approaches, which usually results in bleeding or insufficient cleaning of the area. In this work, the authors describe an approach that can support the early control of the IPDA, which results in better bleeding control, less blood loss, and better dissection of the uncinate process.
Meanwhile, conventional laparotomy or laparoscopy pancreatoduodenectomy requires a Kocher maneuver for the wide mobilization of the duodenum and pancreatic head4. However, with this maneuver, the tumor cells have the potential capacity to metastasize via the portal vein (PV), as the surgeon might squeeze the tumor while holding it during surgery4,5,6. The no-touch isolation technique is one of the popular concepts in pancreatoduodenectomy. Although it has not been proven by large clinical trials whether this surgical intervention could enhance the cancer-related prognosis of pancreatic cancer patients, the study of Hirota et al.7 reported the significance of no-touch technology in preventing cancer cell metastasis by using molecular markers (CEA mRNA) to detect cancer cells in the portal vein blood. In their study, the no-touch technique group had a lower spread rate of portal vein cancer cells and a higher 3 year survival rate than the conventional technique group. No-touch LPD has been reported by the team of the current authors previously as an ideal oncological operation process fitting the &#34;tumor-free&#34; principle8,9.
This article presents the management of the uncinate process in no-touch LPD. The median-anterior and left-posterior approaches to the SMA were performed to deal precisely with the IPDA. To achieve the no-touch isolation technique in LPD, the blood supply to the duodenum and pancreatic heads must be cut off at the very early stage of the operation, after which the tumor can be isolated intact, resected in situ, and finally, removed en bloc.
The purpose and advantages of this strategy are to ensure the safe and complete excision of the uncinate process and mesopancreas based on a multi-angle arterial approach10. This article aims to explore the efficacy and safety of this technique for the management of the uncinate process in no-touch LPD, which might improve the R0 resection rate11.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>3D Laparoscope</td>
			<td>STORZ</td>
			<td>TC200,TC302</td>
			<td></td>
		</tr>
		<tr>
			<td>Cisatracurium Besylate Injection</td>
			<td>Hengrui Pharma</td>
			<td>H20183042</td>
			<td></td>
		</tr>
		<tr>
			<td>Dual-source dual-energy&#160; CT</td>
			<td>SOMATOM</td>
			<td>Definition FLASH</td>
			<td></td>
		</tr>
		<tr>
			<td>Echelon Flex Powered Plus Articulating Endoscopic Linear Cutter and Endopath Echelon Endoscopic Linear Cutter Reloads with Gripping Surface Technology</td>
			<td>Ethicon Endo-Surgery</td>
			<td>ECR60G/GST60G</td>
			<td></td>
		</tr>
		<tr>
			<td>ENDOPATH XCEL Trocars</td>
			<td>Johnson &#38; Johnson</td>
			<td>CB5LT/CB12LT</td>
			<td></td>
		</tr>
		<tr>
			<td>HARMONIC ACE Ultrasonic Surgical Devices</td>
			<td>Ethicon Endo-Surgery</td>
			<td>HAR36</td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic bulldog clamps</td>
			<td>Aesculap</td>
			<td>FB367R,FB369R</td>
			<td></td>
		</tr>
		<tr>
			<td>Ligating Clips</td>
			<td>Teleflex Medical</td>
			<td>5,44,22,05,44,23,05,44,000</td>
			<td></td>
		</tr>
		<tr>
			<td>Nacrotrend anaesthesia monitoring system&#160;</td>
			<td>Monitor Technik,Bad Bramsted</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>PROLENE Polypropylene Nonabsorbable Suture/5/0</td>
			<td>Johnson &#38; Johnson</td>
			<td>W8556</td>
			<td></td>
		</tr>
		<tr>
			<td>Propofol Injectable Emulsion</td>
			<td>Aspen Pharma Trading Limited</td>
			<td>H20171275</td>
			<td></td>
		</tr>
		<tr>
			<td>Remifentanil Hydrochloride for injection</td>
			<td>Humanwell Healthcare</td>
			<td>H20030197</td>
			<td></td>
		</tr>
		<tr>
			<td>Sevoflurane for Inhalation</td>
			<td>Hengrui Pharma</td>
			<td>H20070172</td>
			<td></td>
		</tr>
		<tr>
			<td>Sufentanil Citrate Injecton</td>
			<td>Humanwell Healthcare</td>
			<td>H20054171</td>
			<td></td>
		</tr>
		<tr>
			<td>Trocars</td>
			<td>AOFO</td>
			<td>FQ-D1/5.5mm 10.5mm</td>
			<td></td>
		</tr>
		<tr>
			<td>Ultrasonic Surgical &#38; Electrosurgical Generator</td>
			<td>Ethicon Endo-Surgery</td>
			<td>GEN11CN</td>
			<td></td>
		</tr>
	</tbody>
</table>

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.

A male patient aged 59 years old with symptoms including upper abdominal pain and jaundice was hospitalized in our department. He had no previous medical history and a relatively moderate normal body mass index (23.94 kg/m2). A contrast-enhanced CT scan was performed, and a tumor with a diameter of approximately 5.5 cm x 4.6 cm x 6.3 cm was found at the head and uncinate process of the pancreas (Figure 10). No evidence of distant metastasis was found, and percutaneous transhepatic cholangica...

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Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy

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 ...

management-uncinate-process-no-touch-laparoscopic

Research

JoVE Journal

Medicine

715 Views.  The Second Affiliated Hospital of Guangzhou University of Chinese Medicine. 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).

Video: Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is respect for patient's values, preferences, and expressed needs. Yet specific approaches to gaining this understanding and translating it to quality care in the clinical setting are lacking. From a patient perspective quality is not a simple concept but is best understood in terms of five dimensions: technical outcomes; decision-making efficiency; amenities and convenience; information and emotional support; and overall patient satisfaction. Failure to consider quality from this five-pronged perspective results in a focus on medical outcomes, without considering the processes central to quality from the patient's perspective and vital to achieving good outcomes. In this paper, we argue for applying the concept of fair process in clinical settings. Fair process involves using a collaborative approach to exploring diagnostic issues and treatments with patients, explaining the rationale for decisions, setting expectations about roles and responsibilities, and implementing a core plan and ongoing evaluation. Fair process opens the door to bringing patient expertise into the clinical setting and the work of developing health care goals and strategies. This paper provides a step by step illustration of an innovative visual approach, called photovoice or photo-elicitation, to achieve fair process in clinical work with acquired brain injury survivors and others living with chronic health conditions. Applying this visual tool and methodology in the clinical setting will enhance patient-provider communication; engage patients as partners in identifying challenges, strengths, goals, and strategies; and support evaluation of progress over time. Asking patients to bring visuals of their lives into the clinical interaction can help to illuminate gaps in clinical knowledge, forge better therapeutic relationships with patients living with chronic conditions such as brain injury, and identify patient-centered goals and possibilities for healing. The process illustrated here can be used by clinicians, (primary care physicians, rehabilitation therapists, neurologists, neuropsychologists, psychologists, and others) working with people living with chronic conditions such as acquired brain injury, mental illness, physical disabilities, HIV/AIDS, substance abuse, or post-traumatic stress, and by leaders of support groups for the types of patients described above and their family members or caregivers.

This paper illustrates an innovative visual approach (photovoice or photo-elicitation) to achieve fair process in clinical care for patients living with chronic health conditions, illuminate gaps in clinical knowledge, forge better therapeutic relationships, and identify patient-centered goals and possibilities for healing.

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is ...

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 ...

The Dyspepsia Educational Tool As a Novel Aid in Dyspepsia Management

Digital educational tools have a well-established role in current healthcare. In particular, disorders that are managed non-pharmacologically benefit from this development, as it enables patient engagement in self-management. Dyspepsia is a condition thought to arise from gastric and duodenal perturbations, brain-gut axis disturbances, and dietary factors. Behavioral interventions are a major part of dyspepsia treatment, hence patient engagement and motivation through education is essential. Protocols that describe the development process of such educational tools are scarce. We provide a methodology describing development of a dyspepsia educational tool. Assessment of users' needs is the first step, followed by a literature search. The content is developed based on the main themes and entered into a content management system, to build the program. Final adjustments are made after a pilot test of the tool. The presented protocol can be used as a guide for development of a digital dyspepsia educational tool or as a tool for similar situations.

This protocol describes the development process of a digital dyspepsia educational tool. Assessment of unmet needs and literature, content development, and building of the tool are presented. The methodology can be used as a guide for future development of digital educational tools.

Digital educational tools have a well-established role in current healthcare. In particular, disorders that are managed non-pharmacologically benefit from ...

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 ...

Creating Radio-cephalic Arteriovenous Fistula in the Forearm with a Modified No-Touch Technique

Autologous arteriovenous fistula (AVF) is the primary and best option to obtain vascular access for hemodialysis treatment; other options are arteriovenous graft (AVG) and central venous catheterization (CVC). The implementation of radio-cephalic autologous arteriovenous fistula (RC-AVF) in the forearm was preferred among patients with superior vascular conditions. However, there is a high rate of early fistula failure. The chosen surgical method is understood to have an effect on the maturation of the fistula. New surgical procedures such as radial artery deviation and reimplantation (RADAR) have been significantly improved for juxta-anastomotic stenosis. Nevertheless, new problems such as stenosis of arteries and narrowing of surgical indication were also found. In this report, we presented a modified no-touch technique (MNTT) to create an RC-AVF, in which the venous and arterial wall avoid devascularization and the radial artery does not sever.

We present a modified no-touch technique (MNTT) to create a radio-cephalic arteriovenous fistula (RC-AVF) in which the venous and arterial wall avoid devascularization and the radial artery does not sever.

Autologous arteriovenous fistula (AVF) is the primary and best option to obtain vascular access for hemodialysis treatment; other options are ...

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

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

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

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

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

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore apical support for treating POP. Sacrocolpopexy and pectopexy are indicated for apical prolapse. Using a synthetic mesh in these techniques increases success by enhancing apical support. However, the implantation of synthetic mesh is associated with mesh-related complications. In addition, the exorbitant cost of synthetic mesh and lack of universal access limit the popularity of these procedures. The current study develops a unique technique known as laparoscopic non-mesh cerclage pectopexy (LNMCP), in which permanent cervical cerclage sutures are embedded in the round ligament until the iliopectineal ligament. The iliopectineal ligament was sutured, resulting in a firm cervical suspension. The procedure was successfully performed in 16 cases in the hospital. The surgical duration was 67.8 min &plusmn; 15.5 min, and the blood loss was 73.1 mL &plusmn; 51.1 mL. No procedural complications were seen. LNMCP is associated with an objective success rate of 100% and a subjective success rate of 93.8%. LNMCP for patients with apical prolapse obviates the need for a mesh, thereby avoiding complications associated with mesh erosion and reducing medical costs. In addition, it is easy to perform even in resource-poor areas without access to synthetic mesh.

The present pilot study describes the development of laparoscopic non-mesh cerclage pectopexy to treat pelvic organ prolapse. The procedure can be used to prevent any complications associated with the use of mesh.

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore ...

Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing incisional hernias. The laparoscopic IPOM involves implanting the mesh into the abdominal cavity through laparoscopy to repair an abdominal wall hernia. In the IPOM surgery, after the closure of the hernia ring, an anti-adhesion mesh is placed laparoscopically. The correct placement of this mesh is critical to the success of the method, and surgical skills are required to achieve perfect placement. If the mesh placement is not mastered properly, the operation and anesthesia time will be prolonged. In addition, improper placement of the mesh can lead to serious consequences, such as intestinal obstruction and mesh infection. A "contraposition and alignment" mesh fixation method is described in this study, which involves pre-marking the fixation position of the mesh to reduce the difficulty of mesh placement. A properly placed mesh is completely flat on the peritoneum, the edges are not curled or wrapped, and the mesh is adhered firmly such that there is no displacement after removing the pneumoperitoneum pressure. The "contraposition and alignment" mesh fixation technique offers the advantages of reliable placement of the mesh and fewer complications than other techniques, and it is easy to learn and master. It also allows for positioning the nail gun in advance based on the anatomy of the incisional hernia. This enables the use of the minimum number of nails possible while still ensuring good fixation, which can reduce the occurrence of complications and reduce the cost of surgery. Thus, the mesh fixation method described here is highly suitable for clinical applications based on the aforementioned advantages.

Presented here is a method for improving the mesh placement in laparoscopic incisional hernia repair, which can shorten the time required for mesh fixation and reduce the occurrence of postoperative chronic pain.

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing ...

Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery

For recurrent choledocholithiasis, abdominal adhesions in previous surgeries lead to changes in anatomical structures, and a secondary injury occurs easily when performing another operation for laparoscopic common bile duct exploration (LCBDE), which was once considered a relative contraindication. In view of the limitations of the current surgical technique, this study summarized the surgical approaches and crucial anatomical landmarks for reoperation for LCBDE. Four general surgical approaches were proposed to expose the common bile duct, including the ligamentum teres hepatis approach, the anterior hepatic duodenal ligament approach, the right hepatic duodenal ligament approach, and the hybrid approach. Additionally, this study highlighted seven crucial anatomical landmarks: the parietal peritoneum, the gastrointestinal serosa, the ligamentum teres hepatis, the inferior margin of the liver, the gastric antrum, the duodenum, and the hepatic flexure of the colon, which were helpful to safely separate abdominal adhesions and expose the common bile duct. Moreover, to shorten the time of choledocholithotomy, a sequential method was innovatively applied for the removal of the stones in common bile duct. Mastering the above surgical approaches, including identifying crucial anatomical landmarks and adopting the sequential method will improve the safety of reoperation for LCBDE, shorten the operation time, promote the fast recovery of patients, reduce postoperative complications, and contribute to the popularization and application of this technique.

Programmed surgery based on surgical methods and anatomical markers helps shorten the operation time, reduce complications, and improve the safety of the surgery. This study investigated and summarized the surgical methods and anatomic markers of laparoscopic common bile duct exploration in patients with a history of biliary tract surgery.

For recurrent choledocholithiasis, abdominal adhesions in previous surgeries lead to changes in anatomical structures, and a secondary injury occurs ...

Application of Laparoscopic Hepatectomy Combined with Intraoperative Microwave Ablation in Colorectal Cancer Liver Metastasis

Laparoscopic hepatectomy is a common treatment for colorectal cancer liver metastasis. Previously, a sufficient number of functional liver masses had to be maintained during laparoscopic hepatectomy, with a residual liver volume of &gt;40% in cirrhotic patients and &gt;30% in non-cirrhotic patients. The high incidence of complications such as bleeding, bile leakage, or liver failure due to the exposure and difficulty of the resection of specific liver segments such as S2 and S7 reduces the success rate of liver resection. At present, microwave ablation is mainly applied in the treatment of liver metastasis using a percutaneous approach, which makes it difficult to identify hidden parts or small lesions. For some liver segments, the percutaneous puncture of liver segment 7 (S7) is likely to pass through the thoracic cavity, and the percutaneous puncture of liver segment 2 (S2) adjacent to the diaphragm is likely to injure the diaphragm and heart; these issues restrict the application of percutaneous ablation in colorectal cancer liver metastasis. Considering multiple lesions, laparoscopic microwave ablation combined with hepatectomy was performed in this study. The location of the lesions was determined by contrast-enhanced ultrasound under laparoscopy, and small lesions that were difficult to detect before the operation were identified. For the scattered lesions, which had diameters less than 3 cm and were difficult to resect, ablation was adopted to substitute hepatectomy. This technique helped to more explicitly locate the tumors, simplified the operation procedures, reduced the risk of complications such as bleeding and bile leakage, shortened the operation time, accelerated the postoperative recovery, significantly improved the success rate of operation, and enhanced the clinical prognosis of colorectal cancer liver metastasis by surgical resection.

This protocol describes the laparoscopic resection of colorectal cancer liver metastases combined with ultrasound-guided microwave ablation. This technique can safely, effectively, and accurately treat refractory liver metastases &lt;3 cm, reduce postoperative complications, and accelerate the postoperative rehabilitation of patients.

Laparoscopic hepatectomy is a common treatment for colorectal cancer liver metastasis. Previously, a sufficient number of functional liver masses had to ...