title: Laparoscopic pancreatoduodenectomy with superior mesenteric artery-first approach and pancreatogastrostomy assisted by mini-laparotomy.
abstract: BACKGROUND
  Laparoscopic pancreatoduodenectomy (LPD) is a complex procedure. Critical steps are achieving a negative retroperitoneal margin and re-establishing pancreatoenteric continuity minimizing postoperative pancreatic leak risk. Aiming at increasing the rate of R0 resection during pancreatoduodenectomy, many experienced teams have recommended the superior mesenteric artery (SMA)-first approach, consisting in early identification of the SMA at its origin, with further resection guided by SMA anatomic course. We describe our technique of LPD with SMA-first approach and pancreatogastrostomy assisted by mini-laparotomy.
  
  
  METHODS
  The video concerns a 77-year-old man undergoing our variant of LPD for a 2.5-cm pancreatic head mass. After kocherization, the SMA is identified above the left renocaval confluence and dissected-free from the surrounding tissue. Dissection of the posterior pancreatic aspect exposes the confluence between splenic vein, superior mesenteric vein (SMV), and portal vein. Following duodenal section, the common hepatic artery is dissected and the gastroduodenal artery sectioned at the origin. The first jejunal loop is divided, skeletonized, and passed behind the superior mesenteric vessel. Following pancreatic transection, the uncinate process is dissected from the SMV and the SMA is cleared from retroportal tissue rejoining the previously dissected plain. Laparoscopic choledocojejunostomy is followed by a mini-laparotomy-assisted pancreatogastrostomy, performed as previously described, and a terminolateral gastrojejeunostomy.
  
  
  RESULTS
  Twelve patients underwent our variant of LPD (July 2013-May 2015). Female/male ratio was 3:1, median age 65 years (range 57-79), median operation duration 590 min (580-690), intraoperative blood loss 150 cl (100-250). R0 resection rate was 100 %, and the median number of resected lymph nodes was 24 (22-28). Postoperative complications were grade II in two patients and IIIa in one. Median postoperative length of stay was 16 days (14-21).
  
  
  CONCLUSIONS
  LPD with SMA-first approach with pancreatogastrostomy assisted by a mini-laparotomy well combines the benefits of laparoscopy with low risk of postoperative complications and high rate of curative resection.
authors.affiliation: Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza of Brescia, Via Bissolati 57, Brescia, Italy. gzimmitti@hotmail.com.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Zimmitti
authors.affiliation: Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza of Brescia, Via Bissolati 57, Brescia, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Manzoni
authors.affiliation: Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
authors.forename: Pietro
authors.initials: P
authors.lastname: Addeo
authors.affiliation: Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza of Brescia, Via Bissolati 57, Brescia, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Garatti
authors.affiliation: Department of Oncology, Istituto Ospedaliero Fondazione Poliambulanza of Brescia, Brescia, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Zaniboni
authors.affiliation: Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Bachellier
authors.affiliation: Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza of Brescia, Via Bissolati 57, Brescia, Italy.
authors.forename: Edoardo
authors.initials: E
authors.lastname: Rosso
mesh_terms: D000368:Aged; D004386:Duodenum / Q000601:surgery; D005260:Female; D005774:Gastrostomy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D007813:Laparotomy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D017538:Mesenteric Artery, Superior / Q000601:surgery*; D008875:Middle Aged; D010179:Pancreas / Q000473:pathology / Q000601:surgery; D010190:Pancreatic Neoplasms / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications / Q000209:etiology
keywords: Laparoscopic; Mini-laparotomy; Pancreato-gastrostomy; Pancreatoduodenectomy; SMA-first approach