title: Pure laparoscopic pancreatoduodenectomy with initial approach to the superior mesenteric artery.
abstract: BACKGROUND
  The "artery-first approach" (AFA) to the superior mesenteric artery allows an early assessment of resectability of pancreatic tumours and could improve the benefits of laparoscopy, reducing invasiveness, especially for unresectable tumours.
  
  
  OBJECTIVE
  To describe our technique of pure laparoscopic pancreatoduodenectomy (PLPD) with the AFA, and to report the surgical outcomes of this procedure in a small series of 12 patients through a retrospective analysis of a prospectively collected database.
  
  
  METHODS
  Twelve selected patients underwent elective full laparoscopic pancreatoduodenectomy with the AFA. The technical aspects of the procedure are described in detail and the included images facilitate the understanding of the procedure.
  
  
  RESULTS
  The mean operative time was 300 min (range: 250-540 min). No intraoperative complications were observed. No conversion to laparotomy was necessary. The mean postoperative hospital stay was 18 days (range: 8-42). Mortality was null. There were 3 major complications at the 3rd post-operative month follow-up: 2 patients reporting a grade A pancreatic fistula and one biliary fistula.
  
  
  CONCLUSIONS
  Our work shows that pure laparoscopic pancreatoduodenectomy (PLPD) with the AFA is feasible, in selected patients. The AFA could improve on the advantages of laparoscopy in the identification of unresectable patients, and it also allows early control of vascular structures.
authors.affiliation: Centre Hospitalier de Luxembourg, Service de Chirurgie Générale et Mini-invasive, Luxembourg City, Luxembourg GD.
authors.forename: Juan Santiago
authors.initials: JS
authors.lastname: Azagra
authors.affiliation: Centre Hospitalier de Luxembourg, Service de Chirurgie Générale et Mini-invasive, Luxembourg City, Luxembourg GD.
authors.forename: Luca
authors.initials: L
authors.lastname: Arru
authors.affiliation: Centre Hospitalier de Luxembourg, Service de Chirurgie Générale et Mini-invasive, Luxembourg City, Luxembourg GD.
authors.forename: Sergio
authors.initials: S
authors.lastname: Estévez
authors.affiliation: Centre Hospitalier de Luxembourg, Service de Chirurgie Générale et Mini-invasive, Luxembourg City, Luxembourg GD.
authors.forename: Makkai-Popa
authors.initials: MP
authors.lastname: Silviu-Tiberiu
authors.affiliation: Centre Hospitalier de Luxembourg, Service de Chirurgie Générale et Mini-invasive, Luxembourg City, Luxembourg GD.
authors.forename: Virginie
authors.initials: V
authors.lastname: Poulain
authors.affiliation: Centre Hospitalier de Luxembourg, Service de Chirurgie Générale et Mini-invasive, Luxembourg City, Luxembourg GD.
authors.forename: Martine
authors.initials: M
authors.lastname: Goergen
keywords: artery first approach; feasibility; laparoscopy; pancreatoduodenectomy; pure laparoscopy; short-term outcomes