title: A Novel "Artery First" Approach Allowing Safe Resection in Laparoscopic Pancreaticoduodenectomy: The Uncinate Process First Approach.
abstract: OBJECTIVE
  Laparoscopic pancreaticoduodenectomy (LPD) is still a challenging operation, particularly because the dissection around the superior mesenteric artery (SMA) and bleeding control are difficult. Although it has been reported that early ligation of the origin of the inferior pancreaticoduodenal artery (IPDA) reduces blood loss, it is difficult to laparoscopically expose the origin of the IPDA. We sought to develop a novel approach to simplify the dissection of the IPDA and reduce bleeding.
  
  
  METHODS
  The uncinate process was exposed at the left posterior side of the SMA, and the branches of the IPDA were divided at positions where they enter and exit the uncinate process before isolating the pancreatic head from the right aspect of the SMA. Ten patients were operated using this new approach, and the results were retrospectively compared to those of 22 patients treated with conventional LPD.
  
  
  RESULTS
  The operation times did not differ significantly between the two groups. However, the intraoperative blood loss was significantly lower in the "uncinate process first" group than in the conventional LPD group. (162.7 ml vs. 463.8 ml, respectively; P = 0.023).
  
  
  CONCLUSIONS
  The new approach facilitates the initial dissection of the IPDA at the right side of the SMA, reducing intraopera- tive blood loss.
authors.forename: Yuichi
authors.initials: Y
authors.lastname: Nagakawa
authors.forename: Yuichi
authors.initials: Y
authors.lastname: Hosokawa
authors.forename: Yatsuka
authors.initials: Y
authors.lastname: Sahara
authors.forename: Chie
authors.initials: C
authors.lastname: Takishita
authors.forename: Tetsushi
authors.initials: T
authors.lastname: Nakajima
authors.forename: Yosuke
authors.initials: Y
authors.lastname: Hijikata
authors.forename: Tomoya
authors.initials: T
authors.lastname: Tago
authors.forename: Kazuhiko
authors.initials: K
authors.lastname: Kasuya
authors.forename: Akihiko
authors.initials: A
authors.lastname: Tsuchida
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater; D001650:Bile Duct Neoplasms / Q000601:surgery*; D016063:Blood Loss, Surgical; D021441:Carcinoma, Pancreatic Ductal / Q000601:surgery*; D018281:Cholangiocarcinoma / Q000601:surgery*; D004210:Dissection / Q000379:methods; D004386:Duodenum / Q000098:blood supply; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008026:Ligation; D008297:Male; D017538:Mesenteric Artery, Superior / Q000601:surgery*; D008875:Middle Aged; D018358:Neuroendocrine Tumors / Q000601:surgery*; D061646:Operative Time; D010179:Pancreas / Q000098:blood supply; D010190:Pancreatic Neoplasms / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000379:methods*; D011183:Postoperative Complications; D012189:Retrospective Studies