Safe and reliable approach and appropriate indication during the initial attempts for laparoscopic pancreatoduodenectomy

Although laparoscopic pancreaticoduodenectomy (LPD) has been expected as minimally invasive surgery, security of the safety is required especially during the initial attempts. Based on our results, we describe an appropriate indication for LPD during the initial attempts, and show our surgical approach and effective retraction methods allowing safe resection in LPD. Indication during the learning curve: We reviewed surgical results in during the initial attempts. Operating time of patients with anatomical variant of the hepatic artery and cholangitis was significantly longer than that without them. Blood loss of patients with BMI of higher than 22 was significantly higher than that with less than 22. Surgical approach: Each retraction methods were establised to achieve an effective three-way retraction. We also applied a novel laparoscopic approach, termed the uncinate process first approach, in which the branches of the IPDA are dissected first at positions where they enter the uncinate process, which allows safe dissection around the SMA. After introducing this approach, the intraoperative blood loss was significantly decreased compared to the conventional approach. Conclusion: LPD should be performed in selected patients with less BMI and without anatomical variant of the hepatic artery and cholangitis during the leranig curve. In addition, our procedure is usefull to safly perform LPD with optimal operative field.