Semiderotation technique for robotic pancreaticoduodenectomy

One of the reasons of the difficulties in robotic pancreaticoduodenectomy (RPD) is the anatomical complexity of the branches of the SMA around the pancreatic head. We have developed “Semi-derotation technique” based on new recognition of the anatomy around the pancreatic head as a safe strategy for artery-first approach in MIPD.
Methods
Semi-derotation technique simplifies anatomic situation by partially derotating the rotation of the mesentery occurred during the embryonic period. After Kocher’s maneuver, “the Gordian anchor” which we named the dorsal area of the SMA and the SMV contacting the uncinated process of the pancreatic head is divided and the fixation of the rotation of the mesentery are released. After the transected jejunum is pulled to the right side of the SMA, the rotation of the mesentery of the dissected side is released with the duodenum pulled up to the ventral side. 
Results
After derotation of the mesentery, the direction of all brunches of the SMA is limited to the sagittal direction. We can get a good operative field with a minimum number of forceps and artery first approach can be performed easily and safely in RPD.  
Conclusions
Semi-derotation technique is considered as a safe strategy for RPD.