Superior mesenteric artery-first approach with laparoscopic pancreaticoduodenectomy

Laparoscopic technique has conquered almost all the abdominal operations, and laparoscopic pancreaticoduodenectomy (LPD) has become a routine procedure due to its advantages in intraoperative blood loss, postoperative recovery and shorter hospital stay. With the improved surgical techniques and accumulated laparoscopic experience in recent years, the resectability of pancreatic cancer is determined by the involvement of superior mesenteric artery (SMA) instead of the portal vein (PV)/superior mesenteric vein (SMV) invasion, leading to the birth of “artery-first approach”. In our experience, SMA-first approach has its advantage in patients with local advanced pancreatic cancer requiring combination with SMV resection. Right posterior SMA approach and inferior infracolic SMA approach are the two easy and practical techniques among the popular SAM-first approaches demonstrated for LPD. However, it is necessary for pancreatic surgeons to be skilled with the different techniques in case of some challenging occasions.