**1. Introduction**

Recently, laparoscopic surgery has been used for pancreas surgery. Laparoscopic pancreatic surgery has gradually expanded to include pancreaticoduodenectomy (PD) [1–3]. However, as the outcomes of feasibility and safety have become better yearly in the laparoscopic pan‐ creaticoduodenectomy (LPD), a superior operative skill must be required. Therefore, LPD

and reproduction in any medium, provided the original work is properly cited.

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, remains technically a difficult surgery with high rates of mortality and morbidity for usual HPB surgeons. LPD is a challenging operation for multiple reasons, including but not limited to the following: difficult access and exposure of the pancreas, which is situated in the ret‐ roperitoneum; hemorrhage control from major vasculature, a technically demanding recon‐ struction of the biliary and pancreatic remnants; maintaining oncologic surgical principles; and surgeon fatigue from a long operation requiring intense concentration. Limitations of the laparoscopic approach include the inability to palpate the lesion or surrounding vascular structures. Owing to the limitations of LPD, we reported a new surgical device of hybrid laparoscopic complete uncinatectomy of the pancreas by Shuriken‐shaped umbilicoplasty with the sliding window's method [4] in pursuit of both safety and cosmetic advantages. In this chapter, we would like to demonstrate our modified novel technique of Shuriken‐shaped umbilicoplasty with the real‐time moving sliding window's method in pancreas for PD by mini‐laparotomy. Our technique might be used for PD from complete mini‐laparotomy to hybrid laparoscopic operation and be a useful procedure with the advantages of cosmetic, safety, and learning tools to the complete LPD.

The pancreatic fistula is a major obstacle as a complication after pancreatojejunostomy (PJ) in PD would result in intra‐abdominal abscess or bleeding from arterial aneurism. A recon‐ struction of PJ has been reported; however, the pancreatic leakage (PL) has not disappeared. The cause for PL might be divided into two factors. First is the host's factors and second is the surgeon's factors (**Table 1**). The host's factors are their nutrition status, diabetes mellitus, pancreatitis, aging, liver cirrhosis, and so on. Those conditions might influence wound heal‐ ing, immunocompetence, and susceptibility to infection. The surgeon's factors are technical problems including their surgical skill, surgical instruments, and reconstruction's method. In this study, we will also demonstrate the new PJ technique by pancreatic stent slide guiding method (PSSGM).



PL: leakage of pancreatic juice; PvC: papilla vater carcinoma; BL: leakage of bile juice; BDC: bile duct cancer; DM: diabetes mellitus; PK: pancreatic cancer; Mini‐Lap: mini‐laparotomy.

Pancreatic leakage was the only one case of grade A by ISGPF classification. Two patients suffered from liver abscess and their hospital stay prolonged by 42 and 90 postoperative days, respectively. There were no cases that had bile leakage.

**Table 1.** Profiles and perioperative data of 10 patients who underwent PD with the Shuriken‐shaped umbilicoplasty.

### **2. Surgical procedures**

remains technically a difficult surgery with high rates of mortality and morbidity for usual HPB surgeons. LPD is a challenging operation for multiple reasons, including but not limited to the following: difficult access and exposure of the pancreas, which is situated in the ret‐ roperitoneum; hemorrhage control from major vasculature, a technically demanding recon‐ struction of the biliary and pancreatic remnants; maintaining oncologic surgical principles; and surgeon fatigue from a long operation requiring intense concentration. Limitations of the laparoscopic approach include the inability to palpate the lesion or surrounding vascular structures. Owing to the limitations of LPD, we reported a new surgical device of hybrid laparoscopic complete uncinatectomy of the pancreas by Shuriken‐shaped umbilicoplasty with the sliding window's method [4] in pursuit of both safety and cosmetic advantages. In this chapter, we would like to demonstrate our modified novel technique of Shuriken‐shaped umbilicoplasty with the real‐time moving sliding window's method in pancreas for PD by mini‐laparotomy. Our technique might be used for PD from complete mini‐laparotomy to hybrid laparoscopic operation and be a useful procedure with the advantages of cosmetic,

The pancreatic fistula is a major obstacle as a complication after pancreatojejunostomy (PJ) in PD would result in intra‐abdominal abscess or bleeding from arterial aneurism. A recon‐ struction of PJ has been reported; however, the pancreatic leakage (PL) has not disappeared. The cause for PL might be divided into two factors. First is the host's factors and second is the surgeon's factors (**Table 1**). The host's factors are their nutrition status, diabetes mellitus, pancreatitis, aging, liver cirrhosis, and so on. Those conditions might influence wound heal‐ ing, immunocompetence, and susceptibility to infection. The surgeon's factors are technical problems including their surgical skill, surgical instruments, and reconstruction's method. In this study, we will also demonstrate the new PJ technique by pancreatic stent slide guiding

safety, and learning tools to the complete LPD.

**sliding window's method**

**Operative time**

**Blood loss**

 M 66 PvC HALS 980 2256 23 – – – – F 69 BDC + Mini‐Lap 492 257 37 – – – – F 77 PK + Mini‐Lap 445 389 17 – – – – M 78 PK + Mini‐Lap 659 1026 18 – – – DM F 75 PK + Mini‐Lap 517 673 31 – – – – M 77 BDC + Mini‐Lap 485 914 17 – – – –

7 M 68 PvC + Mini‐Lap 482 344 36 Grade A – Bleeding

8 F 70 BDC + Mini‐Lap 577 1375 42 – – Liver abscess Cholangitis

**Hospital stay**

**PL BL Other** 

**postoperative complications**

of gastric anastomosis –

**Preoperative complications**

method (PSSGM).

182 Challenges in Pancreatic Pathology

**Case Sex Age Disease Real time** 

#### **2.1. Shuriken‐shaped umbilicoplasty with the sliding window's method**

The patient was placed in the supine position with legs closed. Hybrid laparoscopic surgery was performed by the hand‐assisted or the direct manipulation with a small open wound by the sliding window's method. Under general anesthesia, a Shuriken‐shaped umbilical skin incision was made 6 cm horizontally, 4 cm longitudinally and 1.8 cm wide. The intermedi‐ ate skin between outside and inside skin incision was removed. Subcutaneous tissue around the umbilicus and the upper abdominal subcutaneous region was dissected, and the upper abdominal minilaparotomy, from 8 to 12 cm, was performed (**Figures 1** and **2**). GelPort was used for the hand‐assisted laparoscopic surgery.

After that, two of Kent retractors for the upper region and two of surgical arms for the lower region are placed at each bilateral side.

#### **2.2. Real‐time moving window's method for PD**

The three operative fields were divided into the hepatic hilus region, pancreas head region, and SMA region (**Figure 3**). The four retractors were moved according to each operative region. For each operation of the hepatodudenal and common hepatic arterial regions, Kent retractor was pulled forward to the right or left upper by placing surgical gazes at the right sub‐ diaphragmatic space. And then, for the paraduodenal approach of SMA or Treize'ligament, the right or left surgical arm was pulled to the right lower direction or the left lower direction after loosening the Kent retractor. For the pancreas head region, Kent retractor was pulled toward the middle upper after loosening the surgical arms.

The operative manipulations were done and were the same as those of the usual open PD.

Especially, the processing of IPDA was firstly made by paraduodenal approach under the concept of "artery first" before dealing with SMV.

**Figure 1.** Schema of Shuriken‐shaped umbilicoplasty with sliding window's method. The figure shows each step of our procedure by the laparotomy from ① to ⑤ and umbilicoplasty by reefing in ⑥.

**Figure 2.** Operative photographs of Shuriken‐shaped umbilicoplasty with sliding window's method. The figure also shows each step from ① to ⑥.

**Figure 3.** Schema of pancreatoduodenectomy by Shuriken‐shaped umbilicoplasty with real‐time sliding window's method using operative photographs. The center photograph shows the setting of operation using two Kent retractors and two surgical arms. The three operative fields, region of hepatic hilus, region of pancreas head, and region of SMA and SMV were exposed by real‐time moving window's method by their retractors. The last photograph shows the 2‐cm operative navel wound by umbilicoplasty and each of the three drains—Winslow`s drain, drain of post pancreaticojejunostomy, and subcutaneous drain.

The hepaticojejunostomy, the pancreaticojejunostomy, and the gastrojejunostomy were done under direct vision without laparoscopic manner. After the reconstruction, three closed drain‐ age tubes were detained in the Winslow foramen, the posterior space of pancreaticojejunostomy, and subcutaneous space, respectively.

#### **2.3. Pancreatojejunostomy by punctured stent slide guiding method (PSSGM)**

#### *2.3.1. The cutting and sealing of pancreas stump*

**Figure 1.** Schema of Shuriken‐shaped umbilicoplasty with sliding window's method. The figure shows each step of our

**Figure 2.** Operative photographs of Shuriken‐shaped umbilicoplasty with sliding window's method. The figure also

procedure by the laparotomy from ① to ⑤ and umbilicoplasty by reefing in ⑥.

shows each step from ① to ⑥.

184 Challenges in Pancreatic Pathology

A cause for PL is due to insufficient sealing of the pancreas stump. We cut the pancreas by using the SonoSurg or the bipolar forceps near the pancreatic duct. The pancreatic duct is cut by the surgical knife.

#### *2.3.2. Anastomosis of duct to "seromuscular layer"*

We consider that the major cause for PL is technical problems at the anastomosis in the PJ. The possible problems of PJ anastomosis are thought to be two reasons. One is a difference of caliber between the jejunal orifice and the pancreatic duct. The other is an inside out of jejunal mucosa in anastomosis of the duct to mucosa (**Figure 4**). These problems lead to PL and local infection around PJ anastomosis. Sometimes, those infections induce the arterial aneurism and its rupture and bleeding. As a solution, we devised the punctured stent slide guiding method. The first step in this method is a puncture of jejunum by a pancreatic stent adapted to the orifice of the pancreatic duct without any incineration of serosa of jejunum as shown in **Figures 5**① and **6A**. This surgical idea might prevent the difference of anastomotic orifice and not resist the healing of anastomosis because of the none of any destroy of fire by the surgical device. The second step is an anastomosis of the duct to jejunal seromuscular layer without the mucosa. This duct to seromuscular anastomosis might prevent the necrosis of mucosa by the ligating strings. These everting suturing by all around 8–10 needles are made by 6‐0PDS doubly armed suture. Both the small orifice of the pancreatic duct and the jejunum are easily and simply anastamosed by each needle sliding on the pancreatic stent tube. After that, the third step is an anastomosis of the pancreatic parenchymal stump by the jejunal seromuscular layers with the Kakita method, utilizing a full, thick penetrating suture for tight stump adhe‐ sion. The last step is a resection of the pancreatic stent with the opposite side for the lost stent. The orifice after resection of stent is closed by suturing.

**Figure 4.** Ideas of technical causes of PL from anastomosis of duct to mucosa in pancreaticojejunostomy. The major technical cause is considered to be pancreaticojejunostomy of duct to mucosa. This origin will be induced by the two cause of the difference of caliber between jejunal orifice and pancreatic duct and the inside out of jejunal mucosa in an anastomosis of duct to mucosa.

#### New Surgical Procedure for Pancreas Head http://dx.doi.org/10.5772/66493 187

mucosa in anastomosis of the duct to mucosa (**Figure 4**). These problems lead to PL and local infection around PJ anastomosis. Sometimes, those infections induce the arterial aneurism and its rupture and bleeding. As a solution, we devised the punctured stent slide guiding method. The first step in this method is a puncture of jejunum by a pancreatic stent adapted to the orifice of the pancreatic duct without any incineration of serosa of jejunum as shown in **Figures 5**① and **6A**. This surgical idea might prevent the difference of anastomotic orifice and not resist the healing of anastomosis because of the none of any destroy of fire by the surgical device. The second step is an anastomosis of the duct to jejunal seromuscular layer without the mucosa. This duct to seromuscular anastomosis might prevent the necrosis of mucosa by the ligating strings. These everting suturing by all around 8–10 needles are made by 6‐0PDS doubly armed suture. Both the small orifice of the pancreatic duct and the jejunum are easily and simply anastamosed by each needle sliding on the pancreatic stent tube. After that, the third step is an anastomosis of the pancreatic parenchymal stump by the jejunal seromuscular layers with the Kakita method, utilizing a full, thick penetrating suture for tight stump adhe‐ sion. The last step is a resection of the pancreatic stent with the opposite side for the lost stent.

**Figure 4.** Ideas of technical causes of PL from anastomosis of duct to mucosa in pancreaticojejunostomy. The major technical cause is considered to be pancreaticojejunostomy of duct to mucosa. This origin will be induced by the two cause of the difference of caliber between jejunal orifice and pancreatic duct and the inside out of jejunal mucosa in an

The orifice after resection of stent is closed by suturing.

186 Challenges in Pancreatic Pathology

anastomosis of duct to mucosa.

**Figure 5.** Schema of duct to seromuscular layer anastomosis by punctured stent slide guiding method (PSSGM). The first step of this device is a puncture of jejunum by a pancreatic stent adapted to the orifice of pancreatic duct without any incineration of serosa of jejunum like **Figure 5**①. After that, the everting suture of seromuscular layer to pancreatic duct by 6‐0PDS double armed absorbed suture is started from upper edge using punctured stent slide guide. The posterior wall is anastomosed by the four or five stitches one by one according to the schema from ② to ⑥ The anterior wall is anastomosed by the consecutive three or four stitches by PSSGM. Finally, all stitches are ligated. The tight adaptation is the modified Kakita method.

**Figure 6.** Operative photographs of pancreaticojejunostomy by punctured stent slide guiding method. Operative photographs showing the procedures of PSSGM according to the schema of **Figure 5**.
