As most surgeons know, even by only holding up the pancreatic head, controlling bleeding from the portal vein system is made easier.7

When abrupt bleeding is encountered, the surgeon can cope with it using both hands because the assistant can keep the pancreatic head held up by pulling up the tape placed at the pancreatic neck. Additionally, by dissecting the connective tissue beside SMA earlier, inflow into the pancreatic head from SMA is shut off earlier and some interspace is created between the pancreatic parenchyma and SMV/PV by pulling the pancreas away from them radially, so that dissection around these veins is made easier despite being the site that bleeds most easily.8 and 9 Consequently, BIBW2992 in vivo the procedure of dissecting the pancreas from the mesenteric vessels can be performed quickly. Because several difficult Akt inhibitor cases with a huge cystic lesion compressing the mesenteric vessels, severe fibrosis caused by obstructive cholangitis or pancreatitis or gastric carcinoma that required simultaneous gastrectomy were included in this series, the mean time for resection was long (263 minutes); however, the minimum time for resection was 169 minutes. Therefore, we believe that the desired time for resecting an uncomplicated case is 3 hours (180 minutes). Also, we have standardized the procedure for laparoscopic reconstruction.4 Taken together, we believe that the desired overall time for laparoscopic PD is 6 hours. In addition,

it is also an advantage of the current procedure that transecting the pancreatic neck and CBD last can minimize the spillage of pancreatic juice and bile into the intraperitoneal cavity. These techniques are no more than basic techniques. In practice, the fibrotic change of the hepatoduodenal ligament mafosfamide caused by obstructive jaundice, cholangitis, and/or

the effect of stenting, the fibrotic change around the mesenteric vessels caused by pancreatitis, or the fragility of connective tissues caused by diabetes and/or obesity often increase the difficulty of dissecting around the mesenteric vessels; however, we have realized that the significance and universality of the current technique is apparent, especially in such cases. We had to convert to the open approach in 1 patient due to bleeding from the stump of a thick branch of the SMV, which was located on the back of the SMV. Often, the posterior aspect of the SMV also appears after dividing the connective tissue between SMA and the uncinate process through the hole opened in the ligament of Treitz. In this situation, the SMV, which is normally situated on the right-ventral side of SMA, is pulled out to the left side, passing behind SMA, so that SMV is dislocated improperly. In our conversion case, because we misidentified a thick branch as a thin branch and transected it at the root, only sealing with LigaSure without any ligation or clipping, the stump was opened when the jejunum stump was passed to the right side.