{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T19:10:11Z","timestamp":1778872211351,"version":"3.51.4"},"reference-count":5,"publisher":"Springer Science and Business Media LLC","issue":"6","license":[{"start":{"date-parts":[[2026,1,23]],"date-time":"2026-01-23T00:00:00Z","timestamp":1769126400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,1,23]],"date-time":"2026-01-23T00:00:00Z","timestamp":1769126400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"Suzhou Special Program for the Diagnosis and Treatment Technique of Key Clinical Diseases in 2022","award":["LCZX202235"],"award-info":[{"award-number":["LCZX202235"]}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Ann Surg Oncol"],"published-print":{"date-parts":[[2026,6]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>\n                      Dissection around the superior mesenteric artery (SMA) is a crucial and one of the most challenging processes in laparoscopic pancreaticoduodenectomy (LPD) owing to the deep anatomic location and the indispensable role of SMA. Multiple approaches to SMA during LPD have been proposed, but most of them require the transection of the jejunum or the neck of pancreas in advance and may cause significant tension on mesenteric vessels that may lead to accidental bleeding.\n                      <jats:sup>1\u20133<\/jats:sup>\n                      Here, we describe an in situ anterior approach to the SMA that aids in the early assessment of tumor resectability without any destructive steps and minimizes bleeding risk.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Patients and Methods<\/jats:title>\n                    <jats:p>\n                      An 85-year-old man underwent LPD for a distal common bile duct carcinoma, with a percutaneous transhepatic biliary drainage (PTBD) placed 4 weeks prior. Preoperative imaging showed a rare first jejunal vein that runs in front of the SMA and drains into the junction of the SMV and the spleen vein. The in situ anterior approach to the SMA begins with the identification of superior mesenteric vein (SMV) at the inferior border of the pancreas. The right gastroepiploic vein, and right colic vein and gastrocolic trunk are clipped and divided. The SMV is exposed to the level of third portion of the duodenum. Then the left side of the SMV or the \u201cgroove\u201d between SMV and SMA is dissected. The colic vein draining into the SMV is clipped and divided. The first jejunal vein that drains into the junction of the SMV and the spleen vein is also clipped and divided. With the surgeon and the assistant grasping the fibrofatty tissue in the \u201cgroove\u201d and pulling ventrally in opposite positions, the fibrofatty tissue and neural plexus around the SMA are dissected. In this way the SMA can be skeletonized in a ventral-to-dorsal direction. During the process, the IPDA, the first jejunal artery and their common trunk are identified. The distal end of J1A and the common trunk of IPDA and J1A are securely clipped and divided. The posterior dissection ends when the inferior vena cava or the gauze placed behind the duodenum during the Kocher maneuver is revealed. The dissection could continue cephalad to remove the lymph nodes in the Heidelberg Triangle.\n                      <jats:sup>4<\/jats:sup>\n                      The dorsal pancreatic artery is clipped and divided.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>In this case, the operative time was 340\u00a0min with an estimated blood loss of 200\u00a0ml. The patient recovered uneventfully with no pancreatic fistula and was discharged on postoperative day 8. Histology confirmed poorly-differentiated biliary adenocarcinoma with no involvement of the lymph nodes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>\n                      The video illustrates an in situ anterior approach to dissect the superior mesenteric artery in laparoscopic pancreaticoduodenectomy that largely resembles the supracolic anterior artery-first approach in open surgery proposed by Inoue et al.\n                      <jats:sup>5<\/jats:sup>\n                      This approach reduces the risk of vascular injury and bleeding by omitting the significant tension on mesenteric vessels as organs stay in their original positions, and the nondestructive and \u201creversable\u201d nature makes it easier to achieve an accurate evaluation of tumor resectability early in the surgery.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1245\/s10434-025-18965-4","type":"journal-article","created":{"date-parts":[[2026,1,23]],"date-time":"2026-01-23T12:26:50Z","timestamp":1769171210000},"page":"5100-5101","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["In Situ Anterior Approach to Dissect the Superior Mesenteric Artery in Minimally Invasive Pancreaticoduodenectomy: Step-by-Step Technique and Video"],"prefix":"10.1245","volume":"33","author":[{"given":"Jian-ang","family":"Li","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xingsheng","family":"Lu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yueshan","family":"Du","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wenhui","family":"Lou","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Liang","family":"Liu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lei","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2026,1,23]]},"reference":[{"key":"18965_CR1","doi-asserted-by":"publisher","DOI":"10.1016\/j.heliyon.2024.e27500","volume":"10","author":"JJ Ke","year":"2024","unstructured":"Ke JJ, Liu FQ, Ke JJ, Cai HQ, Liu YH, Ji B. Application of the superior mesenteric artery-first approach in laparoscopic pancreatoduodenectomy: a literature review. Heliyon. 2024;10:e27500.","journal-title":"Heliyon."},{"key":"18965_CR2","doi-asserted-by":"publisher","first-page":"425","DOI":"10.1186\/s12893-021-01433-7","volume":"21","author":"YQ Cai","year":"2021","unstructured":"Cai YQ, Cai H, Peng B. Anterior approach in situ resection for total laparoscopic pancreaticoduodenectomy. BMC Surg. 2021;21:425.","journal-title":"BMC Surg."},{"key":"18965_CR3","doi-asserted-by":"publisher","first-page":"7450","DOI":"10.1245\/s10434-025-17704-z","volume":"32","author":"A Fassari","year":"2025","unstructured":"Fassari A, De Blasi V, Amariutei A, Rosso E. Overcoming the challenges of uncinate process oncologic management: the left-side approach in minimally invasive pancreatoduodenectomy: step-by-step technique and video. Ann Surg Oncol. 2025;32:7450\u20131.","journal-title":"Ann Surg Oncol."},{"key":"18965_CR4","doi-asserted-by":"publisher","first-page":"1613","DOI":"10.1245\/s10434-019-08101-4","volume":"27","author":"E Rosso","year":"2020","unstructured":"Rosso E, Zimmitti G, Iannelli A, Garatti M. The \u2018TRIANGLE Operation\u2019 by laparoscopy: radical pancreaticoduodenectomy with major vascular resection for borderline resectable pancreatic head cancer. Ann Surg Oncol. 2020;27:1613\u20134.","journal-title":"Ann Surg Oncol."},{"key":"18965_CR5","doi-asserted-by":"publisher","first-page":"1092","DOI":"10.1097\/SLA.0000000000001065","volume":"262","author":"Y Inoue","year":"2015","unstructured":"Inoue Y, Saiura A, Yoshioka R, et al. Pancreatoduodenectomy with systematic mesopancreas dissection using a supracolic anterior artery-first approach. Ann Surg. 2015;262:1092\u2013101.","journal-title":"Ann Surg."}],"container-title":["Annals of Surgical Oncology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1245\/s10434-025-18965-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1245\/s10434-025-18965-4","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1245\/s10434-025-18965-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T18:27:15Z","timestamp":1778869635000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1245\/s10434-025-18965-4"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,23]]},"references-count":5,"journal-issue":{"issue":"6","published-print":{"date-parts":[[2026,6]]}},"alternative-id":["18965"],"URL":"https:\/\/doi.org\/10.1245\/s10434-025-18965-4","relation":{},"ISSN":["1068-9265","1534-4681"],"issn-type":[{"value":"1068-9265","type":"print"},{"value":"1534-4681","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,23]]},"assertion":[{"value":"22 October 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"12 December 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"23 January 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The authors declare no conflicts of interest.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Disclosure"}}]}}