Background
Although many surgical procedures are now routinely performed laparoscopically, pure laparoscopic pancreaticoduodenectomy (LPD) is not widely performed because of the technical difficulty of pancreatic resection and the complexity of reconstruction procedures. As postoperative pancreatic anastomotic leakage carries an increased risk of intra-abdominal hemorrhage and a high mortality rate, some surgeons avoid intracorporeal reconstruction, and use a hybrid laparoscopic-open approach to increase the safety and the feasibility of pancreatic anastomosis. Although a hybrid approach may reduce operative risk, it also results in loss of the potential advantages of minimally invasive surgery. Several reports have described techniques for laparoscopic pancreaticojejunostomy (PJ), but most are adaptations of open procedures. Just as in open surgery, LPD carries an increased risk of postoperative pancreatic fistula formation in patients with soft pancreatic texture or a small pancreatic duct. This increased risk may be attributed to the technical difficulty of performing the traditional duct-to-mucosa anastomosis in the pancreatic-enteric reconstruction. Magnification laparoscopy can be useful for this duct-to-mucosa anastomosis, but the restricted range of motion of laparoscopic forceps sometimes makes it difficult to perform the anastomosis. There have been an increasing number of robotic PD which may facilitate execution of complex reconstruction, but robotic PD is feasible only for highly selected patients. We therefore consider it necessary to establish novel pancreatic-enteric anastomosis techniques that are simple, feasible to perform, provide secure fixation between the enteric wall and the pancreas, and are specifically developed for LPD. We describe herein our novel pancreatic-gastric anastomosis technique (PG) in pure LPD.