The superior mesenteric artery (SMA) first approach prior to the isolation of the portal vein (PV)/superior mesenteric vein (SMV) from the pancreatoduodenal region during pancreatoduodenectomy was introduced to reduce blood loss due to congestion caused by the PV/SMV first approach. There are several SMA first approaches: the mesenteric approach for pancreatic head cancer and the anterior approach for other periampullary diseases are usually employed at our institution. In these approaches, identification of the first jejunal vein is a critical step to determine the optimal area for lymph node dissection along the SMA (mesoduodenum), and to identify the starting point of the SMA first approach to insulate the flow of the inferior pancreatoduodenal artery. We herein describe our SMA first approach with first jejunal vein-oriented mesenteric excision during pancreatoduodenectomy.
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