5 After all Haenawa sutures have been placed, first the most

cranial side Haenawa suture is ligated. Then, inner layer procedures are performed, and the other Haenawa sutures are ligated in sequence from the cranial to caudal side (Fig. 3). The choledocojejunostomy and duodeno- or gastro-jejunostomy are then performed. Before closing the abdomen, a closed-suction drain is placed in the pancreatic anastomosis area. From August 2011 to November 2012, 20 patients underwent laparoscopic PD and 3 patients underwent laparoscopic MP at Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital. The 23 patients Natural Product Library had a median age of 68 years (range 34 to 86 years). The male:female ratio was 14:9. Histopathologic diagnosis was intraductal papillary mucinous neoplasm in 10, papilla carcinoma in 5, pancreatic carcinoma in 3 patients, and pancreatic

SCH727965 mw neuroendocrine tumor, bile duct neuroendocrine tumor, duodenal carcinoma, solid and pseudo-papillary neoplasm, and serous cystadenoma in 1 patient, respectively. In 17 of 23 patients, excluding 5 patients for whom we performed P-JS via the open approach and a patient for whom we performed P-JS via the laparoscopic approach for the first time, P-JS was performed by our standardized method using Haenawa. Of these 17, the internal drainage method was performed in 12 and duct-to-mucosal anastomosis was performed in 5 patients for the inner layer. The mean overall operative time among 17 patients was 462 minutes (range 341 to 656 minutes), with mean blood loss of 126 g (range 0 to 350 g). Of 17 patients who underwent laparoscopic P-JS using Haenawa, in 12 with the internal drainage method and 5 with duct-to-mucosal anastomosis, the mean times for P-JS were 81 minutes (range 48 to 111 minutes) and 103 minutes (range 79 to 156 minutes), respectively. Postoperative complications occurred in 8 patients. Postoperative pancreatic fistula (POPF) of Grades A and B6 occurred

in 1 and 2 patients, respectively, and peptic ulcer, portal vein thrombus, congestion of the afferent Alanine-glyoxylate transaminase loop jejunum, abdominal abscess, and pneumonitis occurred in 1 patient, respectively. In all patients, complications were resolved with conservative measures. Laparoscopic PD has yet to be accepted as a generalized surgical method because of both the difficulty and time consumption of pancreaticoenteric anastomosis.1 and 2 In our first case of totally laparoscopic P-JS, for which we did not use our current procedure, we felt marked stress, especially during P-JS. More than 1 hour on average is required for P-JS; however, we feel that our stress was reduced by eliminating the tangles of sutures retained without ligation after stitching. Therefore, we believe that totally laparoscopic P-JS is feasible using our current procedure with Haenawa.