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Purpose In this study, a three-step novel surgical technique was developed for incisional hernia, in which a laparoscopic procedure with a mini-laparotomy is combined: so-called ‘three-step incisional hybrid repair’. The aim of this study was to reduce the risk of intestinal lacerations during adhesiolysis and recurrence rate by better symmetrical overlap placement of the mesh. Objectives To evaluate first perioperative outcomes with this technique. Methods From 2016 to 2020, 70 patients (65.7% females) with an incisional hernia of > 2 and ≤ 10 cm underwent a elective three-step incisional hybrid repair in two non-academic hospitals performed by two surgeons specialised in abdominal wall surgery. Intra- and postoperative complications, operation time, hospitalisation time and hernia recurrence were assessed. Results Mean operation time was 100 min. Mean hernia size was 4.8 cm; 45 patients (64.3%) had a hernia of 1–5 cm, 25 patients (35.7%) of 6–10 cm. Eight patients had a grade 1 complication (11.4%), five patients a grade 2 (7.1%), two patients (2.8%) a grade 4 complication and one patient (1.4%) a grade 5 complication. Five patients had an intraoperative complication (7.0%), two enterotomies, one serosa injury, one omentum bleeding and one laceration of an epigastric vessel. Mean length of stay was 3.3 days. Four patients (5.6%) developed a hernia recurrence during a mean follow-up of 19.5 weeks. Conclusion A three-step hybrid incisional hernia repair is a safe alternative for incisional hernia repair. Intraoperative complications rate was low.

Obtaining tumor-free resection margins is one of the most important factors for achieving favorable prognosis of patients undergoing resection for hepatobiliary malignancies. In this study, we present our experience of portal vein (PV) wedge resection and patch venoplasty using autologous or homologous vessel grafts for resecting perihilar cholangiocarcinoma, hepatocellular carcinoma, and distal bile duct cancer. Case 1 was 68-year-old male patient with type IV perihilar cholangiocarcinoma who underwent central bisectionectomy with caudate lobectomy and bile duct resection, and PV wedge resection and patch venoplasty with a cryopreserved iliac vein allograft patch. This patient survived 14 months after surgery. Case 2 was 77-year-old male patient with type IIIA perihilar cholangiocarcinoma who underwent left medial sectionectomy with caudate lobectomy, bile duct resection, and PV wedge resection and patch venoplasty with a cryopreserved iliac vein allograft patch. This patient survived 17 months after surgery. Case 3 was 54-year-old male patient with hepatitis B virus-associated liver cirrhosis and hepatocellular carcinoma with PV tumor thrombus who underwent left hepatectomy. The PV wall defect was repaired with an autologous greater saphenous vein patch. This patient survived 11 months after surgery. Case 4 was 65-year-old female patient with distal bile duct cancer who underwent pylorus-preserving pancreaticoduodenectomy, and main PV wedge resection and patch venoplasty with a cryopreserved iliac artery allograft patch. This patient survived 21 months after surgery. In conclusion, PV wedge resection and patch venoplasty can be used to facilitate complete tumor resection in patients undergoing various extents of surgical resection for hepatobiliary malignancies.

Various topical hemostatic agents can help induce coagulation at the liver cut surface. However, hemostasis is usually ineffective in controlling bleeding. We present a case of rescue fibrin glue-infiltrating hemostasis combined with hepatorrhaphy to manage intractable postoperative bleeding from the liver cut surface. The case was a 56-year-old male patient with hepatocellular carcinoma in hepatitis B virus-associated cirrhotic liver. The patient was administered warfarin because of graft replacement of the ascending aorta and hemi-arch one year earlier. After warfarin was discontinued, segment VII partial hepatectomy was performed according to standard procedures. However, considerable bleeding occurred during and after hepatectomy. Bleeding from the liver cut surface was controlled over one hour using surface coagulation and topical application of four kinds of hemostatic agents. However, active abdominal bleeding led to reoperation soon after the hepatectomy. During the reoperation, we identified diffuse oozing from the edge of the liver cut surface which was difficult to control. Thus, we performed direct parenchymal injection of fibrin glue at the bleeding points using 12 fibrin glue kits which induced complete hemostasis. Because the patient would undergo anticoagulation again soon after the operation, we also performed hepatorrhaphy. The patient recovered uneventfully after the reoperation. He has been doing well for six months without complications. In conclusion, fibrin glue-infiltrating hemostasis effectively controlled intractable bleeding from the hepatic cut surface in our case. Thus, it can be considered as an optional method for rescue hemostasis.

Laparoscopic cholecystectomy has a reported incidence of 4%-15% of conversion to an open procedure and one of the main reasons behind the conversion is a gallbladder (GB) wrapped with dense adhesions. It is prudent to convert the procedure to an open operation in patients with particularly dense adhesions when the GB is not visible, preventing safe dissection which carries a potential risk of duodenal or colonic injury. The technique described, namely laparoscopic 'D2 first' approach, enables the completion of laparoscopic procedure in patients with 'obscure' GBs.

A secure pancreatic-enteric anastomosis is widely accepted as the 'Achilles heel' in reconstruction following a pancreaticoduodenectomy. Most morbidity following the procedure is related to the failure of this anastomosis, resulting in intra-abdominal collections, secondary haemorrhage, delayed gastric emptying, need for radiological interventions and re-operation for some patients. Of several techniques available, the 'duct-to-mucosa' technique is widely employed for pancreaticojejunal anastomosis. Among several refinements to facilitate this anastomosis, viz; mobilization of pancreatic stump, magnification with loupes and modifications made on the jejunal side to enable a tension free anastomosis, none seems to address the pancreatic duct in particular. The operative technique of anterior pancreatic duct split described by us enables a wider, well visualized pancreatic duct for a secure duct to mucosa pancreaticojejunal anastomosis.

Infant-to-infant whole liver transplantation (I2I-WLT) has been rarely performed in Korea. Unlike living donor liver transplantation or split liver transplantation, the donor graft portal vein (PV) in I2I-WLT is very small in diameter, so risk of PV complications increases significantly. We present two cases of I2I-WLT with application of side-to-side unification venoplasty for secure PV reconstruction. The first case recipient was a 10-month-old female baby who weighed 6.0 kg. She was diagnosed with progressive familial intrahepatic cholestasis. The deceased donor was a 12-month-old boy. The graft weight was 245 g, so the graft-recipient weight ratio (GRWR) was 4.1%. PV was reconstructed using side-to-side unification venoplasty. The function of graft liver recovered uneventfully and there was no evidence of PV complications. She is currently doing well for 4 years. The second case recipient was a 10-month-old female baby who weighed 8.8 kg. She had also undergone Kasai operation for biliary atresia. GRWR was 6.0%. Because the graft liver was much larger than the native liver, we designed the length of the extrahepatic PV more redundant than the precedent cases to avoid extrinsic compression by the large-sized caudate lobe. The PV was reconstructed using side-to-side unification venoplasty. The function of the graft liver recovered uneventfully. There was no evidence of PV complications. She is currently doing well for 2 years. As the PV size in infant donors and recipients is very small, PV reconstruction in I2I-WLT requires specialized surgical techniques of side-to-side unification venoplasty. Three supplementary video clips are provided.

Background An ever-growing and long surgical waiting list is a challenge within the NHS. Long waiting times can result in complications of the condition with more challenging operations and additional procedures. All of which implies reduced quality of life for patients and increased strain on NHS finances. On an average there are about 160 patients on the waiting list for groin hernia surgeries, with over a half of them waiting more than 30 weeks. Three patients every year breach the 52 weeks timeline, flagging a never event, with negative implications for the trust. Methods The Hernia CAMP model was proposed to improve productivity and enhance patient experience. It helped create a pathway with experienced non-consultant surgeons, stepping up to free up consultants to attend to the pressing cancer and complex cases. This dedicated pathway, improved the patient experience and staff team-spirit too. Results The Hernia CAMP resulted in a 40% improvement in efficiency. With better ratio per list/session, it makes care more cost-effective. It also improved the work environment amongst staff and rapport with patients. The patient-peer support and greater involvement meant better overall experience too. This supportive environment also has the potential for theme-based learning and training. Conclusions The Hernia 'CAMP' is a transferable and adaptable model. It impacts not just long waiting lists, but also improves productivity with definite cost benefits, teambuilding, patient experience and creates a great opportunity to train too.

Purpose: Mesh fixation and broad overlap represent an open issue in umbilical hernia repair. A proprietary-designed implant with tentacle straps at its boundary has been developed to ensure a suture-free repair and a broader coverage of the abdominal wall. The study describes the results of umbilical hernia procedures carried out with the tentacle-shaped implant and the related surgical technique. Methods: A proprietary tentacle-shaped flat mesh having a central body with integrated radiating arms at its edge was used to repair large umbilical hernias in 62 patients. The implant was placed in preperitoneal sublay. The friction of the straps, crossing the abdominal wall thanks to a special needle passer, was intended to assure adequate grip to hold the implant in place assuring a fixation-free procedure and broad overlap of the hernia defect. Results: In a mean follow-up of 48 months (range 10–62 months), 4 seromas and 2 ischemia of the navel skin occurred. No infections, hematomas, chronic pain, mesh dislocation, or recurrence has been reported. Conclusions: The tentacle strap system of the prosthesis effectively ensured an easier implant placement avoiding the need for suturing the mesh. The arms of the implant ensured a proper orientation and stabilization of the mesh in association with a broad defect overlap. The specifically developed surgical procedure showed a quick postoperative recovery, a very low complication rate, and no recurrences even in the long term.

Backgrounds/aims Prevention of excessive bleeding during liver transplantation (LT) operations presents a major challenge. Compared to deceased donor LT, living donor LT (LDLT) is more vulnerable to bleeding because of additional dissection procedures. We herein introduce our technique for prolonged occlusion of the hepatoduodenal ligament applied to recipient hepatectomy for LDLT. Methods Simulated assessment of splanchnic hemodynamics on prolonged occlusion of the hepatoduodenal ligament showed that patients with cirrhotic liver appeared to tolerate the procedure as like in the patients with normal liver. We accumulated experience on the prolonged Pringle maneuver with curved intestinal clamps. Results This technique was applied to more than 60 cases of adult LDLT operations from early 2014 until the end of 2018. Initially, application of this technique was limited to patients showing heavy bleeding during perihilar mobilization. Thereafter, this technique was applied at the start of liver mobilization and stopped after complete mobilization of the retro-hepatic vena cava. Recently, this technique was also applied during dissection of the hepatoduodenal ligament. The mean total occlusion duration was 67±13 minutes. No patient suffered from major serosal peritoneal tearing-associated bleeding or hepatic artery problems. Intentional prolonged occlusion over two hours was applied to five patients who had advanced hepatocellular carcinoma. Conclusions We believe that prolonged occlusion of the hepatoduodenal ligament is a simple effective method to reduce intraoperative bleeding, and that it has potential benefit to reduce the risk of intraoperative tumor spread during LDLT operations.

The "artery-first" approach pancreaticoduodenectomy, with maximal mesopancreas excision and central vascular ligation, represents the current principal determinants of radicality in pancreatic head cancer resection. However, these modifications at the resection stage of pancreaticoduodenectomy constitute extremely demanding and technically complicated procedures. Among the most critical contributing factors in the difficulty of artery-first approaches is the spiral configuration of the mesoduodenum and proximal mesojejunum around the superior mesenteric artery axis. This creates complicated tridimensional anatomy, making surgical dissection in the inferior peripancreatic anatomic area extremely challenging and demanding. The Cattell-Braasch-Valdoni maneuver (right-sided medial visceral mobilization and intestinal derotation maneuver) restores the embryological twist of the duodenojejunal junction, which demystifies the distorted peripancreatic vascular anatomy and facilitates a safe and radical "mesopancreas-first" pancreatic head cancer resection. The aim of this paper was to present the advantages, efficacy, and safety of the Cattell-Braasch-Valdoni maneuver in artery-first approach radical pancreaticoduodenectomy and provide a detailed description of its surgical technique.

Resection of the hepatic segments I+IV (S1+S4) is the most common type of parenchyma-preserving hepatectomy (PPH) for perihilar cholangiocarcinoma (PHCC). The author describes personal experience on the standard and modified techniques for PPH focused on S1+S4 resection in patients with PHCC. 1) Isolated caudate lobectomy with bile duct resection (BDR) is the minimal type of PPH, but not currently recommended due to technical difficulty. 2) Partial hepatectomy of S1+S4a±segment V (S5) with BDR provides wide operative field, but extension of BDR is limited and resection of S1 paracaval portion is still difficult. 3) Resection of S1+S4+S5 with BDR provides wider operative field for complete S1 resection and multiple biliary reconstruction. 4) Resection of S1+S4 with BDR offers very wide operative field and allows wider extent of hilar BDR, and thus presents the most common type of PPH. A supplementary video clip presents the detailed standard surgical procedure for resection of S1+S4 with BDR in a patient with type IIIA PHCC. 5) Modified resection of S1+S4±S5 or segment VIII (S8) with BDR facilitates additional resection of tumor-involved S5 or S8 ducts. 6) Major hilar vascular invasion is usually contraindicated for PPH and only small portal vein invasion requiring wedge resection and patch venoplasty is allowed. In conclusion, PPH can achieve curative resection and improved outcomes in patients with PHCC via reasonable modification of the extent of hepatectomy and hilar BDR. PPH may have advantages in selected patients depending on the extent of tumor, and in patients with high operative risk.

Despite development in endoscopic treatment and minimally invasive surgery for choledocholithiasis, there remains a small number of patients who require bypass Roux-en-Y choledochojejunostomy (RYCJ) because of the intractable occurrence of common bile duct (CBD) stones. We herein present the detailed procedures of open RYCJ customized for intractable choledocholithiasis. The first method is a side-to-end choledochojejunostomy with intraluminal closure of the distal CBD. This method was applied to a 79-year-old female patient who underwent endoscopic retrograde cholangiopancreatography (ERCP) more than 10 times in the past 14 years (Case No. 1). The distal CBD was explored through choledochotomy and then the distal CBD lumen was occluded with internal running sutures. A large-sized choledochojejunostomy was performed. The patient recovered uneventfully and has been doing well for the past 2 years. The second method is an end-to-end choledochojejunostomy with segmental CBD resection. It was applied to a 75-year-old male patient who underwent ERCP 9 times in the past 10 years (Case No. 2). The CBD was resected segmentally and a large-sized choledochojejunostomy was performed. The patient also recovered uneventfully and has been doing well for the past 2 years. In conclusion, the primary indication of bypass RYCJ is intractable choledocholithiasis which requires numerous sessions of endoscopic stone removal over a long period. Open RYCJ is the preferred procedure to date. If the papilla is patulous, the distal CBD should be occluded or resected to prevent reflux ascending cholangitis. We recommend to resect the intrapancreatic distal CBD if it is markedly dilated like choledochal cyst.

Backgrounds/aims Penrose drain and Jackson-Pratt (JP) drain have benefits and drawbacks in terms of functional reliability of prolonged duration and easiness of bedside management. We have developed a suction-type cigarette drain (SCD) to compensate for the drawbacks. Methods We have used SCDs in leak-prone or contaminated hepatopancreatobiliary surgeries since 2020. Herein, we describe key elements of our 20-year experience with the management of SCDs. Results The SCD is available as two-piece and three-piece types. The two-piece SCD is a cigarette drain consisted of a silastic Penrose drain and Jackson-Pratt (JP) drain bearing multiple side holes. The three-piece SCD is a cigarette drain consisted of a silastic Penrose drain, internally located Nelaton catheter with multiple side-holes, and a connecting JP drain tube and bulb. These SCDs were inserted into the abdominal wall with a hemostat clamps and sealed with air-tight ties. Three sets of SCDs were usually inserted in more than 100 cases of patients who underwent pancreatoduodenectomy, and none of them underwent repeat surgery for postoperative pancreatic fistula. In more than 30 patients with extensive abdominal contamination, a single SCD was usually inserted into the high-risk point of fluid collection and none of them underwent repeat surgery to manage collection of abnormal fluid or abscess formation. Conclusions Our experience suggests that SCD is highly reliable and acceptably convenient for clinical application in abdominal drainage.

Backgrounds/aims To prevent large-for-size graft-related complications in small infant patients, the size of a left lateral segment (LLS) graft can be reduced to be a hyperreduced LLS (HRLLS) graft. Methods This study was intended to describe the detailed techniques for harvesting and implanting HRLLS grafts developed in a high-volume liver transplantation (LT) center. Results The mean recipient age was 4.0±1.7 months (range: 3-6) and body weight was 5.3±1.4 kg (range: 4.1-6.9). Primary diagnoses of the recipients were progressive familial intrahepatic cholestasis in 2 and biliary atresia in 1. The types of LT were living donor LT in 1 and split deceased donor LT in 2. Non-anatomical size reduction was performed to the transected LLS grafts. The mean weight of the HRLLS grafts was 191.7±62.1 g (range: 120-230) and graft-recipient weight ratio was 3.75±1.57% (range: 2.45-5.49). Widening venoplasty was applied to the graft left hepatic vein outflow orifice. Vein homograft interposition was used in a case with portal vein hypoplasia. Types of the abdomen wound closure were one case of primary repair, one of two-staged closure with a mesh, and one of three-staged repair with a silo and a mesh. All three patients recovered uneventfully from the LT operation and are doing well to date for more than 6 years after transplantation. Conclusions Making a HRLLS graft through non-anatomical resection during living donor LT and split deceased donor LT can be a useful option for treating small infant patients.

The role of surgical management for chronic pancreatitis in providing pain relief and improving quality of life is significant. Surgical techniques involving pancreatic head resection scored more over the drainage procedures. Among the resection procedures, Frey's procedure received widespread acceptance. However, the exact extent of pancreatic head resection to be performed and the limits of the resection are still debatable. The present report of bile duct preserving pancreatic head resection (BDPPHR) describes an innovative approach to the pancreatic head and conclusively defines the extent of head resection. The simplicity, feasibility and easy reproducibility of the BDPPHR is also reiterated.

Pancreatic cancers exhibit a surgical challenge, in light of frequent vascular involvement. In absence of metastatic spread, vascular invasion is the predominant limiting factor for determining the resectability. With progression of time vascular involvement is no longer considered a surgical contraindication. However these complex procedures are fraught with technical challenges. Portal clamping required for vascular resection and reconstruction results in hepatic ischemia and visceral congestion. In order to mitigate these untoward effects, surgeons have tried diverse techniques including venous shunts. Venous shunting facilitates the resection and allows for an enhanced exposure and a safe procedure. Previously described techniques were either cumbersome or failed to maintain portal flow. We present a technique of transient mesoportal shunt, to facilitate vascular resection during pancreatoduodenectomy. This technique is both simple and maintains portal flow throughout the procedure preventing both hepatic ischemia and visceral congestion.

Introduction In a single centre evaluation of a novel hernia repair device, 200 consecutive patients underwent 247 laparoscopic (TAPP) groin hernia repairs (47 bilateral) using n-butyl-2-cyanoacrylate (Liquiband®Fix8™) for mesh fixation and peritoneal closure over a 2-year period by a single experienced laparoscopic surgeon. Patients and methods All groin hernia patients requiring TAPP repair were included in the study: Inguinal 142, Femoral 14, Spigelian 4, and Inguinal disruption 40. A retrospective review of the data was performed. There were 161 males and 39 females, mean age 55 years (range 20–89 years). Mesh fixation was successful in all 247 TAPP repairs, and 90% of patients had a successful peritoneal closure using the device (20 patients required the use of conventional tacks to complete closure). Follow-up Patients were followed up with an out-patient visit at 6 weeks post-op, followed by a Patient Initiated Follow Up programme, and a final Telephone follow-up. To date all patients have completed 1 year of follow-up, and 70% of patients 2 years of follow-up (median 29 months, range 14 to 40 months). Results There were very few procedure-related adverse events: groin seromas 6 (2.4%), port site bleeding 2 (0.3%), port site hernia 2 (0.3%), and only 1 groin hernia recurrence (0.4%). Prospective surgeon scoring of satisfaction for mesh fixation, peritoneal closure, and device clogging was favourable and increased following the initial learning phase. Changes in the device design during the study period improved the efficacy of the device significantly. Conclusion This retrospective study shows that mesh fixation and peritoneal closure using the Liquiband®Fix8™ device is feasible, safe, practical, and is easy to learn.

Backgrounds/Aims: Open surgery for choledochal cyst has a disadvantage of skin incision scar from operative wound, which can be a definite disadvantage especially in young female patients. This study focused on the cosmetic aspect of skin incision for resection of choledochal cyst in young female patients. Methods: During a 2-year study period, 11 adult female patients aged less than 40 years underwent primary resection of choledochal cyst by a single surgeon. The cosmetic effect of two types of skin incision was evaluated. Results: The patients underwent mini-laparotomy through either a right subcostal incision (n=8) or an upper midline incision (n=3). The mean length of skin incision was 10 cm for right subcostal incisions and 9 cm for upper midline incisions. It took approximately 1 hour to repair the operative wound meticulously in both groups. At the 6 month to 1 year follow-up, a slight bulge on the skin scar was observed in 3 (37.5%) patients of the right subcostal incision group and 1 (33.3%) patient of the upper midline incision group. Conclusions: The results of this preliminary study support the claim that cosmetic effect of the upper midline incision for CCD surgery appears to be non-inferior to that of the right subcostal incision if the incision is placed accurately and repaired very meticulously.

Backgrounds/Aims: Intrahepatic cholangiocacinoma (IHCC) can result in spread of tumor cells to the lymph nodes (LNs) around the gastric lesser curvature. Extensive dissection of the gastric lesser curvature can induce injury to the extragastric vagus nerve branches that control motility of the pyloric sphincter and result in intractable gastric stasis. Herein, we presented our experience of preventive pyloroplasty added to resection of IHCC to address dissection-induced gastric stasis in 6 patients during 15-years. Methods: We analyzed the survival outcomes of 54 IHCC patients presenting left-sided LN metastasis. Nine study patients who underwent extended left-sided LN dissection including lesser curvature LN dissection were selected and divided into 2 groups according to performance of preventive pyloroplasty and the incidence of gastric stasis was analyzed. Results: All 54 patients were classified as stage IV due to T1-3N1M0 stage. The tumor recurrence rate were 56.4% at 1 year, 84.3% at 3 years and 84.3% at 5 years; and the overall patient survival rate were 51.9% at 1 year, 13.6% at 3 years and 6.8% at 5 years. In all 3 study patients who did not receive pyloroplasty, overt postoperative gastric stasis persisted for ＞10 days leading to prolonged hospital stay. In contrast, none of the 6 study patients who underwent pyloroplasty suffered from gastric stasis. Conclusions: Pyloroplasty is a useful surgical option to prevent gastric stasis when extensive left-sided LN dissection is required in IHCC patients with LN metastasis who have very poor post-resection prognosis.

Portal hypertension induces congestion of the liver and spleen, thus any capsular or parenchymal injury to these organs can produce intractable bleeding which generally is not easily controlled. To cope with intractable bleeding such as being encountered during liver transplantation, we developed an infiltrating hemostasis technique as a conceptual shift from conventional application methods, in which fibrin glue is locally injected into the bleeding area on the liver or spleen. This technique, which uses a fibrin glue kit (2 ml kit; Greenplast, Green Cross, Seoul, Korea), consists of inserting the needle 0.5-1 cm deep at the bleeding point, forcefully injecting 1 ml of fibrin glue contained in the fibrin glue kit, and then slowly withdrawing the needle with continuous forceful injection of the remaining 1 ml of fibrin glue. We have successfully performed this procedure in 6 cases of living donor liver transplantation and in 2 cases of non-transplant resection of the cirrhotic livers with hepatocellular carcinoma. This technique was also successfully applied to one liver transplant recipient in which intractable bleeding occurred from a small laceration at the spleen. Our fibrin glue-infiltrating hemostasis would be indicated to intractable bleeding from the hepatic or splenic cut surface. In such a situation, it would be applicable as a second-line rescue method for hemostasis.

Secure reconstruction of multiple hepatic ducts that are severely damaged by tumor invasion or iatrogenic injury is a challenge. Failure of percutaneous or endoscopic biliary stenting requires lifelong placement of one or more percutaneous transhepatic biliary drainage (PTBD) tubes. For such difficult situations, we devised a surgical technique termed cluster hepaticojejunostomy (HJ), which can be coupled with palliative bile duct resection. The cluster HJ technique consisted of applying multiple internal biliary stents and a single wide porto-enterostomy to the surrounding connective tissues. The technique is described in detail in the present case report. Performing cluster HJ benefits from three technical tips as follows: making the multiple bile duct openings wide and parallel after sequential side-to-side unification; radially anchoring and traction of the suture materials at the anterior anastomotic suture line; and making multiple segmented continuous sutures at the posterior anastomotic suture line. Thus, cluster HJ with radial spreading anchoring traction technique is a useful surgical method for secure reconstruction of severely damaged hilar bile ducts.

Backgrounds/aims It is needed to ensure bowel and biliary tract continuity after pancreaticoduodenectomies. It is possible to find a variety of reconstruction methods in literature. Methods We realized a modified reconstruction method by performing proximal gastrojejunostomy, on a jejunal loop after Whipple's pancreticoduodenectomy, with surgical succes in 7 patients with pancreatic head or periampullary carcinomas in a low-volume hospital 2009-2017. Results A modified jejunal loop reconstruction method, was performed in 7 patients after Whipple's pancreaticoduodenectomy. We had no perioperative mortality. Pancreatic fistula treated with medical attempts was observed following post-operative pancreatitis in a patient. No marginal ulceration was observed. Delayed gastric emptying was not observed, except for post-operative acute pancreatitis and pancreatic fistula developing in a patient. Conclusions A modified reconstruction method by performing proximal gastrojejunostomy on a jejunal loop, can be considered as alternative reconstructive surgical procedure after pancreaticoduodenectomy.

Pancreaticoenteric anastomosis is the origin of postoperative pancreatic fistula (POPF). Although a variety of methods have been proposed to decrease the POPF rate, randomized controlled trials performed so far have failed to demonstrate superiority of any particular method to the others. Cattell-Warren duct-to-mucosa pancreaticojejunostomy (PJ) is a widely practiced procedure. Their method is challenging, especially when the pancreatic duct is small. We assumed that the difficulty resides in the pancreatic duct becoming difficult to access when the posterior row is tied before suturing the anterior row. We have modified the duct-to-mucosa PJ so that the entire circumference of the inner layer can be sutured and tied in one-step by anchoring and retracting the anterior row. The jejunal roux-limb and pancreatic stump are positioned spatially apart, allowing enough space for free needle work. During a 13-year period, 151 patients underwent pancreaticoduodenectomy with this method, and the cumulative POPF and mortality rates were 37.1% and 4.6%, respectively. These rates were stable throughout the study period, implicating a relative independence from surgeons' experience. We believe that our method is intuitive, easy to grasp, and can be readily adopted even by surgeons not accustomed to pancreaticoduodenectomy.

Anomalous portal vein (PV) branching of the donor liver is uncommon and usually makes two, or rarely, more separate PV branches at the right liver graft. Autologous PV Y-graft interposition has long been regarded as the standard procedure, but is currently replaced with the newly developed technique of conjoined unification venoplasty (CUV) due to its superior results. Herein, we presented a case of CUV application to three PV openings of a right liver graft. The recipient was a 32-year-old male patient with hepatitis B virus-associated liver cirrhosis. The living liver donor was his 33-year-old sister who had a type III PV anomaly, but the right posterior PV branch was bifurcated early into separate branches of the segments VI and VII, thus three right liver PV branches were cut separately. We used the CUV technique consisting of placement of a small vein unification patch between three PV orifices, followed by overlying coverage with a crotch-opened autologous portal Y-graft. The portal Y-graft was excised and its crotches were incised to make a wide common orifice. Three bidirectional running sutures were required to attach the crotch-opened autologous portal Y-graft. After portal reperfusion, the conjoined PV portion bulged like a tennis ball, providing a wide range of alignment tolerance. The patient recovered uneventfully from the liver transplantation operation. The CUV technique enabled uneventful reconstruction of triple donor PV orifices. Thus, CUV can be a useful and effective technical option for reconstruction of right liver grafts with various anomalous PVs.