UNASSIGNED: Laparoscopic pancreaticoduodenectomy (LPD) is a complicated surgical procedure that has recently been performed safely. A superior mesenteric artery (SMA)-first approach can allow complete mesopancreas resection, maximizing surgical margins and R0 resection rates. Therefore, the SMA-first approach is recommended. This review is a literature summary of recent updates of the SMA approaches for LPD and informs clinical practice of the advantages of its various approach.
UNASSIGNED: A systematic literature search was performed on the PubMed (MEDLINE) database using truncated word searches and medical subject headings to identify all pertinent published studies.
UNASSIGNED: After searching PubMed, 303 studies were identified and reviewed, of which 25 described the SMA-first approach, including the anterior, posterior, right, and left approaches, fully described in 5, 6, 13, and 6 articles, respectively.
UNASSIGNED: The SMA-first approach is the standard surgical technique for LPD. This review summarized each SMA-first approach\'s distinct advantages and indications.

BACKGROUND: Minimally invasive pancreaticoduodenectomy (MIPD) has recently been safely performed by experts, and various methods for resection have been reported. This review summarizes the literature describing surgical approaches for MIPD.
METHODS: A systematic literature search of PubMed (MEDLINE) was conducted for studies reporting robotic and laparoscopic pancreaticoduodenectomy; the reference lists of review articles were searched. Of 444 articles yielded, 23 manuscripts describing the surgical approach to dissect around the superior mesenteric artery (SMA), including hand-searched articles, were assessed.
RESULTS: Various approaches to dissect around the SMA have been reported. These approaches were categorized according to the direction toward the SMA when initiating dissection around the SMA: anterior approach (two articles), posterior approach (four articles), right approach (16 articles), and left approach (three articles). Thus, many reports used the right approach. Most articles provided a technical description. Some articles showed the advantage of their method in a comparison study. However, these were single-center retrospective studies with a small sample size.
CONCLUSIONS: Various approaches for MIPD have been reported; however, few authors have reported the advantage of their methods compared to other methods. Further discussion is needed to clarify the appropriate surgical approach to the SMA during MIPD.

When pancreatic head cancer invades the superior mesenteric artery (SMA), attempts at curative resection are aborted. Preoperative imaging diagnostics to determine the surgical curability have yet to surpass the intraoperative information acquired via inspection, palpation, and trial dissection. Pancreatoduodenectomy (PD) is a standard measure for treating periampullary cancers. In conventional PD, SMA invasion is usually identified by dissecting the retroportal lamina, which connects the uncinate process and SMA nerve plexus after dividing the neck of the pancreas. During PD for pancreatic head cancer, this retroperitoneal margin frequently vitiates surgical curability. SMA-first approaches during PD are methods where the SMA is dissected first by severing the posterior pancreatic capsule to assess the SMA involvement of pancreatic cancer early in the operation. The first report of such an approach prompted subsequent reports of various maneuvers that are now known collectively as \"artery-first\" approaches. We herein review those approaches by classifying them according to (1) the side of the mesocolon from where the SMA approach occurs (supracolic or infracolic) and (2) the direction of access (right or left and anterior or posterior). The steps of the reported PD procedures are numbered according to a timeline and summarized using anatomical division of the SMA.