Dumitrascu etal. compared artery-rst PD with standard PD [9]. They reported that artery-rst PD can be completed faster and with less blood loss, and with no difference in postoperative complications. Figueras etal. conducted a sim­ilar study and also found that artery-rst PD required less time, resulted in less blood loss, again with no difference in

proximal jejunum and passing them to the right under the superior mesenteric vessels [17]. In 2010, Hackert et al. reported an “uncinate-rst” approach to rst dissect between the pancreatic uncinate and SMA [18]. Nakamura et al. reported that the FJV can be identied rst, after which the SMA can be accessed for a safer approach. Shrikhande etal. reported advantages in terms of blood loss, reduced opera­tive time, postoperative complications, lymph node dissec­tion, and margin status.

Although not necessarily artery-rst, there are also many reports on approaching from the pancreatic uncinate when performing laparoscopic PD.Zimmitti etal. reported that the right-uncinate approach is useful as an artery-rst approach in laparoscopic PD [19, 20]. However, it is also true that the right-uncinate approach often overlaps with the right­posterior approach in some procedural elements, and it is dif­cult to clearly classify them. The Cattell-Braasch maneuver involves dissecting the right-sided white line of Toldt, dissect­ing the dorsal side of the ascending colon and the mesentery of the small intestine, and additionally performing sufcient kocherization to elevate it broadly to the left, including the pancreatic head of the duodenum. This method ensures that the root of the SMA can be approached [21, 22]. There is also the derotation technique by Sugiyama etal. to be considered. This is a method to expand the mesopancreas to the right side by generously dissecting the proximal small intestine from the duodenum, releasing the mesenteric rotation, and exten­sively pulling the mesopancreas to the right side in order to reliably approach the root of the artery branching from the SMA to the pancreatic head [23, 24]. This approach is gener­ally easier to understand anatomically because of the traction deployment of the pancreatic head, and it is easier to deter­mine the resectability between the SMA and the tumor on the ventral side of the pancreatic head.