How to do pancreatic transection during robotic pancreaticoduodenectomy. Is hanging manoeuvre always necessary?

Since its first description in 1898, pancreaticoduodenectomy has constantly been improved, allowing increasingly more complex operations to be performed even with a minimally invasive approach: laparoscopic and, in recent years, robotic approach. In most cases, similarly to open surgery, parenchymal transection is performed after the creation of a retropancreatic tunnel to ensure adequate control of the mesenteric vessels before sectioning the parenchyma. Sometimes tunnelling can be very difficult even dangerous to achieve, due to conditions such as: vascular involvement by the neoplasm of superior mesenteric vein (SMV) or portal vein (PV); fibrosis secondary to acute pancreatitis (AP) or radiotherapy. In such conditions, it seems suitable to avoid tunnelling before parenchymal transection. We will describe how we perform the standard technique which we will call 'Tunnel First approach' (TF) and then our new 'Parenchyma Transection-First' (PTF) approach in its two variants: 'bottom to top' and 'top to bottom'.