Background : We showcase a video presentation of a 50-year-old patient who underwent a laparoscopic pylorus-preserving pancreaticoduodenectomy (PPPD) for a 4cm mucinous cystic neoplasm. 3D laparoscopic techniques were used. The pancreatojejunostomy anastomosis was performed using a duct-to-mucosa technique in the setting of a soft pancreas and small pancreatic duct (2mm). The patient recovered uneventfully and was discharged home on post-operative day 4.

Methods : We demonstrated the key steps of this operation, including: Operating theatre set-up and laparoscopic ports placement Resection stage 1) Division of the right gastroepiploic vessels and right gastric artery 2) Division of the duodenum at D1 3) Kocher manoeuvre 4) Creation of a retropancreatic tunnel 5) Dissection of the hepatoduodenal ligament 6) Dissection of Kim’s triangle 7) Division of the gastroduodenal artery 8) Division of the common bile duct 9) Transection of the pancreatic neck and pancreatic duct 10) Mobilisation of the mesentery around D3 and proximal jejunum 11) Division of the proximal jejunum Reconstruction stage 1) Pancreatojejunostomy (serosa layers and duct-to-mucosa layer) 2) Hepaticojejunostomy 3) Gastrojejunostomy (exteriorised)

Results : Histology: (A) Proximal bile duct margin (frozen section): No evidence of high-grade dysplasia or malignancy (B) Station 8 lymph node, biopsy: No lymph node tissue or malignancy seen (C) Pancreatic tissue, biopsy: Benign pancreatic tissue (D) Head of pancreas cystic lesion, Whipple's resection: Serous cystic neoplasm (serous cystadenoma), 4.1 cm in size Eleven lymph nodes with no evidence of malignancy (0/11) Resection margins not involved by tumour (E) Gallbladder, cholecystectomy: Chronic cholecystitis and cholelithiasis

Conclusions : Our video highlights that the duct-to-mucosa technique for pancreatojejunostomy anastomosis is technically feasible and safe, even in the setting of a soft pancreas and small pancreatic duct.