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anastomosis can be done elegantly, securing the sutures in turn, even in patients with duct sizes of 2-3 mm.
Normally we place around four stitches for the posterior wall and three for the anterior. The knots are
always placed outside the lumen over a handcrafted internal stent made either from a feeding tube of FG3
or 4, depending on the diameter of the pancreatic duct. After the duct to mucosa anastomosis, two more
transverse mattress sutures are placed caudal to the first between the pancreatic remnant and posterior
jejunum for further anchoring and hemostasis. Usually, we complete the middle mattress suture on either
side of the duct. The three Blumgart stitches are then passed through the anterior jejunum before securing
each in turn. A recent publication reported that modified Blumgart anastomosis in robotic
pancreatoduodenectomy is a simple and safe procedure that provides non-inferior surgical outcomes
[14]
compared to open technique .

(2)Non-visible pancreatic duct
In the case of a non-visible pancreatic duct, the pancreatic remnant is mobilized at least 4 cm off the splenic
vein, which allows the tension-free anastomosis of the pancreatic remnant to the posterior wall of the
stomach. After the pancreatic mobilization, hemostatic sutures are applied to the pancreatic cut surface
using 3-0 PDS. Then, a 2 cm gastrotomy is made in the posterior wall of the stomach using hook diathermy.
Subsequently, anchoring sutures were made between the anterior wall of the pancreas (3 cm away from the
cut margin) and the posterior wall of the stomach on the proximal side of gastrotomy) using 3/0 PDS. Then,
an anterior gastrotomy is made just opposite the posterior gastrotomy. With the use of graspers through the
anterior gastrotomy, the pancreatic cut surface is pulled inside the gastric lumen for about 1.5-2 cm. After
stabilizing the pancreatic cut surface, the posterior surface of the pancreas is sutured with the posterior wall
of the stomach distal side of the gastrotomy using 3/0 PDS. Then, through the anterior gastrotomy, the
pancreatic remnant is sutured on the gastric lumen side with 3/0 PDS. After complete hemostasis, the
anterior gastrotomy is closed with 3-0 PDS (Pancreaticogastrostomy for soft pancreas without a visible
[15]
pancreatic duct, pulling technique) .
Biliary anastomosis
The common hepatic duct stump is mobilized from the right hepatic artery to avoid inadvertent stitches in
the artery. Bile duct hemostasis is secured and flushed with saline to remove the debris to prevent the risk of
postoperative cholangitis. Duct to mucosa hepaticojejunostomy is reconstructed at 20 cm distal to the
pancreaticojejunostomy over a handcrafted plastic stent made from a feeding tube of FG3 or 4 for ducts less
than 8 mm. If the duct size is over 8 mm, we use continuous sutures for the posterior wall using 3/0
FILBLOC (Assut Europe, Italy) or 3/0 V-Loc (Covidien, USA) and interrupted sutures for the anterior wall
using 4/0 PDS. If the duct is less than 8 mm, we prefer interrupted sutures for both the anterior and
posterior walls with 4/0 PDS. Following the hepaticojejunostomy, we anchor the jejunum to the
retroperitoneum distal to the anastomosis. At the end of this step, fluid around the anastomosis and swabs
are removed.

Gastric anastomosis
This anastomosis is reconstructed at 60 cm distal to hepaticojejunostomy in the antecolic fashion. During
this step, the anchoring stitch of the jejunum to the anterior abdominal wall, completed in the earlier part of
the operation, is removed and the jejunum is moved towards the posterior wall of the stomach. Then, an
enterotomy is made in the jejunum, and a gastrotomy in the posterior wall of the stomach for stapler
insertion. Through the assistant port, the stapler (Endo GIA Articulating reload with Tri-staple technology
45 mm vascular/medium, Covidien) is inserted and the gastro-jejunal anastomosis is made after placing the
thicker blade on the stomach side and thinner blade on the jejunal side. The enterotomy is closed with a
continuous suture using 3/0 FILBLOC or V-Loc. During this anastomosis, the Cadiere forceps in arm 4 are