Application of Laparoscopic Programmatic Neurolymphatic Radical Pancreaticoduodenectomy in Pancreatic Head Cancer

Summary

This protocol introduces Laparoscopic Programmatic Neurolymphatic Radical Pancreaticoduodenectomy (LPNRPD), a standardized surgical approach for pancreatic head cancer, emphasizing safety, reproducibility, and effective R0 resection through modular techniques and radical neurolymphatic dissection.

Abstract

Laparoscopic pancreaticoduodenectomy (LPD) has become a widely adopted surgical approach for treating pancreatic head cancer. Traditional open pancreaticoduodenectomy (OPD) is associated with significant surgical trauma, with postoperative hospital stays often exceeding 2 weeks. In contrast, LPD presents higher surgical risks due to the lack of standardized protocols, particularly posing challenges in minimally invasive resection and anastomosis. In addition, the optimal extent of lymphatic and neural dissection in pancreatic head cancer remains controversial and continues to be actively debated. To address these challenges in traditional pancreatic cancer treatment, we developed a modular surgical approach and a dual-surgeon model to systematize laparoscopic pancreatic surgery. Our novel Laparoscopic Programmatic Neurolymphatic Radical Pancreaticoduodenectomy (LPNRPD) technique not only ensures surgical safety but is also user-friendly, making it particularly suitable for laparoscopic surgery beginners. For radical resection of pancreatic head cancer, we propose that complete dissection of the peripancreatic neural plexus is critical for achieving R0 resection. Through multicenter RCT studies, we established standardized protocols for radical neurolymphatic dissection tailored to different subtypes of pancreatic cancer. For patients with resectable pancreatic head cancer (preoperative CA19-9 < 200 U/mL, no vascular invasion), we recommend the LPNRPD strategy. However, the successful implementation of LPNRPD heavily relies on the surgeon's skill and expertise. This article provides a comprehensive overview of the techniques for performing LPNRPD, emphasizing its safety, reproducibility, and applicability in the context of pancreatic head cancer treatment.

Introduction

Pancreatic cancer, known as the king of cancer, is marked by late detection, low resectability, and poor prognosis. Surgical resection remains the only potentially curative treatment and a critical first step. Despite advancements in multidisciplinary strategies, the 5-year survival rate after R0 resection remains unsatisfactory, highlighting the need for improved therapies¹.

Perineural invasion (PNI), marked by tumor infiltration and spread along nerves, is a key driver of early progression, recurrence, and poor prognosis in cancer patients^2,3. With an incidence exceeding 90% in pancreatic cancer, PNI often begins as pathological neural proliferation during early PanIN-like lesions in approximately 80% of cases⁴. It not only causes severe pain and reduced quality of life but also undermines treatment efficacy⁵. Pancreaticoduodenectomy (PD) is the standard treatment for pancreatic head cancer⁶. However, traditional PD fails to address the dense neural plexus between the celiac artery (CA) and superior mesenteric artery (SMA), leaving patients vulnerable to early recurrence and metastasis. Previous randomized controlled trials (RCTs) comparing standard pancreaticoduodenectomy (SPD) with extended pancreaticoduodenectomy (EPD) have demonstrated that EPD offers no survival advantage over the standard Whipple procedure despite its theoretical benefits^7,8,9. Our team has long focused on radical nerve dissection for pancreatic cancer, pioneering the first precise neural dissection map for pancreatic cancer surgery¹⁰. Through multicenter RCTs, we demonstrated that radical pancreaticoduodenectomy combined with retroperitoneal nerve dissection significantly prolongs disease-free survival and alleviates pathological pain, providing high-level evidence for nerve-targeted radical surgery⁶. With advancements in technology, we have successfully transitioned from open to fully laparoscopic nerve dissection^11,12,13,14. Enhancing surgical outcomes while ensuring safety remains a central goal in pancreatic cancer treatment.

In 2017, Chinese experts issued consensus guidelines on LPD, recommending that teams meet the following criteria: (1) extensive experience with OPD, including the ability to manage intraoperative and postoperative complications and timely conversion to open surgery; (2) proficiency in laparoscopic skills such as suturing, knotting, dissection, and hemostasis; and (3) a stable surgical team comprising the lead surgeon, first assistant, camera operator, scrub nurse, and anesthesiologist, fostering consistent workflows and collective growth during the initial learning curve. For pancreatic head cancer patients, routine implementation of LPD requires overcoming the learning curve and establishing a multidisciplinary treatment (MDT) model. This approach ensures thorough preoperative assessment of tumor biology, patient comorbidities, and the likelihood of achieving R0 resection. Recent research by Renyi et al. analyzed 1,029 LPD cases across multiple centers in China, showing that mastering the LPD learning curve typically requires performing 104 cases¹⁵. Both domestic and international expert guidelines emphasize that LPD should be conducted at high-volume centers. Definitions of high-volume thresholds range from 10 to 50 cases annually^16,17. In the U.S., analysis of 3,079 LPD cases from 2010 to 2017 demonstrated that the threshold for high-volume centers has decreased from 22 to 20 cases annually, reflecting growing surgeon experience and improved safety outcomes^16,18.

Minimally invasive surgery represents the future of pancreatic cancer treatment. Since the release of the Chinese Expert Consensus on LPD¹⁹, the development of LPD has accelerated significantly, accompanied by a surge of related publications. However, most cases are still concentrated in large pancreatic centers, predominantly involving ampullary cancer, distal bile duct cancer, duodenal cancer, and benign or low-grade periampullary tumors. Many surgeons remain cautious about performing fully laparoscopic radical surgery for pancreatic cancer²⁰. Studies have demonstrated that laparoscopic radical pancreaticoduodenectomy for pancreatic head cancer is safe, but is primarily recommended for high-volume pancreatic centers with substantial LPD experience^21,22,23. Moreover, laparoscopic surgery achieves oncologic outcomes comparable to or better than open surgery^24,25,26. Based on our experience, laparoscopic procedures can shorten postoperative hospital stays, facilitating earlier initiation of adjuvant therapy. As one of the earliest teams in China to adopt LPD, we have developed a unique programmatic surgical workflow^13,15,27. In recent years, we have actively promoted the standardized and programmatic application of LPD and radical nerve dissection techniques for pancreatic cancer nationwide. Additionally, we have contributed to drafting Chinese expert consensus guidelines on LPD. Drawing on our experience with laparoscopic radical surgery for pancreatic head cancer, we now present the standardized workflow for Laparoscopic Programmatic Neurolymphatic Radical Pancreaticoduodenectomy (LPNRPD). The overall goal of the LPNRPD method is to establish a safe, standardized, and reproducible surgical strategy for radical resection of pancreatic head cancer using a fully laparoscopic approach. Given the complexity of PD, especially the challenges of neurolymphatic dissection and vascular proximity, we developed a modular technique rooted in anatomical landmarks and a dual-surgeon model. Each procedural step was designed with a specific rationale: (1) to improve operative visualization and efficiency through vascular-axis-centered dissection, (2) to ensure radicality by targeting lymph node stations and neural plexuses associated with early recurrence, and (3) to minimize complications by adopting standardized anastomotic techniques. By breaking down the operation into discrete, teachable modules, LPNRPD facilitates training, improves reproducibility, and reduces learning-curve-related morbidity, making advanced laparoscopic pancreatic surgery more accessible and safer across surgical teams.

Protocol

This study included 76 patients who underwent LPNRPD between August 2019 and January 2022. The protocol received approval from the Institutional Review Board of Guangdong Provincial People's Hospital, and all participants provided written informed consent. The Table of Materials provides details of the consumables and equipment used.

1. Inclusion criteria

1. Include patients with pancreatic head carcinoma, including ductal adenocarcinoma (64 cases), adenosquamous carcinoma (11 cases), and colloid carcinoma (1 case).
2. Include patients with tumor involvement of the CA, SMA, or abdominal aorta (AA) of less than 180°, with no non-reconstructable invasion of the portal vein (PV) or superior mesenteric vein (SMV).
3. Include patients with absence of distant metastasis, good general condition, allowing tolerance for laparoscopic surgery, procedures performed by a consistent and dedicated surgical team and written informed consent was provided.

2. Exclusion criteria

1. Exclude patients with locally advanced tumors or distant metastasis and poor general condition precluding tolerance for laparoscopic surgery.

3. Preoperative preparation

1. Perform preoperative biliary drainage for patients whose total bilirubin exceeds 200 µmol/L. Choose either percutaneous transhepatic cholangial drainage (PTCD) or endoscopic retrograde cholangiopancreatography (ERCP) with stent placement. Schedule surgery once bilirubin falls below 100 µmol/L and remove PTCD catheters before discharge.
2. Administer cross-matched red-blood-cell transfusion when haemoglobin is < 70 g/L and raise haemoglobin to ≥ 80 g/L prior for anesthetic induction.
3. Place the patient on a liquid diet plus oral lactulose (Duphalac) 7 days before surgery to prepare the bowel. Enforce a 6 h fast on the operation day and give 200 mL of clear carbohydrate drink 2 h before transfer to theatre to reduce peri-operative insulin resistance.

4. Surgical technique

1. Surgeon preparation for key points of programmatic and radical dissection
   1. Transect the stomach first, then sequentially transect the pancreas, jejunum, and common bile duct, keeping each step centered on the vascular axis (Figure 1A).
   2. Adopt Chen's Middle (venous) approach when vascular reconstruction is not required. Expose the PV-SMV venous axis from the anterior aspect of the first hepatic hilum to the pancreatic uncinate process. Resect posterior to the same venous axis and complete the uncinatetohilum dissection (Figure 1B).
   3. Perform lymphoneural dissection around the vascular axis. Follow the arterial axes CHA, PHA, CA, and SMA-CA, focusing on the area between the SMA and CA roots.
   4. Remove lymph node groups 13, 17, 5, 6, 8, 9, 14 (a-d), 12 (a, b, c, h), and 16 (a2, b1; Figure 1C).
   5. Excise the nerve plexuses of groups 8 and 12, the rightsided 270° CA-SMA-AA plexus, and the posterior pancreatichead plexus (Figure 1C).
2. Operating-room setup and trocar placement
   1. Arrange the operating room (Figure 2A). Place the energy platform at the patient's right cranial side and position the laparoscopic tower at the patient's left cranial side. Set the instrument trolley at the patient's right caudal side.
   2. Position the team and the patient (Figure 2A,B). Stand the primary surgeon on the patient's right; place the first assistant on the left; locate the scopist between the legs. Lay the patient supine; abduct the right arm for intravenous access; spread the legs 45° - 60°. After trocar insertion, tilt the table to 30° reverse-Trendelenburg and rotate 30° right-side-up.
   3. Create pneumoperitoneum as described below (Figure 2C).
      1. Prepare the umbilicus and surrounding 10 cm of skin with 3% povidone-iodine solution in concentric circles, allow it to dry.
      2. Use a #11 disposable scalpel to make a 12-mm vertical infra-umbilical skin incision. Insert a Veress needle; insufflate CO₂ to 12 mmHg; verify stable pressure.
      3. Introduce a 12 mm camera trocar through the same incision and survey the abdomen for metastasis.
   4. Insert working trocars under vision (Figure 2C). Place a 12 mm trocar at the right anterior-axillary line/costal-margin intersection. Insert a 12 mm trocar at the left anterior-axillary line/costal-margin intersection. Insert two additional 12-mm trocars at the right and left mid-clavicular/costal-margin intersections, ensuring ≥ 7 cm distance between trocars.
3. Liver suspension and stomach transection
   1. Suspend the left liver lobe. Elevate the left hepatic lobe with an atraumatic grasping forceps and divide the lesser omentum using an ultrasonic harmonic scalpel (Figure 3A). Insert a purse-string needle 3 cm left of the xiphoid; encircle the round ligament intra-abdominally; exit 5 cm right of the xiphoid (Figure 3B). Secure the suture to the lesser omentum with three 5 mm clips and tighten to suspend the lobe (Figure 3C).
   2. Mobilize and transect the stomach. Divide the gastrocolic ligament with the ultrasonic scalpel and clip the gastroepiploic vessels (Figure 3D). Dissect the lesser curvature in the same manner and clip the left gastric vessels with 12 mm clips (Figure 3E). Position a 60 mm linear stapler across the stomach body and fire to transect (Figure 3F). Retract the nasogastric tube to < 40 cm before stapling to avoid stapling the tube.
4. Mobilization of the superior border of the pancreas and vascular dissection.
   1. Mobilize the pancreatic superior border and elevate the stomach gently to expose the upper pancreatic edge (Figure 4A). Skeletonize and excise neuro-lymphatic tissue of group 8a en bloc (Figure 4B).
   2. Expose hepatic arteries. Identify the common hepatic artery (CHA) and clip the right gastric artery with a 5 mm clip (Figure 4C). Continue cephalad along the proper hepatic artery (PHA); expose the right hepatic artery. Visualize the anterior portal-vein surface and clear peri-PHA connective and lymphatic tissue (Figure 4D).
   3. Control the gastroduodenal artery. Retract the CHA rightward to reveal the gastroduodenal artery (GDA; Figure 4E). Ligate the GDA root with 7-0 silk and place two 5 mm clips distal to the knot (Figure 4F). Tie the silk suture gently to avoid intimal injury; overtightening may compromise arterial integrity.
5. Mobilization of the inferior pancreatic border and venous dissection
   1. Transect the pancreatic neck. Expose the anterior surface of the SMV at the inferior pancreatic border (Figure 5A). Ligate the inferior central pancreatic vein and open the retropancreatic tunnel. Transect the pancreatic neck with the ultrasonic scalpel on low power (Figure 5B). Maintain a smooth transection plane; dissect the main pancreatic duct with scissors (Figure 5C), not the ultrasonic blade.
   2. Control Henle's trunk. Dissect and ligate the right (or accessory right) colic vein (Figure 5D). Continue cephalad to expose Henle's trunk (Figure 5E). Pass a 9 cm 1-0 silk ligature around the trunk root; place a 5 mm clip directly on the knot and a 10 mm clip distally (Figure 5F); transect the vessel with scissors. Clip the Hem-o-lok over the knot to prevent slippage.
6. Kocher maneuver and duodenal mobilization
   1. Perform the Kocher maneuver. Elevate the descending duodenum with non-traumatic forceps (Figure 6A). Dissect the plane between the duodenum's lateral posterior wall and the colon to expose the anterior wall of the inferior vena cava (IVC; Figure 6B). Grasp a broad segment of intestinal wall to avoid puncture.
   2. Mobilize the posterior pancreatic head. Extend the Kocher incision medially to expose the left renal vein and abdominal aorta (Figure 6C). Excise 16B1 neuro-lymphatic tissue and reveal the anterior longitudinal ligament (Figure 6D).
   3. Retract the jejunum and divide it. Continue freeing the horizontal duodenum and draw the proximal jejunum behind the SMV and SMA toward the right (Figure 6E). Mobilize the proximal jejunal mesentery and transect the jejunum with a laparoscopic stapler (Figure 6F).
7. Uncinate process and SMA/SMV branch management
   1. Expose and control the inferior veins. Lift the horizontal duodenum outward and upward with atraumatic graspers (Figure 7A). Dissect cranially from the inferior duodenal mesentery to reveal the first jejunal vein (FJV) and inferior pancreaticoduodenal vein (IPDV; Figure 7B). Clip and divide the IPDV.
   2. Dissect between the uncinate and the SMA/SMV. Separate the tissue plane between the uncinate process and the SMV/SMA en bloc. Expose the first jejunal artery (J1A) and inferior pancreaticoduodenal artery (IPDA; Figure 7C); clip and divide both vessels when an uncinate mass is present (Figure 7D). Excise lymph-node groups 12a, 12b, 12c and 12d.
   3. Clear residual vascular and neural tissue. Continue cephalad dissection; clip and divide remaining uncinate-process veins and arteries (Figure 7E). Remove neuro-lymphatic tissue posterior to the uncinate process to complete the clearance (Figure 7F).
8. Heidelberg triangle neuro-lymphatic dissection
   1. Strip neuro-lymphatic tissue along the SMA trunk. Identify the inferior border of the SMA (Figure 8A). Dissect cranially along the SMA sheath, removing all surrounding nodes and neural fibres until the CA origin is reached (Figure 8B).
   2. Skeletonise the CHA from right to left. Peel peri-arterial lymphatic and neural tissue away from the CHA while advancing toward its left border (Figure 8C,D).
   3. Complete the Heidelberg-triangle clearance. Elevate the left renal vein gently with a soft retractor to reveal the right renal artery (Figure 8E). Start at the cleared 16A2 area and dissect residual neuro-lymphatic tissue from the outer-inferior margin toward the inner-superior apex (Figure 8F).
9. Biliary tract management and specimen retrieval
   1. Clear group-12 nodes (Figure 9A). Follow the right hepatic artery cranially. Excise peri-arterial neuro-lymphatic tissue of station 12 en bloc.
   2. Mobilize the gallbladder (Figure 9B). Elevate the fundus and dissect the gallbladder bed from the liver capsule to improve exposure.
   3. Divide the common bile duct (Figure 9C). Isolate the CBD; place proximal and distal clips. Transect the duct between the clips and confirm complete pancreaticoduodenal specimen release.
   4. Retrieve the specimen (Figure 9D). Place the specimen into a sterile retrieval bag; seal the bag securely. Drop the bagged specimen into the pelvis for temporary storage. Close the extraction port; insufflate CO₂ to 12 mmHg to continue the procedure . Avoid tearing the retrieval bag when manipulating large or calcified specimens.
10. Intra-operative field confirmation after resection
    1. Display major venous landmarks (Figure 10A). Identify and clear the surfaces of the SMV, IVC, left renal vein (LRV), and right renal artery (RRA). Expose the AA and the anterior longitudinal ligament (ALL).
    2. Expose arterial structures and Heidelberg Triangle (Figure 10B). Trace the CA from its origin and skeletonize its trunk. Follow the CHA distally and visualize its bifurcation. Dissect the SMA sheath to complete definition of the Heidelberg triangle borders.
11. Duct-to-mucosa pancreaticojejunostomy
    1. Prepare the pancreatic-duct stent (Figure 11A). Select a 13-15 cm stent appropriate to duct calibre. Bevel the end that will enter the pancreatic duct at 45° and cut a single side hole 1 cm proximal to that beveled tip.
    2. Prepare the sutures. Cut two 25 cm single-needle 4-0 Prolene sutures for outer continuous layers (Figure 11B). Tie two 5-0 PDS sutures together to create a double-needle, 9 cm-per-needle construct for duct-to-mucosa stitches (Figure 11C).
    3. Stitch the posterior outer layer. Excise a 3 mm biopsy from the main pancreatic duct for pathology (Figure 11D). Use one 4-0 Prolene to run continuously between the posterior pancreatic capsule and the jejunal seromuscular layer (Figure 11E). Encompass the superior and inferior edges of the posterior pancreatic artery stump to minimise postoperative bleeding.
    4. Create the duct-to-mucosa anastomosis. Fashion a jejunal enterotomy matching the duct or stent diameter with an electrocautery hook (Figure 11F). Place continuous posterior duct-to-mucosa stitches from cranial to caudal using the double-needle PDS (Figure 11G). Insert the stent and complete the anterior duct-to-mucosa layer in the same direction (Figure 11H).
    5. Stitch the anterior outer layer. Run the second 4-0 Prolene continuously from caudal to cranial between the anterior pancreatic capsule and jejunal seromuscular layer (Figure 11I). Ensure each bite captures adequate pancreatic parenchyma and jejunal wall to fully cover the stump without tension.
12. Hepaticojejunostomy
    1. Select the suture material. Choose a double-needle barbed suture or a double-needle PDS according to bile-duct diameter and wall thickness. Modify the PDS double-needle in the same manner described for the pancreaticojejunostomy if PDS is selected.
    2. Place the biliary stent when indicated. Insert a 5 cm, 12-Fr stent into non-dilated bile ducts; cut a single side hole 1 cm from the ductal end to enhance drainage.
    3. Construct the hepaticojejunostomy. Fashion a jejunal enterotomy equal to one-half of the bile-duct diameter with an electrocautery hook (Figure 12A). Perform a continuous circumferential anastomosis between the bile duct and jejunum (Figure 12B); place the stent before closing the anterior row when required, then complete the anterior continuous suture line (Figure 12C).
13. Gastrojejunostomy
    1. Position the jejunum and fire the stapler. Identify a jejunal loop 40 cm distal to the ligament of Treitz, lying anterior to the transverse colon. Elevate the selected jejunal segment toward the greater curvature; suspend both the greater curvature and jejunum with 4-0 Prolene stay sutures. Apply a 60 mm linear stapler to create the gastrojejunostomy (Figure 12D). Inspect the intraluminal side of the anastomosis for bleeding before withdrawing the stapler.
    2. Close and reinforce the stapler entry. Close the common enterotomy with a single-needle V-Loc barbed suture in a continuous full-thickness fashion, then add a second continuous seromuscular layer (Figure 12E). Reinforce any exposed staple intersections using 4-0 Prolene figure-of-eight sutures (Figure 12F).
14. Placement of drainage tubes
    1. Position an 8-mm silicone tube directly behind the pancreaticojejunostomy (Figure 12G).
    2. Insert an 8-mm double-lumen irrigating tube behind the hepaticojejunostomy (Figure 12H).
    3. Advance a 10 mm double-lumen irrigating tube anterior to the pancreaticojejunostomy, directing the tip posterior to the caudate lobe (Figure 12I). Cross the distal ends of the two 8-mm tubes to create an efficient flush-and-drain circuit when irrigation is required.

5. Post-operative management

1. Checking infection markers every other postoperative day (POD 1, 3, 5, etc.)
   1. Check a complete blood count (focus on WBC) with an automated analyzer. Measure serum C-reactive protein (CRP) and procalcitonin (PCT), send drain fluid for cell count/differential, and-if temperature exceeds 38.5 °C-obtain peripheral-blood and ascitic cultures for bacteria and fungi.
   2. Initiate or adjust antibiotics if any marker is above the institutional threshold.
2. Delivering routine supportive therapy
   1. Administer proton-pump inhibitors, octreotide, hepatoprotective agents, and enteral nutrition.
   2. Continue octreotide for 7 days if POD-5 drain amylase remains elevated.
   3. Provide nebulized saline 3x daily to aid sputum clearance.
3. Removing tubes according to defined criteria.
   1. Nasogastric tube: Withdraw the tube on POD 1 morning after confirming the absence of gastrointestinal bleeding.
   2. Urinary catheter: Remove the catheter within 48 h if the patient can ambulate or void spontaneously.
   3. Abdominal drains: Confirm that drain amylase is < 3x upper-limit serum value. Ensure output is < 100 mL/ d for 3 consecutive days. Verify the absence of bile leak, enteric fistula, chylous leak, or infected fluid collection. Remove the drain when all three conditions are satisfied. Re-image the abdomen with ultrasound or CT if drain output increases or changes color after POD 5.

Results

Baseline and intraoperative data (Table 1)
From January 2018 to January 2022, a total of 76 cases of LPNRPD were performed. The conversion rate to open surgery was 10.5%, and the rate of laparoscopic venous reconstruction was 5.3%. The proportion of preoperative biliary drainage was 39.4%. The median operative time was 250 min (135-425 min), median intraoperative blood loss was 50 mL (20-1500 mL), and the rate of intraoperative red blood cell transfusion was 13.2%.

Discussion

Current expert consensus, both domestically and internationally, recommends performing LPD in high-volume pancreatic minimally invasive surgery centers²⁰. As surgical experience accumulates, the learning curve for LPD has progressively shortened. An analysis by Adam's team at Duke University, based on 865 LPD cases in the United States from 2000 to 2012, showed that performing more than 22 LPDs annually significantly reduces postoperative complications¹⁸. Updated data f...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
4-0 Prolene *5 strands		8521	None
4-0 Prolene *5 strands		W8557	None
5-0 PDS suture *2 strands		PDP148	None
5-0 Prolene *5 strands		W8310/EPH8710	None
0 Absorbable suture *1 strand		VCP752D	None
3-0 (15 cm) V-LOC suture *1 strand		LOCL0614	None
4-0 (7x7 cm) Absorbable suture *1 strand		VCP771D	None
5-0 Prolene *5 strands		EPH8710?W8310/W8710	None
5-0 *3 strands		PDP148	None
4-0 Prolene *2 strands		HS6855	None
Titanium clips *3 packages			None
Trocars (12mm) *5			None
Ultracision Harmonic Curved Scissors *1		HAR36CN	None
Straight cut closure *1		PSEE60A	None
60mm blue and white nails for cutting closure device *2 (each)		ECR60B	None
Multifunctional Abdominal Drainage Tubes *1 (each)		M8A/M10A	None
Hem-o-lok Green Clips *20 packages			None
Hem-o-lok Purple Clips *10 packages			None
Hem-o-lok Brown Clips *5 packages			None
4K3D Fluoroscopy			None
Bipolar Electrocoagulation Clamp			None
Ultrasonic Scalpel Handle			None