Inclusion Criteria:

1. Patients with periampullary disease who have to be treated by PPPD

- pancreatic cancer, distal bile duct cancer, duodenal cancer, and so on.

2. 20 year to 80 year-old patients

3. In terms of general performance status, the patients with more than 70% of the
Karnofsky score or ECOG 0 to 1.

Exclusion Criteria:

1. Patients with unresectable or locally advanced and metastatic cancer.

2. The patient who does not want to take the operation.

3. The patient with more than 3 of ASA score.

4. Drug abusers or alcoholics.

5. Non-compliances

6. The patient who does not want to participate the clinical trials.

7. The patients who can not read or understand about informed consent form such as a
mentally retarded person, the blind, illiteracy, or foreigner.

8. The patient who have previous transabdominal surgery

9. The patient who have to have resection of other organs or vessels other than standard
PPPD

10. The patient who is indicated to laparoscopic PPPD