Lecture : SMA first’ approach for pancreas cancer has developed for early determination of resectability before an irreversible step and obtaining the tumor negative histology of SMA resection margin in technique of pancreatoduodenectomy (PD). Since non-resectability is now determined by involvement of the superior mesenteric artery (SMA), this approach is arousing surgeon’s concern. Six approaches are well known for this approach in technique : posterior approach, medial uncinate approach, inferior infracolic or mesenteric approach, left posterior approach, inferior supracolic approach and superior approach. These six approaches can provide a range of options for the early determination of arterial involvement, depending on the location and size of the tumour, and before the ‘point of no return’. Whether these approaches will achieve an increase in the proportion of patients with negative margins, improvement of locoregional recurrence and increase of long-term survival has yet to be determined. In this session, I will present the techniques and some issues of this artery first approach in pancreas cancer surgery.