Sir,A pseudocyst of pancreas not responding to conservative management and persisting beyond 6 weeks requires internal or external percutaneous drainage. The different techniques described for internal drainage are cystogastrostomy, cystoduodenostomy and Roux-en-Y cystojejunostomy. There are two techniques described to do this procedure laparoscopically, i.e. “transgastric” and “intragastric” approaches. The intragastric approach needs the help of a “Gastroscope” whereas transgastric method only uses the standard laparoscopic instruments. Laparoscopic anterior transgastric cystogastrostomy is the easier approach in the available options of laparoscopic treatment of retrogastric pseudocyst of pancreas. We present an improvisation of existing technique that avoids the use of any endostaplers or endosuturing during cystogastrostomy. All the cases were evaluated as per the protocol mentioned in standard textbooks. The patient was placed in the supine position and the head end was elevated 30° with a slight left side up. A 4-port technique was used for this procedure [Figure 1]. One 10-mm port was placed at the umbilicus. Next three 5-mm ports were placed at right hypochondrium, left hypochondrium and epigastrium, respectively. Both 10-mm and 5-mm telescopes (30°) were used. Operating instruments were of 5-mm size. The energy source used was the ultrasonic scalpel (Harmonic, Ethicon). The pneumoperitonium was maintained with CO2 at 10 to 12 mmHg. Initial diagnostic laparoscopy with a 10-mm telescope at the umbilical port was done to delineate the size and location of pseudocyst and also to exclude any hepatobiliary pathology. The anterior stomach wall was hitched up with sutures and anterior gastrotomy was done by using the ultrasonic scalpel. Then 5-mm telescope was placed through the epigastric port. The needle aspirator was inserted through the right-sided port to aspirate the pseudocyst. Cystotomy was done using the harmonic scalpel. After creating adequate opening the interior of the cyst was seen for any necrotic material. The margin of window in the posterior stomach wall and the cyst was inspected for any bleeding [Figure 1]. The anterior stomach wall was re-approximated by endosuturing using polyglactin 3-0. All the ports were closed accordingly. The mean operating time was 110 minutes. Patients were ambulatory after 24 hours. Average hospital stay was 4-6 days. All the cases were followed up till 2-3 months post-operatively. The post-operative ultrasonography of abdomen excluded any residual disease. There were no postoperative complications. Laparoscopic cystogastrostomy was described in adults since 1994. There are many published papers regarding the laparoscopic management of pseudocyst of pancreas in children but they have either used endostaplers or endosuturing for cystogastrostomy.[123] By using ultrasonic scalpel like Harmonic (Ethicon) there is no need of suturing of the posterior stomach wall with the pseudocyst if hemostasis is maintained properly. With this early experience it seems to be a simple, safe and cost-effective technique in children.
Figure 1
Port positions and intraoperative picture showing cystogastrostomy
Port positions and intraoperative picture showing cystogastrostomy
Figure 1