Extramucosal pancreaticojejunostomy at laparoscopic pancreaticoduodenectomy.

While the 'best pancreatic anastomosis technique' debate is going during Whipple procedure, the laparoscopic pancreaticoduodenectomy lately began to appear more and more often in the medical literature. All the popular anastomosis techniques used in open pancreas surgery are being experienced in laparoscopic pancreaticoduodenectomy. However, when they were adapted to laparoscopy, their implementation was not technically easy, and assistance of robotic surgery was sometimes required at the pancreatic anastomosis stage of the procedure. Feasibility and simplicity of a new technique have a vital role in its adaptation to laparoscopic surgery. We frequently use the extra-mucosal single row handsewn anastomosis method in open and laparoscopic surgery of the stomach, small and large bowel and we found it easy and reliable. Here, we defined the adaptation of this technique to the laparoscopic pancreas anastomosis. The outcomes were not inferior to the other previously described techniques and it has the advantage of simplicity.

INTRODUCTION

Pancreaticoduodenectomy is the most effective known treatment method of pancreatic head cancer. However, the morbidity of pancreaticoduodenectomy is still high, and the pancreas anastomosis is the principal determinant of the post-operative morbidity and mortality. So far, lots of pancreas anastomosis techniques were experienced in the literature, but none of them demonstrated a clear superiority over the others. The available up-to-date data put forwarded that the success of pancreas anastomosis was directly related to the experience of the surgeon. While the ‘best anastomosis technique’ debate is going on, laparoscopic pancreaticoduodenectomy lately began to appear more and more often in the medical literature. All the popular anastomosis techniques used in open pancreas surgery are being experienced in laparoscopic pancreaticoduodenectomy.[1] However, when they were adapted to laparoscopy, their implementation was not technically easy, and assistance of robotic surgery was sometimes required at the anastomosis stage of the procedure. Feasibility and simplicity of the laparoscopic technique have a vital role on the widespread acceptance of the laparoscopic pancreaticoduodenectomy. We frequently use the extramucosal anastomosis method in open and laparoscopic surgeries of stomach, small and large bowel anastomosis and found it easy and reliable. Here, we presented the details of this technique that were adapted to the laparoscopic pancreas anastomosis.

SURGICAL TECHNIQUE

Preparation

Patient was placed in Lloyd-Davies position, and a 12 mm trocar was inserted 2 cm below the umbilicus after pneumoperitoneum. Two more 12 mm trocars were placed to the intersection points of vertical midclavicular lines and transverse umbilical line. Two 5 mm trocars were at the right flank and left upper quadrant. Liver was retracted with a Nathanson retractor through a subxiphoid trocar.

Resection

After Kocher manoeuvre, inferior vena cava, left renal vein and the third part of the duodenum were visualised. First part of the duodenum was transected 2 cm below the pylorus with an endoscopic stapler (Covidien Endo GIA 60 mm). At the hepatic hilum, gastroduodenal artery was divided, hilar lymph nodes were swept to the duodenum, the common bile duct was transected over the junction of ductus cysticus and the gallbladder was added to the specimen. At the jejunal part of the procedure, proximal jejunum was divided 5 cm distal from the duodenojejunal ligament (Covidien Endo GIA 60 mm) and moved to the right upper quadrant. Neck of the pancreas was then transected, head of the pancreas separated from the portomesenteric vein, and finally, the uncinate process was divided. The specimen was kept in the right subdiaphragmatic area.

Reconstruction

We first constructed the hepaticojejunostomy with the retrocolic proximal jejunum with a 4/0 polydioxanone suture (running, single row, no stent). Biliary limb was transected at 60 cm with a laparoscopic linear stapler (Covidien Endo GIA 60 mm) and the second proximal bowel was passed through the mesocolon. Seromuscular layers of the jejunum were sutured to the posterior edge of the pancreatic cut surface [Figure 1a and b]. The suture material was a 30 in length 3/0 polypropylene with a bulky knot at the end. After completing the posterior row, a 2 cm long jejunotomy was done [Figure 2a], and the extramucosal suturing went on at the anterior row [Figure 2b]. When the anastomosis was completed [Figure 3a], the suture was tied with the knotted tip [Figure 3b]. No catheter was placed into the Wirsung. Anastomosis lasted almost 10 min. Duodenojejunostomy was created 60 cm distal to this anastomosis, and biliary limb was anastomosed 50 cm distal to duodenojejunostomy. The specimen was extracted, and two drains were placed.

Figure 1

(a) The suture material was a 30 in length 3/0 polypropylene with a bulky knot at the end, (b) seromuscular layers of the jejunum were sutured to the posterior edge of the pancreatic cut surface

Figure 2

(a) After completing the posterior row of pancreaticojejunostomy, a 2 cm long jejunotomy was done, (b) the extramucosal suturing went on at the anterior row

Figure 3

(a) The anastomosis was completed, (b) the suture was tied with the knotted tip

DISCUSSION

During open surgery, creating an extramucosal anastomosis between the two gastrointestinal tubes is practical and safe.[2] It was also experienced at the biliary anastomosis as hepaticojejunostomy.[3] We frequently prefer this technique for the gastrointestinal anastomosis during open or laparoscopic surgeries. Relying on our previous experiences, here, we tried this technique here for the pancreaticojejunal anastomosis. The advantages of the technique were (i) to be independent from the diameter of the pancreatic duct and (ii) to be created by a single row running suturing. We observed that duration of pancreatic anastomosis shorter than the duration of biliary and the intestinal anastomosis. We cannot conclude that this was a better technique than the other methods. However, in a limited number of patients, it worked well. Clinically and biochemically, there was no fistula. The main point of this technique was its simplicity.

To build an isolated intestinal limb to the pancreaticojejunostomy could have increased the safety of anastomosis. We prefer the isolated limb techniques in open pancreaticoduodenectomy as well. By separation of the intestinal loops for biliary and pancreatic anastomosis, we aim to prevent the activation of pancreatic enzymes. Although isolated limb anastomosis was not associated with a lower incidence of pancreatic fistula, it may contribute to decreasing fistula severity and provide an easier management.[4] Isolated limb technique in laparoscopic pancreaticoduodenectomy had been previously reported in only three cases with satisfactory results in the literature.[5] A previous meta-analysis revealed that this modification was not superior to single loupe anastomosis.[6] However, we believe in that preventing the meeting of pancreatic juice and bile in the peritoneum may help a better management of the pancreatic fistula.

We do not believe that extramucosal anastomosis can prone to anastomotic strictures. In our practice, we use extramucosal anastomosis widely for several gastrointestinal anastomosis (small intestine, large bowel, oesophagus and stomach), and we did not observed any increase in the stricture rates. This technique was applied in two cases. Post-operative drain amylase values of the patients were shown in Figure 4. According to the pancreas fistula score, both cases were graded as no fistula. Although our experiences were limited, we can say that this simple technique worked well. Other techniques such as duct-to-mucosa usually need a robotic assistance. Pancreaticojejunostomy with dunking technique requires two-row sutures. In the extramucosal technique, no robotic assistance is necessary, and a single row anastomosis is enough.

Figure 4

Post-operative drain amylase values on days 1–9

CONCLUSION

Extra-mucosal pancreatic anastomosis of the pancreaticoduodenectomy was a promising technique. Of course, its validity should be confirmed by larger studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.