Laparoscopic pancreatoduodenectomy with modified Blumgart pancreaticojejunostomy. The patient is a 67-year old female with a one-centimeter ampullary tumor presenting with obstructive jaundice. She underwent endoscopic ultrasound that showed a large polypoid lesion of the ampulla.
A plastic biliary stent is placed at preoperative ERCP. Pathology shows an adenoma of the common bile duct with focal high-grade dysplasia. The CT scan shows the lesion as well as the dilated main pancreatic duct.
Place the patient in French position with the left arm abducted to 90 degrees. The first surgeon stands between the patient's legs, the first and second assistant on the left and right side. The suprapubic region is kept free for a Pfannenstiel incision to extract the specimen.
A 6-port technique is used. Place a needle straight transcutaneously in the epigastric region, around the Teres ligament to retract the ligament to the ventral abdominal wall. Mobilize the hepatic flexure.
Perform a wide Kocher maneuver exposing the inferior caval vein, the origin of the superior mesenteric artery, and the ligament of Treitz. Expose the superior mesenteric vein and its confluence with the gastroepiploic vein. Dissect the latter and transect it using clips and articulating sealer.
Now, clear the distal part of the stomach just one centimeter proximal to the pylorus and transect it using an endostapler. Identify the hepatic artery, portal vein, and gastroduodenal artery. Encircle the gastroduodenal artery with a vessel loop and divide it, leaving two plastic locking clips on the patient's side and one on the specimen's side.
Create the pancreatic tunnel by blunt dissection using the articulating sealer, and sling the pancreas with a quarter length vessel loop. Mobilize the ligament of Treitz and divide the first jejunal loop with an endostapler using vascular cartridge. Now complete the mobilization of the first loop up to the mesenteric root.
Suture the two ends of the jejunum to each other to facilitate passage of both under the mesenteric root to the patient's right side. Dissect the uncinate process with the articulating sealer from the lateral aspect of the SMV and first jejunal branch. Working in layers from ventral to dorsal, retract the SMV medially to expose the SMA.
Transect the pancreas using monopolar diathermy, managing bleeding with bipolar diathermy. Transect the pancreatic duct with scissors. Dissect all retroperitoneal nodes while visualizing the SMA.
Identify the hepatic duct and divide it between a laparoscopic bulldog proximally and a plastic locking clip distally on the hepatic duct. Next place the specimen in a plastic retrieval bag and temporarily leave it in the lower abdomen. Start the reconstruction phase, performing the pancreaticojejunostomy according to the modified Blumgart technique with four barbed sutures.
Pass the sutures through the pancreas approximately one centimeter from the cut edge, then pass them dorsally through the bowel and back through the pancreas. After passing, drive the needle through the loop, tighten it, and place it far from the pancreas. Repeat this procedure for each suture, taking care not to obstruct the pancreatic duct.
Create a two-millimeter enterotomy in the jejunum using a diathermy hook. Place four to six duct-to-mucosa sutures, using a small blunt needle, first the eight and five o'clock sutures with the knot inside. Hereafter, put a 12-centimeter 6 or 8 French pediatric nasogastric feeding tube as an internal pancreatic stent.
Place the final 11 and two o'clock sutures with the knot outside. Complete the anastomosis by picking up the ventral side of the jejunum with the original four barbed sutures, inserting them first anteriorly through the jejunal wall and then back through the ventral side of the pancreas, securing each with a clip. Suture the gall bladder to the ventral abdominal wall for further liver retraction and exposure of the hepatoduodenal ligament.
Approximately five centimeter further on the jejunal loop, create a two to five-millimeter antimesenterial enterotomy with the diathermy hook. Perform an end-to-side hepaticojejunostomy with interrupted absorbable threaded 5/0 sutures, starting with a suture between six o'clock on the bile duct and 12 o'clock in the enterotomy. Continue it from caudally to cranially, alternating between left and right of the hepaticojejunostomy.
Place a surgical drain from the right subcostal space through the foramen of Winslow ending at the superior border of the pancreaticojejunostomy. Create a small enterotomy and small gastrostomy just ventral from the staple line and perform a side-to-side stapled antecolic gastrojejunostomy. Close the remaining opening with a single suture, 3/0, barbed.
Place a second drain through the most right-sided five-millimeter trocar caudally of the pancreaticojejunostomy with the tip under the gastrojejunostomy. Cover the pancreaticojejunostomy and the stump of the GDA with the greater omentum. The operation time was six hours with 150 milliliter blood loss.
The patient's postoperative course was uncomplicated. No pancreatic leak was detected. The drains were removed at postoperative day five, and the patient discharged on postoperative day six.
Pathology revealed a 1.5-centimeter adenoma with low-grade dysplasia, R0 resection, and 13 negative lymph nodes. Laparoscopic pancreaticoduodenectomy is a technically challenging but safe and reproducible procedure. The modified Blumgart pancreaticojejunostomy is a manageable technique to perform the pancreatic anastomosis.
This procedure must be performed at high volume centers by surgeons with extensive experience in laparoscopic pancreatoduodenectomy and open and laparoscopic pancreatic procedures.
