Robotic lateral pancreaticojejunostomy for chronic pancreatitis. Lateral pancreaticojejunostomy has proven to be a successful procedure for obstructive symptomatic chronic pancreatitis, including excellent long-term outcomes. Robotic procedures including division of the gastroduodenal artery have rarely been described.
A 45 year old male presented with refractory chronic pancreatitis non-responsive to conservative pain management for three years. The patient is in French position. Seven trocars are placed, four robotic and two laparoscopic assistant trocars.
And one trocar for the liver retractor. The capnoperitoneum is created with a Ferris needle in the left hypochondrium. Then the trocars are placed.
The first operative step is the mobilization of the stomach. The greater omentum is opened two centimeters caudal from the gastroepiploic vessels. The snake retractor retracts the stomach and the left liver ventrally and cranially.
The identification of the pancreatic ducts with ultrasonography. An intraoperative ultrasound is performed to locate the main pancreatic duct which is then opened using the robotic monopolar diathermy hook. Once the trajectory of the main pancreatic duct is determined, the pancreas is opened.
The gastroduodenal artery is exposed and ligated on both sides with stitches just below and above the pancreatic duct. The fourth operative step is pulling up the small bowel to identify the Roux limb. The mesocolon is opened and approximately 30 centimeters from Treitz ligament the jejunum is divided using an endostapler.
The future lateral jejunojejunostomy site is marked at the measured distance of 50 centimeters. Now the reconstructive phase starts with the pancreaticojejunostomy. The Roux limb is opened with monopolar electrocautery.
First, the caudal part of the anastomosis is completed with a single row running suture. The cranial part of the anastomosis is completed in the same fashion. The small bowel loops are aligned and one enterotomy is made with monopolar electrocautery in each loop.
Then the anastomosis is created using an endostapler. The remaining opening is closed with the 3-O barbed suture. A single tubular drain is placed next to the pancreatic anastomosis side.
The operative time was 388 minutes with a 200 milliliters estimated blood loss. The post operative close was uncomplicated and the patient was discharged on day four postoperatively. Etiology assessment confirmed the preoperative diagnosis of chronic pancreatitis, fortunately without malignancy.
The described technique for robotic lateral pancreaticojejunostomy with transection of the gastroduodenal artery is a complex but feasible procedure.
