ABSTRACT

Pancreatoduodenectomy is an established procedure for the treatment of benign and
malignant diseases located at the pancreatic head and periampullary region. Despite
technical improvements, postoperative morbidity remains a major concern. Among these
improvements, a technique using two different jejunal loops was described to avoid activation
of pancreatic juice by biliary secretion and therefore reduce severity of pancreatic
fistula [1]. We have recently described a laparoscopic technique of pylorus-preserving
pancreatoduodenectomy (PPPD) with reconstruction of the alimentary tract using isolated
pancreatic drainage [2]. This technique does not decrease the incidence of pancreatic
fistula. However, according to a recent randomized controlled trial, it decreases fistula
severity, duration of stay and medical costs [3]. We present in this video the case of a
60-year-old woman with 2 weeks history of jaundice. CT scan showed a 3-cm tumor, in
the head of the pancreas, suspected for malignancy and a replaced right hepatic artery
from superior mesenteric artery. The surgical procedure was performed with the patient
in a supine position with the surgeon standing between patient’s legs. After resection of
the pancreatic head, reconstruction of the alimentary tract was performed using two different
jejunal loops, one for pancreatojejunostomy and another for hepaticojejunostomy.
Jejunum was divided with stapler to create a second loop for biliary anastomosis, which was
marked using a green suture. Roux-en-Y was created about 40 cm from jejunal edge. Sideto-
side jejunal anastomosis was performed with stapler and a double layered end-to-side
pancreaticojejunostomy was performed. Next, vascular clamp was removed from common
bile duct and an end-to-side hepaticojejunostomy was performed with 5-0 PDS running
suture. Finally, end-to-side duodenojejunal anastomosis was performed using standard
double layer technique in an antecolic fashion. Surgical specimen was put inside a plastic
retrieval bag and extracted through umbilical port. Pneumoperitoneum was reestablished and operative field was checked for bleeding and leaks.
Two drains, one for pancreaticojejunostomy and other for
hepaticojejunostomy were left in place and exteriorized
on the left and right flank, respectively, using trocar incisions.
Histological examination of the surgical specimen
showed a 2.9×2.6 cm adenocarcinoma of the pancreas with
free margins. Two out 20 resected lymph nodes were positive.
Since March 2012, we are considering every patient
for laparoscopic approach, except those with radiological
signs of portal vein invasion, voluminous tumor or
patient refusal. The proportion of laparoscopic approach
for PPPD in our department is about 40% of patients.
In conclusion, laparoscopic pylorus-preserving pancreatoduodenectomy
with double jejunal loop reconstruction is
feasible and may be useful to decrease severity of postoperative
pancreatic fistulas. This video shows the different
steps necessary to perform this complex pancreatic
surgical procedure.