Minimally invasive pancreatic anastomosis after pancreaticoduodenectomy: multi-institutional step by step video description of the technique

Practical Approaches to High-Risk Anastomoses in Robotic Pancreatoduodenectomy

BACKGROUND

Pancreatoduodenectomy (PD) is performed for the treatment of pancreatic head and periampullary tumors and is associated with relatively high postoperative morbidity and mortality. Traditionally conducted as open surgery, PD has evolved with the advent of minimally invasive techniques, including robotic-assisted approaches.

RESULTS

As reported in the literature, minimally invasive PD is becoming a safe and effective alternative surgical approach. Clinically relevant postoperative pancreatic complications, such as fistulas and hemorrhage, remain among the most challenging issues after PD, particularly in high-risk cases. There are several maneuvers that may reduce their incidence and mitigate their postoperative clinical impact.

CONCLUSIONS

In this video, we describe strategies implemented at our center for high-risk PD cases, including some key tips and tricks.

Rationale and tips and tricks for transgastric robotic pancreaticogastrostomy by the double purse-string technique

Pancreaticogastrostomy (PG) is a viable option for selected patients needing a pancreatic anastomosis. The double purse-string technique can facilitate the construction of transgastric PG but in a minimally invasive approach can lead to complications due to lack of tactile feedback. We present an adaptation of double purse-string PG for the robotic surgery, with several modifications. Firstly, the inner purse-string suture is tied through the anterior gastrotomy to improve the approximation of gastric and pancreatic serosae. Secondly, all-around-the-clock intragastric interrupted mattress sutures of e-PTFE are used to secure the pancreatic remnant to the stomach, enhancing improve hemostasis. Thirdly, e-PTFE sutures precise tension calibration due to their elastic properties and resistance to robotic manipulation. Fourthly, retroperitoneal vessels are preemptively covered by passing the pancreatic remnant through a small opening in the omentum, which is rotated upward in the omental bursa. This technique was employed in 20 PGs with no grade C postoperative pancreatic fistula. It offers a viable option robotic pancreatic anastomosis.

Levels of Robotic Mesopancreas Dissection According to Malignancy and Vascular Anatomy: What Surgeons Need to Know

INTRODUCTION

The robotic approach is attracting increasing interest among the surgical community, and more and more series describing robotic pancreatoduodenectomy have been reported. Thus, surgeons performing robotic pancreatoduodenectomy should be confident with this critical step's potential scenarios.

MATERIALS AND METHODS

According to Yosuke et al., there are three different levels of mesopancreas dissection. We describe the main steps for a safe mesopancreas dissection by robotic approach.

RESULTS

This multimedia article provides, for the first time in literature, a comprehensive step-by-step overview of the mesopancreas dissection during robotic pancreatoduodenectomy (PD) and its three different levels according to tumor type.

CONCLUSIONS

Through the tips and indications presented in this multimedia article, we aim to familiarize surgeons with the mesopancreas dissections levels according to type of malignancy and vascular anatomy.

End-to-end invaginated pancreaticojejunostomy during minimally invasive pancreatoduodenectomy: technical description and single center experience

BACKGROUND

Remarkable progress has been made in pancreatic surgery over the last decades with the introduction of minimally invasive techniques. Minimally invasive pancreatoduodenectomy (MIPD) remains one of the most challenging operations in abdominal surgery and it is performed in a few centers worldwide. The treatment of the pancreatic stump is a crucial step of this operation; however, the best strategy to perform pancreatic anastomosis is still debated. In this article, we describe the technical details of our original technique of modified minimally invasive end-to-end invaginated pancreaticojejunostomy (EIPJ) using video footage.

METHODS

In the current study, we retrospectively analyzed a pilot series of 67 consecutive cases of minimally invasive (7 robotic/60 fully laparoscopic) MIPD operated on at the General Surgery Department of the Panico Hospital, Tricase (Italy) between March 2017 and October 2022.The reconstruction phase involved an EIPJ, tailored using an intra-ductal anastomotic plastic stent. The aim of this study was to describe the technique and evaluate the short-term outcomes of patients undergoing MIPD with EIPJ.

RESULTS

The mean operative time to perform the EIPJ was 21.57 ± 3.32 min. Seven patients (10.5%) developed biochemical leaks and 13 (19.4%) developed clinically relevant pancreatic fistulas (grade B or C according to the definition of the International Study Group on Pancreatic Surgery).

CONCLUSION

The early results confirm that this anastomosis is safe, easy to perform, and effective in the hands of hepatobiliopancreatic (HBP) surgeons with experience in minimally invasive surgery.