Laparoscopic bilio-enteric Roux-en-Y gastrojejunostomy for unresectable pancreatic cancer

This video demonstrates the steps and approach to performing a Roux-en-Y bypass of obstructed bile duct and stomach in a patient with inoperable pancreatic cancer. The surgeon fashions a retrocolic Roux loop to anastomose with common bile duct using a single layer absorbable suture, and to the stomach using a stapled anastomosis. Finally a stapled jejuno-jejunal anastomosis is constructed. This is a complex case and requires advanced laparoscopic skills.

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Laparoscopic bilio-enteric Roux-en-Y gastrojejunostomy for unresectable pancreatic cancer

Authors

Abstract

This video demonstrates the steps and approach to performing a Roux-en-Y bypass of obstructed bile duct and stomach in a patient with inoperable pancreatic cancer. The surgeon fashions a retrocolic Roux loop to anastomose with common bile duct using a single layer absorbable suture, and to the stomach using a stapled anastomosis. Finally a stapled jejuno-jejunal anastomosis is constructed. This is a complex case and requires advanced laparoscopic skills.

Catégorie

complex cases

Mots-clés

pancreatic cancer, biliary bypass, gastrojejunostomy, jejuno-jejunostomy, laparoscopic

Type de vidéo

Vidéo chirurgicale

Durée

08'00''

Publication

2005-09

Popularité

Favoris

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Audio

Sous-titres

E-publication

WeBSurg.com, Sept 2005;5(09).
URL: http://www.websurg.com/doi-vd01en1269.htm

Laparoscopic bilio-enteric Roux-en-Y gastrojejunostomy for unresectable pancreatic cancer

1. Hernia reduction 00'21''

The patient is in a supine position. The operator’s position is between the legs and 2 assistants stand on the right and left of the patient. The monitor’s placed at the right shoulder for the operator and 1st assistant. A 2nd monitor is placed to the left in the axis of the 2nd assistant’s visual field. The 1st operative step is the placement of a 10mm optical trocar at the umbilicus and of two 5mm trocars in the left and right of the scope. See the fatty appendix, which is coagulated to shrink it. After visual exploration of the abdominal cavity, the procedure begins by the freeing of the adhesions between the gallbladder and the duodenum and the colon.

2. Hernia sac reduction into the abdominal cavity 01'07''

Three additional trocars are then placed, two 5mm retracting trocars for the left and right costal margins and one operating trocar of 10mm. Exposure of the common bile duct can then be completed as seen here. The pars flaccida is sharply opened using diathermy. And the gastrocolic ligament is then divided in the same manner. At this point, the omental bursa can then be just accessed from both sides of the stomach. A hole is then made in an avascular area at the base of the transverse mesocolon as shown here. And while the assistant lifts up and exposes the third jejunal loop, the surgeon opens the visceral peritoneum in order to isolate the mesenteric vessels. The mesenteric vessels are coagulated using the bipolar forceps and then they are divided. The division of the jejunal loop is performed with a 45mm endoscopic linear stapler.

3. Repair of hiatus 03'57''

And the next step mandates precise coordination between the operator and the assistants to bring up the bowel loops through the transverse mesocolon into the lesser sac. Exposure of the distal end of the jejunal loop is improved by performing a through and through suture in this loop and placing it on anterior retraction. When the enterotomy is created, a small amount of bleeding is encountered and this is controlled by electrocoagulation after exposure is improved with the help of a grasper, which is held in the surgeon’s left hand. At this point, a sharp transverse choledochotomy is performed without coagulation. We can see bile leaking from the common bile duct. The anastomosis is performed by two 4/0 monofilament absorbable running sutures.

4. Fundoplication 05'45''

Extramucosal bites are taken on the common side of the anastomosis, while full-thickness sutures are placed on the jejunal side. It’s certainly the longest and most difficult step of this procedure. The jejunal loop is positioned next to the most caudal portion of the stomach.

5. Recreation of superior phrenogastric ligament 06'30''

The stomach is exposed using sutures fixed to the abdominal wall. After opening the small bowel and gastric walls, the anastomosis is performed with an endoscopic 45mm linear stapler. Of importance is the introduction of each side of the stapler one after the other. An important role is played by the assistant who presents the bowel, hence to be anastomosed. These elements contribute to the creation of anastomosis of optimal quality. The gastric jejunal window is closed using absorbable braided 3/0 sutures shown here. The distal jejunojejunal anastomosis of the Roux-en-Y is performed using the same exposure principles with the same stapling device. A drain is placed next to the biliary enteric anastomosis at the end of the procedure.