Total laparoscopic pylorus-preserving pancreatoduodenectomy for periampullary tumor

The authors show an edited video of a total laparoscopic modified Whipple procedure for an ampullary adenocarcinoma. The patient was obese wth a BMI of 35.6 kg/m2. Surgery was performed at the Hospital Federal de Ipanema in Rio de Janeiro, Brazil. Hand-sewn pancreatico-jejunostomy, choledocho-jejunostomy and duodeno-jenunostomy in a single-loop were performed. Total operative time was 450 minutes with an estimated blood loss of 200mL. The surgical specimen was taken out by a small incision at the left flank, through which a jejunostomy was performed.

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Total laparoscopic pylorus-preserving pancreatoduodenectomy for periampullary tumor

Authors

E Viana, F Neves

Abstract

The authors show an edited video of a total laparoscopic modified Whipple procedure for an ampullary adenocarcinoma. The patient was obese wth a BMI of 35.6 kg/m2. Surgery was performed at the Hospital Federal de Ipanema in Rio de Janeiro, Brazil. Hand-sewn pancreatico-jejunostomy, choledocho-jejunostomy and duodeno-jenunostomy in a single-loop were performed. Total operative time was 450 minutes with an estimated blood loss of 200mL. The surgical specimen was taken out by a small incision at the left flank, through which a jejunostomy was performed.

Classification

contribution

Keywords

Total laparoscopic pylorus-preserving pancreatoduodenectomy, periampullary tumor

Media type

Surgical video

Duration

18'19''

Publication

2012-01

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E-publication

WeBSurg.com, Jan 2012;12(01).
URL: http://www.websurg.com/doi-vd01en3548.htm

Total laparoscopic pylorus-preserving pancreatoduodenectomy for periampullary tumor

1. Beginning of procedure 00'27''

Six trocars are used, with the surgeon and camera assistant positioned between the legs of the patient. An auto-static retractor is used to lift the liver and expose the operative field.

2. Kocher maneuver and transection of duodenum 00'39''

The lesser sac is entered close to the stomach, allowing for visualization of the pancreas. The small screen displays the position of the surgical team. A Kocher maneuver is carried out with ultrasonic dissection. The Kocher maneuver is completed, exposing the vena cava. Now, the head of the pancreas and duodenal arch are completely mobilized. The hepatic pedicle is dissected to expose the anatomy of the hepatic artery. The gastroduodenal artery is divided between clips with an ultrasonic scalpel. The proximal duodenum is transected 2cm below the pylorus with a linear stapler.

3. Warren’s maneuver and transection of the pancreas 03'21''

The superior mesenteric vein is dissected behind the pancreas. Small tributaries are clipped or coagulated with the ultrasonic device. Care is taken not to injure these veins, which can lead to uncontrolled bleeding. The pancreas is isolated and encircled with a vessel loop. Transection of the pancreas is performed with the ultrasonic device, ensuring minimal blood loss.

4. Transection of proximal jejunum with rotation underneath the mesenteric axis 04'53''

The proximal jejunum is transected with a linear stapler, close to the ligament of Treitz. The mesentery is cut with an ultrasonic scalpel and the fourth portion of the duodenum is liberated. The third part of the duodenum is mobilized and the proximal jejunum is pulled beneath the mesenteric vessels.

5. Resection of uncinate process and transection of common bile duct 06'10''

The uncinate process is dissected off the superior mesenteric vein, and its small vessels are carefully ligated. Finally, the common bile duct is divided between clips to minimize spillage of biliary secretion. The surgical specimen is protected with a bag and left outside the surgical field.

6. Pancreaticojejunal anastomosis 08'42''

The main pancreatic duct is identified with a probe, to ensure its patency during the anastomosis. The jejunum is brought to the anastomosis position through the opening at the root of the transverse mesocolon. A side-to-side pancreato-jejunostomy is performed, utilizing non-absorbable suture. Running suture and interrupted suture are used, making sure that the main pancreatic duct is in contact with the opening in the jejunum. The probe is left in place, stenting the anastomosis.

7. Bilio-enteric anastomosis 12'16''

An end-to-side hepatico-jejunostomy is performed, using 3-0 absorbable running suture.

8. Duodenojejunal anastomosis 14'13''

An end-to-side duodenojejunostomy is performed with a single-layer of non-absorbable running suture. Here, the previous stapled line is resected prior to the anastomosis.

9. Cholecystectomy 17'17''

The cholecystectomy is performed in a conventional manner.

10. Drainage of the abdomen 17'47''

The abdominal cavity is irrigated with saline solution. The sub-hepatic space is drained with two aspiration drains, passing along the anastomotic areas.

11. Removal of surgical specimen and jejunostomy 18'01''

A small incision is made at the site of the 12mm trocar and the surgical specimen is taken out. A Witzel jejunostomy is performed through the previously described incision and port sites are closed.