Blumgart method using LAPRA-TY clips facilitates pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy

Abstract

The modified Blumgart method for pancreaticojejunostomy has been shown to reduce the rate of postoperative pancreatic fistula (POPF) in open surgery. We describe a modified Blumgart method using LAPRA-TY suture clips to facilitate laparoscopic pancreaticojejunostomy.We prepared a double-armed 4-0 nonabsorbable monofilament, which was ligated using the LAPRA-TY clip at the tail end, 12-cm in length. Next, the U-suture was placed through the pancreatic stump and the seromuscular layer of the jejunum. We performed duct-to-mucosa suturing with a 5-0 absorbable monofilament. After completing the duct-to-mucosa suturing, as a final step we placed the sutures through the seromuscular layer of the jejunum on the ventral side and tightly secured the thread with the LAPRA-TY clips. We performed laparoscopic Blumgart pancreaticojejunostomy during pancreaticoduodenectomy in 39 patients. We compared the surgical outcomes of 19 patients who underwent Blumgart pancreaticojejunostomy using the LAPRA-TY clips (LAPRA-TY group) with 20 patients undergoing surgery not using the LAPRA-TY clips (conventional group).The rate of clinically relevant postoperative pancreatic fistula in the LAPRA-TY group was 21.1%, which did not differ significantly from the rate of the conventional group. However, the mean time of pancreaticojejunostomy in the LAPRA-TY group was 56.2 min (range, 39-79 min), which was significantly shorter than that of the conventional group (69.7 min; range, 53-105 min, P < .001).Although the modified Blumgart pancreaticojejunostomy using LAPRA-TY suture clips did not improve the pancreatic fistula rate, it allowed for shorter operative times. Thus, this procedure lends itself to positive surgical and patient outcomes.

Figure 1

A, Port placement. OR; the trocar for the operator's right hand. OL; the trocar for the operator's left hand. B, Double-ended needle ligated with 12-cm length using LAPRA-TY suture clips.

Figure 2

A, B, U-shaped sutures on the pancreatic parenchyma and dorsal side of the jejunal seromuscular layer at 2 points. C, Stitching from the dorsal to ventral side of the pancreas. D, Stitching on the dorsal side of the jejunal seromuscular layer. E, Threads are clipped using bulldog forceps. F, The pancreatic duct stent is placed to confirm the direction of the main pancreatic duct.

Figure 3

A, B, Suturing of the posterior semicircle of the duct-to-mucosa anastomosis. C, D, Anterior semicircle of the duct-to-mucosa anastomosis.

Figure 4

A, B, Stitching on the ventral side of the jejunal seromuscular layer. C, D, These sutures are ligated using the LAPRA-TYclip. E, F, The pancreas and the jejunum are tightly secured.