Technique for Robotic Pancreaticojejunostomy

Abstract

Background:: Minimally invasive, robotic techniques for hepatobiliary procedures offer the potential for accelerated recovery and reduced opioid usage. Robotic pancreaticoduodenectomy is a technically challenging procedure with a complex reconstruction. In this regard, standardization of the pancreaticojejunostomy technique is critical for safe adoption of robotic technology in pancreatic surgery.

Study Design:: In this video, we demonstrate the primary steps and associated principles to perform a robotic pancreaticojejunostomy using a modified Blumgart/Nagakawa technique.

Results:: Key steps to this procedure include: 1) exposure and positioning of the pancreatic remnant and jejunal limb; 2) transpancreatic suture placement using augmented sutures with bulldog clamps for organization; 3) duct-to-mucosa anastomosis with well-defined order of suture placement and knot-tying for optimal exposure, tissue handling, and technical ease; 4) completion of the anterior row of transpancreatic sutures using Lapra-TY clips for gentle, but firm tissue apposition; and 5) placement of omental flap and surgical drains in proximity to the reconstruction.

Conclusion:: We described our technique for performing a robotic pancreaticojejunostomy, which compensates for the technical limitations of the robotic approach. These adjustments in combination with the magnified surgical vision and augmented skill associated with the robotic platform allow for safe and reliable performance of the pancreaticojejunostomy technique.

Figure 1.

Resources to facilitate technical ease for robotic pancreaticojejunostomy. We use transpancreatic sutures, which are prepared by tying together two 3–0 Prolene sutures on small half-circle needles (bent straight) cut to a 10-cm length followed by placement of a felt pledget. The pancreatic duct is identified and dilated with 18- to 22-gauge Angiocath IV catheters (Becton Dickinson). A Silastic stent tube (6F) cut to 5cm in length is passed through the jejunal enterotomy to confirm patency and to prevent incorporating the jejunal backwall during suturing.

Figure 2.

(A) Two doubled-armed transpancreatic sutures are placed approximately 5 to 10mm from the cut surface. These sutures are then cinched, approximating the pledget to the jejunal surface, and they are secured with laparoscopic vascular bulldog clamps. (B) An anterior row suture is placed on the pancreatic duct at the 12 o’clock position to provide retraction. This suture is then “hung” and secured with a third bulldog clamp, allowing for better exposure to sew the remainder of the anastomosis. (C) Three posterior row sutures are placed at the 8 o’clock, 6 o’clock, and 4 o’clock positions relative to the pancreatic duct, working from cephalad to caudal. The needle is passed from inside to outside on the pancreatic duct. On the jejunum, the needle is passed from outside to inside. (D) Two additional anterior row sutures are placed at approximately 10 o’clock and 2 o’clock positions on the pancreatic duct. The needle is passed from outside to inside on the jejunum and from inside to outside on the pancreatic duct using a backhand technique. The previously placed 12 o’clock retraction suture is completed by taking a jejunal bite from inside to outside on the bowel. (E) Once the transpancreatic sutures have been completed, an anterior pledget is incorporated and the sutures are secured, gently but firmly, with LAPRA-TY (Ethicon) clips. (F) Placement of surgical drains after completion of the pancreaticojejunostomy.