Triple-layered duct-to-mucosa end-to-side pancreatojejunostomy

Technique:

  1. The first layer of sutures exists of an approximation between the capsule of the pancreatic remnant and the jejunal serosa posteriorly.
  2. The seromuscular coat of the jejunum is incised for a length with the same size as the diameter of the pancreatic stump.
  3. The posterior second suture-row is performed between the pancreatic cut end and the extramucosal or seromuscular layer of the jejunum.
  4. Opposite to the main pancreatic duct, an incision is made in the jejunal mucosa with a size that matches the diameter of the pancreatic duct.
  5. A duct-to-mucosa anastomosis is applied circumferentially, forming the third suture-row.
  6. The second suture-row is continued anteriorly, suturing the anterior pancreatic cut margin and the anterior seromuscular jejunal layer together.
  7. The pancreatic anastomosis is finished by completing the first layer of sutures on the anterior side of the pancreatic capsule and jejunal serosa.

Modifications:

Using two vertical mattress sutures

  1. Before the pancreatic anastomosis is performed, two vertical mattress sutures are applied on both sides of the main pancreatic duct, to consolidate the pancreas. Suture-threads with straight needles are used. The sutures are placed 2-3 mm away from the pancreatic cut end and penetrate the complete pancreatic parenchyma. Care is taken to avoid injury to the main pancreatic duct. The vertical mattress sutures are tied firmly.
  2. A triple-layered duct-to-mucosa end-to-side pancreatojejunostomy is performed as described above, however, the first (most outer) row of sutures is carried out between the serosal layer of the jejunal wall and the preplaced mattress sutures.