Pancreatogastrostomy using a transgastric approach

Pancreatogastrostomy using a transgastric approach

Techniques:

One-layered technique

  1. A vertical incision with a size slightly less than the diameter of the pancreatic stump is made in the posterior wall of the stomach.
  2. Two traction sutures are placed on the superior and inferior sides of the pancreas.
  3. Either an anterior gastrotomy is performed or, in case of a classic Whipple, the clamp is temporarily removed from the transected stomach.
  4. The pancreatic remnant is invaginated into the gastric lumen through the posterior incision, using the traction sutures.
  5. From inside the stomach, either via the anterior incision or via the transected end of the stomach, a single suture-line is performed circumferentially between the pancreatic tissue and the gastric wall.
  6. The stay sutures can be used to secure the pancreatic stump to the posterior stomach wall from the outside.
  7. The anterior incision is closed or the clamp is replaced on the distal gastric stump.

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Using two transpancreatic sutures with buttresses

  1. A gastrotomy is made in the posterior wall of the stomach, with a size about 3/4 the width of the pancreatic remnant.
  2. Two traction sutures are placed on both ends of the pancreas.
  3. An anterior gastrotomy is performed, just above the posterior incision.
  4. Using the two traction sutures, the pancreatic stump is invaginated into the gastric lumen, through the posterior gastrotomy.
  5. The anastomosis is performed using two transpancreatic sutures with buttresses on the superior and inferior borders of the pancreas, placed via the anterior incision; two threads with a straightened needle on both ends and four buttresses were used.
  6. The first suture was placed from within the gastric lumen to outside on one side of the superior corner of the gastrotomy, through the full-thickness of the stomach wall, then from posterior to anterior through the superior pancreatic parenchyma and back to inside the gastric lumen again through the full-thickness of the stomach wall on the other side of the superior corner of the gastrotomy. The second suture was placed in a same manner at the inferior corner of the gastrotomy.
  7. The four buttresses (two on each side) are inserted through the needles and the sutures are tied.
  8. The anterior gastrotomy is closed.

Two-layered technique

  1. A gastrotomy with a size similar to the diameter of the pancreatic remnant is made in the posterior gastric wall.
  2. The pancreatic stump is inserted into the gastric lumen through the posterior gastrotomy.
  3. An outer suture-row is placed circumferentially, between the pancreatic capsule and the seromuscular layer of the gastric wall.
  4. A gastrotomy is performed in the anterior wall of the stomach.
  5. A second, inner suture-row is carried out from inside the gastric lumen, through the anterior gastrotomy, between the gastric mucosa and the parenchyma of the invaginated pancreas.
  6. The anterior gastrotomy is closed.

Binding pancreatogastrostomy

  1. An incision is made in de seromuscular layer of the posterior gastric wall, with a size comparable to the diameter of the pancreatic stump.
  2. Around the seromuscular incision, a purse-string suture is placed.
  3. The mucosal layer of the posterior gastric wall is incised a little smaller than the seromuscular incision.
  4. An anterior gastrotomy is performed.
  5. Through the anterior gastrotomy, a mucosal tube is formed by pulling the edge of the mucosal incision to inside the gastric cavity, and a second purse-string suture is placed around the mucosal opening from within the gastric lumen.
  6. The pancreas is invaginated into the gastric cavity through the posterior gastrotomy.
  7. Both the outer and inner purse-string sutures are tied (respectively outer seromuscular binding and inner mucosal binding).
  8. The anterior gastrotomy is closed.

Single purse-string duct-to-mucosa

  1. The seromuscular layer of the posterior wall of the stomach is excised for a diameter that matches the diameter of the pancreatic stump.
  2. A single purse-string suture was placed around the seromuscular excision.
  3. Two traction sutures are placed on both sides of the pancreatic parenchyma next to the main pancreatic duct.
  4. A 3-5 cm gastrotomy is performed in the anterior gastric wall.
  5. In the middle of the seromuscular excision in the posterior wall of the stomach (similar to the position of the main pancreatic duct), a small hole of about 2-5 mm in diameter is made in the exposed mucosa.
  6. Using the two traction sutures, the main pancreatic duct is pulled into the gastric lumen by bringing the sutures anteriorly, first through the opening in the posterior wall of the stomach and second via the anterior incision. This causes invagination of the pancreas into the gastric lumen with inversion of the gastric mucosa.
  7. The pancreatic parenchyma of the cut surface surrounding the main pancreatic duct is fixed onto the gastric mucosa, using four stitches on each side of the pancreatic duct.
  8. The purse-string suture is tied gently; care is taken to avoid occlusion of the main pancreatic duct.
  9. The anterior gastrotomy is closed.

Double purse-string duct-to-mucosa

  1. A full-thickness incision is made in the posterior wall of the stomach, opposite to the pancreatic stump, with a size 1 cm less than the diameter of the pancreas.
  2. Around the incision, two seromuscular purse-string sutures are placed concentrically, respectively an inner and outer purse-string suture, about 1 cm apart from each other.
  3. A gastrotomy is performed in the anterior gastric wall or, in case of a classic Whipple, the open stump of the distal stomach is used for the anastomosis procedure.
  4. Using two traction sutures, applied at the superior and inferior edges of the pancreatic stump, the pancreas is invaginated into the gastric cavity through the opening in the posterior gastric wall, using the anterior gastrotomy or open distal gastric stump.
  5. The two purse-string sutures are tightened gently; care is taken to avoid occlusion of the main pancreatic duct.
  6. From within the gastric lumen, an additional suture-row is applied between the pancreatic capsule from the invaginated pancreatic remnant and the gastric mucosa.
  7. The anterior gastrotomy is closed or the clamp is replaced on the distal gastric stump.

PUMAP-PG

  1. Through the full-thickness of the posterior gastric wall, a transverse incision of 2 cm in length is made.
  2. A transverse full-thickness incision of 2 cm in length is applied in the anterior wall of the stomach, opposite to the posterior wall incision.
  3. The anastomosis is carried out using one binding purse-string suture and two transfixing mattress sutures, placed between the pancreatic stump and the posterior gastric wall.
  4. Through the anterior gastrotomy, a full-thickness purse-string suture in placed around the incision in the posterior wall of the stomach.
  5. The pancreatic remnant is gently pulled into the stomach, using two traction sutures on both the cranial and caudal ends of the pancreatic remnant.
  6. Two mattress sutures are placed in U-like fashion, one on each side of the main pancreatic duct. Two suture-threads with a straight needle on both ends are used: all four needles are placed from inside the gastric cavity to outside through the posterior gastric wall at the caudal side of the incision, just a few mm above the purse-string suture. Next, the needles penetrate the full-thickness of the pancreatic parenchyma from posterior to anterior and then going back to the gastric lumen through the posterior gastric wall cranial from the incision.  
  7. Care is taken to avoid injury to the main pancreatic duct.
  8. The anterior gastrotomy is closed.

Using two hemstitch sutures

  1. A seromuscular incision is made in the posterior wall of the stomach, with a size similar to the diameter of the pancreatic stump; the mucosa is remained intact at first.
  2. The first hemstitch suture is applied in the seromuscular layer of the gastric wall around the seromuscular incision.
  3. In the centre of the incised seromuscular layer, a lateral stab incision of about 3 cm is carried out in the mucosa of the posterior stomach wall.
  4. The second hemstitch suture is performed in the mucosal layer of the gastric wall around the mucosal incision.
  5. A gastrotomy is made in the anterior gastric wall or, in case of a classic Whipple, the open distal gastric stump is used for the anastomosis procedure.
  6. The pancreatic remnant is invaginated into the gastric cavity through the anterior gastrotomy or via the distal open end of the stomach, using two traction sutures.
  7. The outer, seromuscular hemstitch is tied gently around the pancreas at first, as low as possible.
  8. Second, the inner, mucosal hemstitch is tied from within the gastric lumen, about 1 cm away from the cut edge of the pancreas. Care is taken to avoid occlusion of the main pancreatic duct.
  9. The anterior gastrotomy is closed or the clamp is replaced on the distal gastric stump.