A small transverse incision of about 5 mm is made in the full-thickness of the posterior gastric wall. Around the new-formed opening in the posterior wall of the stomach, a purse-string suture is placed; the distance between the purse-string suture and the incision is 1.5 times the distance between the main pancreatic duct and the edge of the pancreatic cut surface. […]
- A vertical incision with a size slightly less than the diameter of the pancreatic stump is made in the posterior wall of the stomach.
- Two traction sutures are placed on the superior and inferior sides of the pancreas.
- Either an anterior gastrotomy is performed or, in case of a classic Whipple, the clamp is temporarily removed from the transected stomach.
- The pancreatic remnant is invaginated into the gastric lumen through the posterior incision, using the traction sutures.
- 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.
- The stay sutures can be used to secure the pancreatic stump to the posterior stomach wall from the outside.
- The anterior incision is closed or the clamp is replaced on the distal gastric stump.
Using two transpancreatic sutures with buttresses
- A gastrotomy is made in the posterior wall of the stomach, with a size about 3/4 the width of the pancreatic remnant.
- Two traction sutures are placed on both ends of […]
A pancreatic tube is inserted into the main pancreatic duct and secured with a single suture. A row of sutures is placed between the anterior edge of the pancreatic remnant and the seromuscular layer of the posterior gastric wall. A stab incision is made in the seromuscular layer of the posterior stomach wall, prior to the suture row, leaving the mucosa intact. […]
A seromuscular incision is made in the posterior gastric wall, with a size comparable to the diameter of the pancreatic remnant. A small mucosal incision in the centre of the incised seromuscular layer, opposite of the main pancreatic duct. An outer suture-line is performed between the anterior pancreatic capsule and the seromuscular cut edge of the posterior gastric wall first. […]
- The first layer of sutures exists of an approximation between the capsule of the pancreatic remnant and the jejunal serosa posteriorly.
- The seromuscular coat of the jejunum is incised for a length with the same size as the diameter of the pancreatic stump.
- The posterior second suture-row is performed between the pancreatic cut end and the extramucosal or seromuscular layer of the jejunum.
- 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.
- A duct-to-mucosa anastomosis is applied circumferentially, forming the third suture-row.
- The second suture-row is continued anteriorly, suturing the anterior pancreatic cut margin and the anterior seromuscular jejunal layer together.
- The pancreatic anastomosis is finished by completing the first layer of sutures on the anterior side of the pancreatic capsule and jejunal serosa.
Using two vertical mattress sutures
- 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 […]
With resection of the seromuscular wall
- An incision is made in the seromuscular layer of the jejunal wall, comparable with the size of the pancreatic stump.
- Sutures are placed between the posterior edge of the seromuscular jejunal incision and the posterior pancreatic capsule to form the posterior part of the outer suture-row.
- A small opening is made in the centre of the resected serosa, with a diameter that matches the diameter of the main pancreatic duct. Consequently, the jejunal mucosa is exposed at a point exactly opposite the main pancreatic duct.
- The inner suture-row forms the actual duct-to-mucosa anastomosis: to this purpose, the pancreatic duct is sutured to the jejunal mucosa in all directions.
- To complete the outer suture-row anteriorly, the anterior part of the seromuscular jejunal wall incision is anastomosed to the anterior pancreatic capsule.
Without resection of the seromuscular wall: an alternative way to perform the two-layered duct-to-mucosa end-to-side pancreatojejunostomy is without seromuscular incision in the jejunal wall. As a result, the small opening opposite to the pancreatic duct is made in the full-thickness of the jejunal wall. Sutures from the inner, duct-to-mucosa suture-row are now circumferentially placed between the main pancreatic duct and the full-thickness […]