Before transection of the pancreas, two hemostatic sutures are placed cranially and caudally within the pancreatic parenchyma. After resection of the specimen, the anastomosis is started, using a double armed suture. For the first invagination stitch, the needle passed through the entire pancreatic remnant from anterior to posterior, 1 cm away from the cutting edge, cranially from the main pancreatic duct.

Transpancreatic invagination suturing technique

1. Before transection of the pancreas, two hemostatic sutures are placed cranially and caudally within the pancreatic parenchyma.
2. After resection of the specimen, the anastomosis is started, using a double armed suture. For the first invagination stitch, the needle passed through the entire pancreatic remnant from anterior to posterior, 1 cm away from the cutting edge, cranially from the main pancreatic duct. The needle is then placed through the posterior seromuscular layer of the jejunum, 1.5 cm away from the stapled end. Next, the needle is passed again through the entire pancreas – from posterior to anterior – a few millimeters next to the first stitch.
3. A second invagination stitch is placed in a similar fashion, caudally from the main […]
   

The posterior walls of the pancreatic stump and the jejunal cut end are anastomosed by the placement of four completely transpancreatic interlocking mattress-sutures, while the anterior walls are anastomosed by three to four incompletely transpancreatic interlocking mattress-sutures. […]

The inner line of the anastomosis is performed using three or four horizontal mattress sutures parallel to the long axis of the pancreas. First, the needle is placed from outside the jejunum to inside the jejunal lumen, through the anterior caudal side of the jejunal wall about 3-4 cm from the cut edge. The needle is withdrawn from the jejunal opening at the cut end. […]

The seromuscular layer of the first 2-3 cm of the jejunal cut end is removed before the anastomosis is performed, preserving the jejunal mucosa. The pancreatic capsule, about 2 cm away from the cut margin, is anastomosed to the seromuscular coat of the jejunum posteriorly. […]

The cut edges of the pancreas and the jejunum are sutured together circumferentially, forming the inner suture-line. The outer suture-line is performed between the surfaces of the pancreatic capsule and the seromuscular wall of the jejunum, a few centimeters away from the cut ends, causing invertion of the jejunal wall and invagination of the pancreatic stump into the inverted jejunum. […]