Circumferential pedicled omental flap for protection of portomesenteric venous reconstruction and gastroduodenal artery stump following pancreatoduodenectomy

Abstract

Abstract This video demonstrates a technique for creation of an omental tissue barrier to protect a portomesenteric vein reconstruction or gastroduodenal artery (GDA) stump. Following routine pancreatoduodenectomy reconstruction, a generous tongue of omentum is mobilized off the transverse colon ensuring to preserve the feeding branches from the left gastroepiploic artery. The omentum is then passed behind the pancreatojejunostomy above the vein repair site. It is grasped superiorly and passed anterior to the pancreatojejunostomy to exclude the GDA stump. The flap is then secured to the blind end of the jejunum with suture thereby completing the circumferential wrap. Care must be taken in obese patients to trim the flap so it can fit behind the pancreas without devascularizing it or causing tension on the pancreatojejunostomy. If a closed suction drain is desired, it can be passed from the patient's right either in front of or behind the hepaticojejunostomy and placed around the flap. This technique is most applicable to patients with moderate to high risk of pancreatic fistula (small pancreatic duct and/or soft gland) after undergoing PD with an intact omentum. This circumferential, pedicled omental flap is an easy, reproducible, and durable method to protect vascular structures and repairs from pancreatic fistulas.