Laparoscopic frey procedure with management of intraoperative complication

Abstract

This is the case of a 61-year-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last 7 years. Multi-slice CT (MSCT) revealed pancreatic calcifications from 1 to 5-8mm and dilatation of the main pancreatic duct in the body of the pancreas up to 4mm. The patient underwent laparoscopic local resection of the pancreatic head combined with a longitudinal Roux-en-Y pancreaticojejunostomy, a technique known as Frey's procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis. After fashioning the posterior wall of the pancreaticojejunal anastomosis, we faced an intraoperative complication such as a volvulus of the Roux limb causing serious ischemia of the limb. We were forced to remove all previous sutures in order to untwist the Roux limb. The pancreaticojejunostomy was started anew afterwards. The purpose of this video is to demonstrate that Frey's procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. We demonstrate that even a serious intraoperative complication such as a volvulus of the Roux limb can be managed without conversion. Our center has an experience of over 30 laparoscopic Frey's procedures. However, this is the first case where we encountered this complication and we believe this is an experience worth sharing.Yet, we would like to underline that this approach should be used by highly skilled minimally invasive surgeons with an experience in intracorporeal suturing, which is the most challenging stage in Frey's procedure.