Laparoscopic pancreaticojejunostomy with transpancreatic “blumgart” and running “hopkins” sutures and external pancreatic duct stent (PDS)

Abstract

Background: Laparoscopic pancreaticoduodenectomy (LPD) has been increasingly used in patients at high risk of pancreatic leak due to soft glands and small ducts. Varying open techniques can mitigate the risk of this complication, but translation to laparoscopy can be challenging. We describe a laparoscopic pancreaticojejunostomy with transpancreatic ‘Blumgart’ sutures, anterior and posterior running internal layers and placement of an externalized pancreatic duct stent (PDS) utilizing a Seldinger technique. Methods: A totally LPD was performed with percutaneous introduction of a 8 Fr pediatric feeding tube, via Seldinger technique and standard 11 Fr introducer sheath into the jejunal limb. Sutures were tied together to create double armed sutures (DAS) of adequate length. Two 3-0 Vicryl DAS were used for the transpancreatic stiches, followed by a posterior running 3-0 V-Loc row. The external PDS was placed in the duct and secured with 5-0 Polydioxanone DAS. A second anterior running row was performed and the anastomosis was completed after the final anterior stiches were placed through the intestine and tied down. The PDS exit site was secured similarly to a feeding tube with a 3-0 Vicryl purse string suture and two Witzel stitches. Results: 70 y/o woman with pT2N2 pancreatic acinar cell cancer underwent uncomplicated totally LPD with external stent placement. Patient tolerated the procedure well and was discharged home on POD 5. The externalized PDS was removed at 6 weeks post op. She is now 3 months out from surgery and has not had any complications. She is currently undergoing adjuvant chemotherapy. Conclusion: LPD is an established procedure for the treatment of pancreatic head lesions. Patients at high risk of pancreatic leak - soft glands, small ducts, and/or high BMI - may benefit from adapting open techniques that have been shown to decrease complications such as pancreatic fistulas. This laparoscopic method for placing an external PDS may further mitigate potential complications.