Robotic Puestow for Chronic Pancreatitis

Abstract

Introduction: Patients with chronic pancreatitis often present with debilitating pain that limits their day to day function. Numerous drainage and resection procedures have been described. For patients with dilation of the pancreatic duct, a lateral pancreaticojejunostomy (Puestow) can offer significant relief. These patients often have difficult pain control postoperatively due to chronic pain and a minimally invasive approach may offer a benefit. Methods: The accompanying figure demonstrates representative views from a video of a robotic Puestow. The patient had a history of alcoholic pancreatitis, with daily narcotic use. Imaging demonstrated dilated pancreatic duct to 11 mm with presence of intraductal stones, without significant disease in the head. She was motivated to pursue surgery and abstained from alcohol and tobacco products. The da Vinci Xi robotic system was used. The gastrocolic ligament was opened and gastropancreatic folds were divided. The superior and inferior borders of the pancreas were mobilized and a pancreatic ultrasound was performed to delineate the extent of duct dilation. The gastroepiploic vein and gastroduodenal artery were divided to access the neck and head of the pancreas. A longitudinal pancreatic ductotomy was created with cautery and stones were retrieved (top panel). A pancreaticojejejunal anastomosis was created in two layers using V-Loc sutures (bottom panel). Results: The patient recovered uneventfully and was discharged on POD 5. The patient was able to decrease her narcotic use with significant symptomatic improvement. Conclusion: Minimally invasive approaches to management of chronic pancreatitis should be considered to expedite recovery and weaning from narcotics.