Reverse Needle Continuous Suture of the Pancreatic Duct to Jejunal Mucosal Pancreaticointestinal Anastomosis in Laparoscopic Pancreaticoduodenectomy

Summary

To circumvent the difficulty in completing the anastomosis of the pancreatic duct and jejunal mucosa under laparoscopy for patients with a small pancreatic duct and soft and fragile pancreatic tissue, we introduce a reverse needle continuous suture technique for laparoscopic pancreaticojejunostomy of the pancreatic duct and jejunal mucosa.

Abstract

Laparoscopic pancreaticoduodenectomy (LPD) is considered the Mount Everest surgery in laparoscopic surgery due to its complex surgical process, high technical requirements, and high incidence of complications. Pancreatic leakage is a common complication of LPD, and severe pancreatic leakage can endanger the patient's life. The occurrence of pancreatic leakage is influenced by multiple factors, and the choice of pancreaticointestinal anastomosis method and the quality of anastomosis are the only controllable factors during surgery. In order to reduce the occurrence of pancreatic leakage, especially severe pancreatic leakage (grade B/C), pancreatic surgeons have continuously improved and innovated the LPD pancreaticointestinal anastomosis method in recent years. Pancreatic duct jejunal mucosal anastomosis is one of the most widely used pancreatic intestinal anastomosis procedures and has been internationally recognized. Due to the unique perspective, operational limitations, and lack of tactile sensation of laparoscopic suturing, it is difficult to complete the anastomosis of the pancreatic duct and jejunal mucosa under laparoscopy for patients with small pancreatic ducts (< 3 mm) and soft and fragile pancreatic tissue. Our team innovatively applied laparoscopic reverse needle continuous suturing of the pancreatic duct to the jejunal mucosa for pancreas-intestine anastomosis. Compared with the traditional laparoscopic pancreatic duct to jejunal mucosa for pancreas intestine anastomosis, it is more in line with the laparoscopic operation perspective, reduces the difficulty of suturing, shortens the anastomosis time, improves the quality of anastomosis, and reduces the occurrence of pancreatic leakage. Moreover, it can reduce the consumption of sutures and minimize the number of knots.

Introduction

Laparoscopic pancreaticoduodenectomy (LPD) is mainly used to treat malignant tumors around the pancreatic head and ampulla. As first described by Gagner and Pomp in 1994, LPD has the advantages of short hospitalization time and low accidental readmission rate. Compared with traditional open pancreaticoduodenectomy, it has outstanding advantages in reducing pain and shortening hospital stay^1,2. Pancreatic leakage is a common complication of LPD, and severe pancreatic leakage can endanger the patient's life. The occurrence of pancreatic fistula is influenced by various factors. Choosing a reasonable method for pancreatic and intestinal reconstruction can effectively reduce the incidence of postoperative pancreatic fistula, which is the key to successful surgery³. In order to reduce the occurrence of pancreatic leakage, especially severe pancreatic leakage (grade B/C), pancreatic surgeons have continuously improved and innovated the LPD pancreaticointestinal anastomosis method in recent years.

At present, there are problems with pancreatic intestinal anastomosis in LPD: pancreatic jejunal mucosal anastomosis is one of the most widely used pancreatic intestinal anastomosis methods, first proposed by Varco in 1945⁴. It conforms to the growth pattern of mucosa physiologically and can promote the biological healing of pancreatic duct mucosa and jejunal mucosa, making it a widely recognized pancreaticointestinal anastomosis internationally⁵. Due to the unique perspective, operational limitations, and lack of tactile sensation of laparoscopic suturing, the anastomosis of the pancreatic duct and jejunal mucosa is complex and requires high-level laparoscopic suturing techniques. For patients with small pancreatic ducts (< 3 mm) and soft and fragile pancreatic tissue. Even skilled surgeons cannot guarantee the quality of the fit.

The aim of this study is to introduce a laparoscopic reverse needle continuous suture of the pancreatic duct for jejunal mucosal pancreaticointestinal anastomosis in LPD and summarize our experience. This technique uses a 5-0 PDS suture to continuously suture the pancreatic duct and jejunal mucosa. Compared with traditional laparoscopic anastomosis of the pancreatic duct and jejunal mucosa, its advantages include better alignment with the laparoscopic operating perspective, reduced suture difficulty, shorter surgical time, lower incidence of pancreatic leakage, and less suture thread consumption.

Protocol

This study was approved by the ethics committee of our institution, and all patients provided informed consent before participating in the study. The protocol follows the guidelines of the Ethical Review Measures for Biomedical Research Involving Human Subjects (2016), WMA Helsinki Declaration, and CIOMS International Ethical Guidelines for Human Biomedical Research, and was reviewed by the Ethics Committee of Meizhou People's Hospital. Each patient signed an informed consent form for the surgical plan before the surgery.

1. Preoperative steps

1. Administer CT and MR examinations before surgery and perform diagnosis for pancreatic head cancer or periampullary carcinoma. Ensure that the patient has indications for laparoscopic pancreaticoduodenectomy and no surgical contraindications.

2. Initial surgical proc edures

1. Preoperative preparation
   1. Ask the patient to lie flat on the operating table, with both lower limbs separated. Under general anesthesia, disinfect and lay sterile cloth towels according to the routine of upper abdominal surgery.
2. Placing the trocar for laparoscopic operation
   1. According to the expert consensus on laparoscopic pancreaticoduodenectomy, make a 1 cm longitudinal incision using a surgical knife under the navel and establish pneumoperitoneum with CO₂ at a pressure of 12 mmHg. Use the 5-hole method for laparoscopic surgery⁶ (Figure 1).
3. Laparoscopic exploration and resection
   1. Perform laparoscopic abdominal exploration and resection as described below.
   2. Dissect the gastrocolic ligament with an ultrasonic knife, enter the omental sac, and expose the pancreas. Separate and cut off the gastric omentum blood vessels and hepatogastric ligaments from the distal end to the proximal end of the stomach, and use a linear cutting stapler to cut off the junction of the middle and lower one-third of the gastric body.
   3. Separate the hepatoduodenal ligament, expose the hepatic proper artery, common hepatic artery, portal vein, and common bile duct, remove the lymph nodes and adipose tissue of the hepatoduodenal ligament, and remove the lymph nodes adjacent to the common hepatic artery. Separate, ligate, and cut off the right gastric artery and gastroduodenal artery.
   4. Expose the superior mesenteric vein below the pancreatic neck, isolate, ligate, and cut off the gastrocolic vein trunk, and separate the superior mesenteric vein from the loose tissue between the pancreatic neck. Mark the pancreatic resection line in front of the pancreatic neck and cut off the pancreas. Separate the tissue between the pancreatic head and transverse colon mesentery, open the peritoneum on the outer side of the descending duodenum, and separate the fascial space behind the pancreatic head and duodenum.
   5. Cut open the Qu's ligament, pull the proximal jejunum through the superior mesenteric artery and vein to the right side of the pancreatic head, detach the proximal jejunal mesentery, and use a straight cutting stapler to cut the jejunum 10 cm below the Qu's ligament. Separate the mesentery of the uncinate process, separate, ligate, and cut off the pancreatic head, uncinate process branches, and related branches of the portal vein, mesenteric artery, and superior mesenteric vein.
   6. Remove the lymph nodes behind the pancreatic head, duodenum, mesenteric artery, and right side of the abdominal trunk. Dissect the gallbladder triangle, clamp the proximal end of the gallbladder artery with Hemolok, cut the gallbladder artery with an ultrasonic knife, reverse peel off the gallbladder bed, and cut off the common hepatic duct.
   7. At this point, completely remove the distal end of the stomach, duodenum, proximal end of the jejunum, head of the pancreas, gallbladder, common bile duct, and surrounding lymph node adipose tissue, place them in a specimen bag, and take out the specimen bag.
4. Digestive reconstruction
   1. Use the Child method for gastrointestinal reconstruction, including pancreatic intestinal anastomosis, biliary intestinal anastomosis, and gastrointestinal anastomosis.
5. Laparoscopic reverse needle continuous suture of pancreatic duct for jejunal mucosal pancreaticointestinal anastomosis
   1. Perform trial placement of pancreatic duct stent tube (Figure 2A). Using 4-0 non-absorbable suture thread, carry out suturing of the jejunal serosal muscle layer and the posterior pancreatic stump 4 (Figure 2B).
   2. Tighten the continuous suture of the jejunal seromuscular layer and the posterior suture of the pancreatic stump (Figure 2C). Cut open the jejunum, with an incision size equivalent to the diameter of the pancreatic duct (Figure 2D).
   3. With a 5-0 PDS II, carry out suturing of the posterior part of the small incision in the jejunum and the posterior wall of the pancreatic duct with three needles (Figure 2E). Tighten the suture line for the posterior part of the continuous jejunal small incision and the posterior wall of the pancreatic duct (Figure 2F).
   4. Place the pancreatic duct stent tube (Figure 2G). Use 5-0 PDS II to carry out suturing of the anterior part of the small incision in the jejunum and the anterior wall of the pancreatic duct with three needles (Figure 2H).
   5. Knot the suture line of the front and back of the small incision in the jejunum and the anterior and posterior walls of the pancreatic duct through continuous reverse needle suture (Figure 2I).
   6. With a 4-0 non-absorbable suture, perform suturing of the jejunal seromuscular layer and the anterior part of the pancreatic stump with four needles (Figure 2J).
   7. Carry out suturing of the jejunal seromuscular layer and ligation of the suture line at the posterior and anterior ends of the pancreatic stump, complete pancreaticointestinal anastomosis (Figure 2K).
   8. For pancreaticojejunostomy carry out the steps as follows: with a 4-0 non-absorbable suture thread, perform suturing of jejunal serosal muscle layer and posterior pancreatic stump 4 (Figure 3A).
   9. Using 5-0 PDS II, carry out suturing of the posterior part of the small incision in the jejunum and the posterior wall of the pancreatic duct with three needles (Figure 3B).
   10. With a 5-0 PDS II, carry out suturing of the anterior part of the small incision in the jejunum and the anterior wall of the pancreatic duct with three needles (Figure 3C).
   11. Using a 4-0 non-absorbable suture, perform suturing of the jejunal seromuscular layer and the anterior part of the pancreatic stump with four needles (Figure 3D).
6. Bile intestinal anastomosis, gastrointestinal anastomosis
   1. Perform biliary enteric anastomosis and gastrointestinal anastomosis according to the LPD routine. On the intestinal wall of the mesentery, at a distance of about 10 cm from the pancreaticointestinal anastomosis site, make a longitudinal incision equal to the diameter of the common hepatic duct along the intestinal axis to perform end-to-end anastomosis of the common hepatic duct and jejunum.
   2. Suture the posterior wall of the common hepatic duct and the posterior and anterior walls of the small incision of the jejunum continuously with 5-0 PDS II and then ligate.
   3. Perform end-to-side anastomosis using a 60 mm straight cutting stapler between the mesentery margin of the jejunum and the residual stomach, approximately 45 cm below the biliary enteric anastomosis site. Close the remaining incision at the anastomosis site by continuous full-thickness suturing with 4-0 non-absorbable suture.
   4. Rinse the abdominal cavity with warm physiological saline and check that there is no bleeding from the abdominal wound.
   5. Place rubber tubes for drainage above the pancreatic intestinal anastomosis, below the pancreatic intestinal anastomosis, and behind the biliary intestinal anastomosis, respectively, and fix it with 7 silk threads through the abdominal puncture hole.

3. Postoperative care

1. After LPD surgery, patients undergo treatment such as fasting, infection prevention, and venous malnutrition, and other treatments. Eating liquid after an anal exhaust reduces the amount of infusion.
2. At 3 days after surgery, measure amylase levels in the abdominal drainage fluid. Ensure that the concentration of amylase is not higher than three times the upper limit of the normal range of serum amylase.
3. When the patient has no gastrointestinal leakage or abdominal infection, gradually remove the abdominal drainage tube. Ensure no liquid discharge or clear liquid discharge which is less than 20 mL before removal of the drainage tube.
   NOTE: Definition of postoperative pancreatic fistula: In 2016, the International Group of Pancreatic Surgeons (ISGPS) updated the definition and grading of postoperative pancreatic fistula. When the postoperative time is greater than 3 days, the amylase content in the drainage fluid is greater than 3 times the upper limit of the normal serum amylase value, and it is related to the clinical treatment prognosis. The 2016 postoperative pancreatic fistula grading is given in Table 1.
4. If a pancreatic fistula occurs after surgery, perform conservative treatment. If conservative treatment is ineffective, perform an invasive treatment.
5. Change the incision dressing every 3 days after surgery and remove the incision stitches 10 days after surgery. The patient's general condition is good, with no complications, no discomfort such as fever or abdominal pain, and can be discharged.
6. Upto 2 years after discharge, ask the patient to return to the hospital for follow-up every 3 months to understand the patient's general condition, digestive function, and whether there is tumor recurrence and metastasis or not.

Results

From February 2022 to December 2024, the same medical team innovatively used reverse needle continuous suture of the pancreatic duct for 32 cases of jejunal mucosal pancreaticojejunostomy in LPD. According to the 2016 version of the postoperative pancreatic fistula grading criteria⁷, there were 3 cases of B-grade pancreatic fistula, with an incidence rate of 9.4%. There was no C-grade pancreatic leakage, and good treatment results were achieved. We retrospectively analyzed the main intraoperative ...

Discussion

Blumgart pancreaticointestinal anastomosis is a pancreatic intestinal anastomosis technique pioneered by Professor Blumgart at Memorial Sloan Kettering Cancer Center Hospital in 2002⁸. Since its application, Blumgart's pancreaticointestinal anastomosis has gradually been proven to be a safe and effective surgical method due to its lower incidence of pancreatic fistula⁹. The application of this anastomosis is also controversial: if 4-6 non-absorbable threads are needed, ...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
aspirator	Kangji
clips	Kangji
Dissecting forceps	Kangji
Electrocoagulation hook	Kangji
Hemolok	Kangji
High definition laparoscope	STORZ
needle holder	Kangji
Non damaging gripper	Kangji
Polypropylene non absorbable suture	Johnson	HS6855H 0/4
silk thread	Holycon	Number 0
silk thread	Holycon	Number 1
silk thread	Holycon	Number 4
Suction tube	Kangji
Surgical scissors	Kangji
Synthetic absorbable surgical suture	Johnson	Z148H 0/5
ultrasonic knife	Johnson