Robotic-assisted Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Summary

This protocol presents a method for performing a parenchymal sparing robotic-assisted lateral pancreaticojejunostomy intended for appropriately selected patients with a pancreatic duct obstruction without significant inflammation of the pancreatic head. This article demonstrates critical aspects of the operation in a minimally invasive, robotic fashion to treat recurrent acute/chronic pancreatitis.

Abstract

Chronic pancreatitis is a debilitating, benign inflammatory disorder that significantly alters a patient's quality of life. Pancreatic drainage procedures have long been demonstrated to be safe and feasible using laparoscopic and open surgical approaches but have largely been replaced by pancreaticoduodenectomy. Over the past several decades, perioperative outcomes using the robotic platform in hepatobiliary surgery have been rapidly improving and, in many cases, surpassing outcomes in open and laparoscopic approaches. In appropriately selected patients with pancreatic duct obstruction and without an inflammatory mass at the head of the pancreas, there remains a role for parenchymal-sparing operations that relieve recurrent pancreatitis but also limit endocrine and exocrine insufficiency. We present a robotic-assisted lateral pancreaticojejunostomy for a patient with recurrent pancreatitis in the setting of a pancreatic duct stricture. The intention of this manuscript is to provide fellowship-trained hepatobiliary surgeons with a concise and adoptable method for performing robotic-assisted lateral pancreatojejunostomy. This article demonstrates critical aspects of the operation performed in a minimally invasive, robotic fashion to treat recurrent acute/chronic pancreatitis.

Introduction

Lateral pancreaticoduodenectomy, more often referred to as a modified Puestow procedure, is a pillar of open pancreatic surgery. First performed in 1958, this procedure addresses complex chronic pancreatitis with a dilated pancreatic duct and normal pancreatic head while preserving much of the pancreatic parenchyma¹. Primary indications for this operation include chronic pancreatitis with chronic pain, narcotic dependency, and poor quality of life. Drainage procedures typically involve relief of obstruction in the pancreatic duct while preserving the pancreatic head parenchyma. The Puestow procedure falls into the category of drainage procedures for chronic pancreatitis, a group that also includes the Partington and Rochelle modification and the Izbicki procedure². The vast majority of patients with chronic pancreatitis present with the involvement of the pancreatic head and are thus not eligible for drainage procedures and instead undergo resection. The pancreaticoduodenectomy is an extensive procedure with resection of the pancreatic head, duodenum, and a portion of the stomach. The Beger and Frey procedures are also parenchymal resection procedures that involve the removal of the lesion from the pancreatic head while sparing the duodenum and more of the pancreatic parenchyma³.

For much of the history of treatment for chronic pancreatitis, drainage procedures and pancreaticoduodenectomy were the mainstay of treatment. The optimal surgical approach for chronic pancreatitis remains unanswered and should be individualized based on clinical, imaging, and endoscopic assessment. As detailed in the discussion, surgical drainage procedures have recently been shown to have significantly lower 90-day readmission rates and need for reintervention, with no differences in pain scores compared to resective procedures⁴. However, in the era of minimally invasive surgery, drainage procedures have fallen out of favor as compared with other current options: laparoscopic or robotic pancreaticoduodenectomy and duodenal-preserving pancreatic head resections^5,6. While these procedures provide a safe and attainable treatment for the majority of chronic pancreatitis patients, they are highly morbid operations that resect already diseased parenchyma, further increasing the risk of endocrine and exocrine dysfunction. Pancreaticoduodenectomy is most often linked to delayed gastric emptying, bleeding, pancreatic insufficiency, and infection⁷. Distal pancreatectomy is most often complicated by pancreatic fistula and abscess formation/infection^3,8,9. In the interest of preserving pancreatic parenchyma in the surgical treatment of chronic pancreatitis, robotic lateral pancreaticojejunostomy may have an underestimated utility.

Use of robotic surgery in the management of pancreatic disease has advanced rapidly in the past decade, similar to the implementation of laparoscopic surgery decades prior. Both robotic and laparoscopic approaches are associated with decreased recovery times and lower levels of post-operative pain, allowing patients to return to their day-to-day lives sooner^10,11,12. The robotic platform has the additional benefits of 3-dimensional visualization with high magnification and articulating instruments, which is particularly advantageous with the manipulation of delicate pancreatic tissue and suturing complex anastomoses. The extent of a learning curve for robotic pancreatic surgery is controversial; however, it is generally agreed that mastery of port placement and coordination with laparoscopic assistance is critical¹³. As more surgeons graduate from training programs with this skill set, utilizing the versatility of the robotic platform to leverage a minimally invasive approach to all pancreatic procedures that are possible with open surgery is feasible and may improve outcomes associated with surgery for pancreatitis¹⁴.

This paper provides a clear and easily adaptable method for robotic-assisted lateral pancreatojejunostomy. As more surgical techniques are adapted to robotic surgery, we include the largely historical drainage approach in this growing list and ensure the technique is accessible to fellowship-trained hepatobiliary surgeons.

CASE PRESENTATION:
We report a 39-year-old male with no significant past medical history and no history of alcohol or tobacco use. He presents with recurrent episodes of pancreatitis for 5 years in the setting of gallstone pancreatitis, for which a laparoscopic cholecystectomy was performed at the time of his initial presentation. Unfortunately, the episodes recurred and worsened over time. After presentation to our facility, he underwent endoscopic retrograde cholangiopancreatography (ERCP), which revealed pancreatic divisum and pancreatic duct stricture at the neck, which could not be traversed for duct stent placement.

Diagnosis, Assessment, and Plan:
As previously stated, the patient had a significant pancreatic duct stricture in the neck of the pancreas, evidenced by the pancreatogram (Figure 1). Magnetic resonance cholangiopancreatography (MRCP) further elucidated irregular upstream dilation of the pancreatic duct in the body and tail of the pancreas (Figure 2). Importantly, these studies revealed no significant disease of the pancreatic head or major biliary involvement, indicating that this patient was a candidate for a robotic pancreatic drainage procedure to decompress the distal pancreatic duct, thereby limiting further episodes of pancreatitis.

Protocol

Per West Virginia University Office of Human Research Protections protocols and consistent with federal policy, this protocol is classified as non-human subjects research and does not require Institutional Review Board approval. As part of our standard surgical consent process, patients provided informed consent for intraoperative video recording.

1. Patient positioning and port placement

1. The patient was placed supine on a split-leg table with their arms out. Sterile preparation was applied using a chlorhexidine applicator, and the patient was draped in a standard fashion. An incision was made in the upper left quadrant to allow for abdominal entry with the optical separator device. The peritoneal cavity was insufflated with CO₂ and explored with the laparoscope.
2. Four robotic ports were inserted in the upper abdomen, and two assistant ports were inserted in the lower abdomen (Figure 3). The camera was placed in the midline supraumbilical robotic port. In the left lower quadrant, a 12 mm port served as the site for stapler insertion.
3. After ports were inserted, the patient was placed in reverse Trendelenburg with their left side up.

2. Entry into the lesser sac and docking the robot

1. A flexible triangle liver retractor was introduced in the right upper quadrant just caudal to the ribs to retract the liver cranially. The lesser sac was entered using bipolar electrocautery along the greater curvature of the stomach, taking care not to cauterize the gastroepiploic vessels. Following mobilization of the stomach, it was retracted anteriorly along with the liver.
2. The robot was docked, ensuring that the surgeon controlled the robot sitting at the console and a bedside laparoscopic assistant standing between the patient's legs.

3. Identifying the pancreatic duct and longitudinal incision along the body of the pancreas

1. Intraoperative ultrasound was used to identify the dilated pancreatic duct, locate strictures, and track the course of the duct along the body of the pancreas.
2. The body of the pancreas was incised using cauterized scissors primarily along the anterior surface of the duct to the tail. A 4-French Hobbs stent can be used to track the pancreatic duct as it is opened (Figure 4).

4. Dividing loop of jejunum and passage through the retrocolic tunnel

1. Once the pancreatic duct was opened, the ligaments of Treitz and the proximal jejunum were identified. 20 cm distal to this, a loop of jejunum was identified as the site for future anastomosis with the pancreatic duct.
2. Using a bipolar electrocautery device, a mesenteric window was created, and the bowel was divided with a 60 mm purple load of an Endo GIA stapler. The bipolar electrocautery device was again used to divide the mesentery with care to avoid mesenteric vasculature.
3. A retrocolic tunnel was created in the mesentery of the transverse colon using blunt dissection. The Roux limb was then subsequently passed through this space into the lesser sac. It was ensured that the jejunum reached the pancreas without tension.

5. Longitudinal enterotomy and running anastomosis

1. A longitudinal enterotomy on the anti-mesenteric aspect of the jejunum was created using a combination of electrocautery and sharp dissection to match the length of the incision along the pancreas.
2. The anastomosis began at the tail of the pancreas, where two 3-0 barbed sutures were anchored to the distal end of the ductotomy and enterotomy. One barbed suture was run along the inferior aspect of the anastomosis, while the other was run along the superior aspect of the anastomosis. Again, a 4-French Hobbs stent was used to ensure the duct remains patent, particularly at the beginning and end of anastomosis creation (Figure 4).
3. The anastomosis was completed when the barbed sutures met at the neck of the pancreas, where they were tied together.

6. Re-establishing GI continuity with jejunojejunostomy

1. Neo-gastrointestinal anatomy was confirmed by identification of the Roux and Biliopancreatic limbs. Small enterotomies were created near the previously stapled edge of the jejunum and a segment of jejunum more distal at the Roux limb, approximately 50 cm. A 60 mm purple load endo GIA staple fire was used to create a side-to-side jejunojejunostomy.
2. The common enterotomy was closed with 3-0 barbed sutures followed by interrupted 3-0 silk Lembert sutures. 3-0 silk sutures were again used to close the colon mesenteric defect created around the Roux limb.

7. Placing drains and abdominal closure

1. Two drains were placed using previously placed robotic port-sites. One drain passed posterior to the pancreaticojejunal anastomosis, and the other anterior to the anastomosis. The liver retractor was removed, and the stomach was returned to anatomical position.
2. The abdomen was extensively irrigated. A laparoscopic port-site closure device was used to close a 12 mm assistant port with #1 absorbable sutures. The skin and subcutaneous tissue were irrigated and closed with 4-0 monofilament absorbable suture.

Results

This patient had an unremarkable postoperative course with drain amylases decreasing from 139 U/L to 15 U/L anteriorly, and 48 U/L to 13 U/L posteriorly on postoperative days one and three, respectively, indicating no pancreatic leak. His drains were removed at the time of discharge on post-operative Day 4, and he experienced a significant improvement in quality of life with mild intermittent and infrequent pain episodes at two years following surgery. He is not narcotic dependent. The patient's blood glucose remained we...

Discussion

Here we present a robotic approach to lateral pancreaticojejunostomy for the management of chronic pancreatitis with pancreatic duct stricture. Critical steps demonstrated for a successful operation include our precise robotic port placement, the use of intra-operative ultrasound to track the pancreatic duct along the pancreatic body, and performing a longitudinal pancreatic ductotomy with the use of a 4-French Hobbs stent. Additionally, our technique for the pancreaticojejunostomy anastomosis is highlighted using two ru...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Pneumoclear smoke evacuation tube set	STRYKER	620050350	Smoke evacuator tubing
Smoke MGMT EXTD Nozzle for 4in electrode	Medtronic	VSMEN4	Electrocautery pencil with smoke evacuation
Smoke pencil with edge electrode 10Ft	Medtronic	VSMP10	Electrode for electrocautery
BLAKE Silicone Drain, Size 19 Fr, Round	Ethicon	2232	Abdominal drain
Jackson-Pratt bulb reservoir 100cc	McKesson	SU1301305	Drainage suction bulb reservoir
Garment compress Medium, Calf	Zimmer Biomet	VG501M	Sequential compression device applied to calves for deep venous thrombosis prophylaxis
Suction tube handle, Bulb tip Yankauer	McKesson	K86	Yankauer Suction handle
Suction Tubing 20FT, 9/32 inch	McKesson	N720A	Suction tubing
BD ChloraPrep Hi-Lite Orange 26-mL applicator with sterile solution	BD (Becton, Dickinsone and Company)	930815	Sterile Chlorhexidine preparation
80mm Angled Triangle base, 5mm	Mediflex	91683-A	Flexible liver retractor
Optical Obturator, 8mm, bladeless	Intuitive Surgical	470359	Obturator for placement of robotic trocar
Monopolar Curved scissor tip cover accessory	Intuitive Surgical	400180
Da Vinci XI Universal Seal 5-12mm	Intuitive Surgical	470500	Robotic Trocar seal
Endo GIA Ultra Universal Stapler	Covidien	EGIAUXL	Laparoscopic stapler
Stapler reload, 60mm, reinforced	Covidien	SIGTRSB60AXT
Skin Stapler	Covidien	8886803712	Skin stapler
SURGICEL Absorbable Hemostat	Ethicon	1952S	Hemostatic cellulose
Laparoscopic Clip applier 5mm	Covidien	176630	Laparoscopic clip applier
Laparoscopic Clip applier 10mm	Covidien	176657	Laparoscopic clip applier
Laparoscopic sealer/divider, Maryland, curved Jaw	Covidien	LF1944
Step insufflation/access needle, 100mm	Covidien	S100000	Laparoscopic blunt tip access needle
Suction irrigation system, battery operated	McKesson	250070520
Bladeless Trocar, 15mm size, 100mm length	Covidien	NB15STF
Bladeless Trocar, 12mm size, 100mm length	Covidien	NONB12STF
Bladeless Trocar, 5mm size, 100mm length	Covidien	NONB5STF
Bladeless optical trocar, 5mm size, 100mm length	Covidien	ONB5STF
First Entry Access System, 5x100mm	Applied Medical	CTF03
Coaxial umbilical cable	Medtronic	203CXC
Exofin Skin Adhesive	McKesson	EX71010	Skin Adhesive
Laparotomy sponge, 4"x18", X-ray and RF-Detectable	Medtronic	L041804P01C1
Laparoscopic Blade Electrode, 6.5"	Coviden	E14506	Laparoscopic electrocautery blade
Laparoscopic electrode Flat L-hook	Covidien	E3774-36C	Laparoscopic electrocautery hook
Banded bag 28"x36"	McKesson	13628	Cover non-sterile equipment in sterle field
Surgical utility drape with tape	Medline	DYNJP2405	Drapes for sterile field
Sterile table Drape, 4'	Grayline Medical	418HDS
OR Fluid warming drape	Medline	SDREC44
Sterile surgical Leggings 31" W X 48" L	McKesson	89408
Da Vinci XI Column Drape	Intuitive Surgical	470341	Sterile drape for bedside robot
Da Vinci XI Arm Drape	Intuitive Surgical	470015	Sterile drape for robotic arms
Surgical Gown	McKesson	41734
Endoscopic surgery swab	Covidien	173019	Swab fluid and assist with blunt dissection
Clean and protect laparoscope lense	McKesson	21345
Vessel sealer extend	Intuitive Surgical	480422
Cadiere	Intuitive Surgical	471049
Fenestrated Bipolar	Intuitive Surgical	471205
Maryland Bipolar	Intuitive Surgical	471172
Tip up Grasper	Intuitive Surgical	471344
Prograsp	Intuitive Surgical	471093
Hook electrocautery	Intuitive Surgical	470183
Monopolar curved scissors	Intuitive Surgical	470179
Large SutureCut needle driver	Intuitive Surgical	471296
Large needle driver	Intuitive Surgical	471006
Small grasping forcep	Intuitive Surgical	471400
Robot Ultrasound Transducer probe	BK Medical	8826	Robotic Drop-in Ultrasound transducer
2-0 Silk Suture - Cut to 8"	Ethicon	K833-H
5-0 Polydioxanone RB-2 Cut to 5"	Ethicon	Z148-H
4-0 V-Loc CV-23 6" x2	Covidien	VLOCM0024
4-0 Prolene on RB 1	Ethicon	8557H
3-0 V-LOC V-20 6" x 3	Covidien	VLOCM0604
0 Vicryl Ties	Ethicon	J646H
#1 Vicryl Suture	Medtronic	CL-64-M
4-0 Monocryl	Ethicon	Y496G
Umbilical tape	Ethicon	W276