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have long been demonstrated to be safe and feasible using laparoscopic and open surgical approaches but have largely been replaced by pancreaticoduodenectomy.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 procedure....

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 ....

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