Name: Modified Single-Loop Reconstruction for Pancreaticoduodenectomy (Video) | JoVE Journal
Uploaded: 2019-09-28T12:30:00.000+00:00
Duration: 13 s
Description: Learn modified single-loop reconstruction for pancreaticoduodenectomy to reduce postoperative pancreatic fistula severity. This surgical technique separates pancreatic secretion from bile without extending operative time.

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This protocol focuses on the reconstruction phase of PD using mSLR and follows the guidelines of the ethics committee of the Ruhr-University Bochum, Germany.
NOTE: Patients with a resectable tumor of the pancreatic head, the papillary region or severe refractory chronic calcifying pancreatitis underwent PD. Resectability was present if the tumor had less than 50 % contact to the peripancreatic arteries and did not infiltrate the portal vein or the superior mesenteric vein. Distant metastases in cases of adenocarcinomas were also contraindications for PD. The resection technique in PD is standardized and described in detail elsewhere11,12. It does not affect the type of reconstruction itself.
1. Patient preparation
<ol>
	<li>After the patient has been brought to the operation theatre by the nurses, have the anesthesiologist start the anesthesia. Monitor the depth of anesthesia throughout the operation by the anesthesiologist including continuous check of the vital signs.</li>
</ol>
2. Establishing the indication for mSLR
<ol>
	<li>Confirm the indication for a mSLR after the resection phase in PD. Construct a mSLR in cases of a high-risk pancreatic remnant characterized by soft and fragile pancreatic tissue and/or a tiny main pancreatic duct with a diameter of 1-2 mm.</li>
	<li>Palpate the pancreas to determine subjectively whether the pancreatic texture is soft or hard. Use a Shore durometer to measure the pancreatic texture. Shore units &#60; 40 are characteristic for soft pancreata.</li>
</ol>
3. Reconstruction phase: mobilization of the jejunal loop
<ol>
	<li>Resect the first 10 inches of the jejunum to provide enough length of the mesentery. The jejunum follows the duodenum and begins after the ligament of Treitz.</li>
	<li>Advance the loop into the right upper abdominal quadrant through a wide slit in the transverse mesocolon distal to the right colic artery.</li>
	<li>Close the slit with an interrupted polypropylene 4 &#8211; 0 suture.</li>
	<li>Oversew the stapled line with a continuous PDS 5-0 suture.</li>
</ol>
4. Reconstruction phase: pancreaticojejunostomy
<ol>
	<li>Position the jejunal loop as demonstrated in Figure 1 (&#8220;modified single-loop reconstruction&#8221;) to construct an end-to-side pancreaticojejunostomy.</li>
	<li>Create a double-layer, end-to-side, duct-to-mucosa PJ using an interrupted polydioxanone (PDS) 5-0 suture for the outer layer and interrupted polypropylene 5-0 suture for the inner layer.</li>
	<li>Use interrupted sutures between the pancreatic duct and the jejunal mucosa for the inner layer. Construct the outer layer with single sutures between the pancreatic parenchyma/capsule and the seromuscular layer of the jejunal loop.</li>
</ol>
5. Preparation of the long jejunal limb and jejunojejunostomy
<ol>
	<li>Choose a jejunal segment between the PJ and HJ (which will be constructed afterwards), which measures 25&#8211;35 cm instead of 10 cm as in conventional single-loop reconstruction. Create the jejuno-jejunostomy before or after construction of the HJ.</li>
	<li>Now construct an additional side-to-side jejunojejunal anastomosis at the lowest point between the afferent and efferent limbs of the HJ. Begin by placing marking sutures at the sites of the jejuno-jejunostomy with single PDS 5-0 stitches.</li>
	<li>Perform the intestinal anastomosis in a continuous double-layer PDS 5-0 suture technique. Construct the outer layer of the backwall with a continuous seromuscular suture. Perform the inner layer of the backwall with a continuous suture with stitching of all jejunal layers on both sides. Construct the inner layer and the outer layer of the front wall in the same way.</li>
	<li>Ensure that the anastomosis is sufficiently wide &#8211; about 1 inch. This allows good flow of bile and pancreatic secretions even in the early postoperative period when themucosa is edematous and may obstruct a narrow anastomosis. Close the slit around the jejunal loop using interrupted polypropylene 5-0 sutures.</li>
</ol>
6. Reconstruction phase: hepaticojejunostomy
<ol>
	<li>Use a single-layer interrupted or continuous PDS 5-0 suture for construction of the HJ. Use interrupted sutures especially for tiny ducts. Ensure that the stitches enclose all jejunal layers and all layers of the common bile duct.</li>
	<li>Splint thin-walled and tiny common bile ducts with an externally diverted T-tube.</li>
</ol>
7. Reconstruction phase: duodenojejunostomy
<ol>
	<li>Reconstruct the intestinal passage with an end-to-side, double-layer duodeno(pyloro-)jejunostomy using continuous PDS 4-0 sutures.</li>
	<li>Construct continuous seromusculary sutures for the outer layer of the back- and front wall as described in step 5.3. Use continuous sutures with stitching of all duodenojejunal layers for the inner layers of the anastomosis.</li>
</ol>
8. Management of drainages, postoperative medical treatment and POPF - monitoring
<ol>
	<li>At the end of the surgery, place 2 intraabdominal soft silicone drains in the vicinity of the HJ and PJ. Channel them separately through the skin of the right and left middle abdomen.</li>
	<li>Apply subcutaneous octreotide 100 &#181;g three times a day for 7 days after surgery. Use pasireotide as an alternative.</li>
	<li>Determine pancreatic amylase and lipase activity in the drain fluid every 48 h beginning on postoperative day 3.</li>
	<li>Discharge the patient once they have recovered from surgery &#8211; usually around postoperative day 21. Ensure that the drainages have been removed, the patient is fully mobile and able to eat regularly.</li>
	<li>Perform follow-up investigations including computed-tomography of the abdomen, magnet-resonance-cholangiopancreatography and esophagogastroscopy at least 6, 12 and 24 months after surgery to rule out tumor recurrence, metastases and anastomotic ulcers. The tumor marker carbohydrate antigen 19 &#8211; 9 must be determined as well.</li>
</ol>

<ol><li>Cameron, J. L., He, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Two+thousand+consecutive+pancreaticoduodenectomies%5BTitle%5D)+AND+%22Journal+of+American+College+of+Surgeons%22%5BJournal%5D)">Two thousand consecutive pancreaticoduodenectomies.</a> Journal of American College of Surgeons. 220 (4), 530-536 (2015).</li>
<li>Keck, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pancreatogastrostomy+Versus+Pancreatojejunostomy+for+RECOnstruction+After+PANCreatoduodenectomy+%28RECOPANC%2C+DRKS+00000767%29%3A+Perioperative+and+Long-term+Results+of+a+Multicenter+Randomized+Controlled+Trial%5BTitle%5D)+AND+%22Annals+of+Surgery%22%5BJournal%5D)">Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and Long-term Results of a Multicenter Randomized Controlled Trial.</a> Annals of Surgery. 263 (3), 440-449 (2016).</li>
<li>Deng, L. H., Xiong, J. J., Xia, Q. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Isolated+Roux-en-Y+pancreaticojejunostomy+versus+conventional+pancreaticojejunostomy+after+pancreaticoduodenectomy%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Journal+of+Evidence+Based+Medicine%22%5BJournal%5D)">Isolated Roux-en-Y pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a systematic review and meta-analysis.</a> Journal of Evidence Based Medicine. 10 (1), 37-45 (2017).</li>
<li>Klaiber, U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Meta-analysis+of+complication+rates+for+single-loop+versus+dual-loop+%28Roux-en-Y%29+with+isolated+pancreaticojejunostomy+reconstruction+after+pancreaticoduodenectomy%5BTitle%5D)+AND+%22British+Journal+of+Surgery%22%5BJournal%5D)">Meta-analysis of complication rates for single-loop versus dual-loop (Roux-en-Y) with isolated pancreaticojejunostomy reconstruction after pancreaticoduodenectomy.</a> British Journal of Surgery. 102 (4), 331-340 (2015).</li>
<li>Eshmuminov, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Systematic+review+and+meta-analysis+of+postoperative+pancreatic+fistula+rates+using+the+updated+2016+International+Study+Group+Pancreatic+Fistula+definition+in+patients+undergoing+pancreatic+resection+with+soft+and+hard+pancreatic+texture%5BTitle%5D)+AND+%22HPB+%28Oxford%29%22%5BJournal%5D)">Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture.</a> HPB (Oxford). 20 (11), 992-1003 (2018).</li>
<li>Ke, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+prospective%2C+randomized+trial+of+Roux-en-Y+reconstruction+with+isolated+pancreatic+drainage+versus+conventional+loop+reconstruction+after+pancreaticoduodenectomy%5BTitle%5D)+AND+%22Surgery%22%5BJournal%5D)">A prospective, randomized trial of Roux-en-Y reconstruction with isolated pancreatic drainage versus conventional loop reconstruction after pancreaticoduodenectomy.</a> Surgery. 153 (6), 743-752 (2013).</li>
<li>El Nakeeb, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Isolated+Roux+loop+pancreaticojejunostomy+versus+pancreaticogastrostomy+after+pancreaticoduodenectomy%3A+a+prospective+randomized+study%5BTitle%5D)+AND+%22HPB+%28Oxford%29%22%5BJournal%5D)">Isolated Roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a prospective randomized study.</a> HPB (Oxford). 16 (8), 713-722 (2014).</li>
<li>Tani, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Randomized+clinical+trial+of+isolated+Roux-en-Y+versus+conventional+reconstruction+after+pancreaticoduodenectomy%5BTitle%5D)+AND+%22British+Journal+of+Surgery%22%5BJournal%5D)">Randomized clinical trial of isolated Roux-en-Y versus conventional reconstruction after pancreaticoduodenectomy.</a> British Journal of Surgery. 101 (9), 1084-1091 (2014).</li>
<li>Machado, M. C., da Cunha, J. E., Bacchella, T., Bove, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+modified+technique+for+the+reconstruction+of+the+alimentary+tract+after+pancreatoduodenectomy%5BTitle%5D)+AND+%22Surgery+Gynecology+Obstetrics%22%5BJournal%5D)">A modified technique for the reconstruction of the alimentary tract after pancreatoduodenectomy.</a> Surgery Gynecology Obstetrics. 143 (2), 271-272 (1976).</li>
<li>Aghalarov, I., Herzog, T., Uhl, W., Belyaev, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+modified+single-loop+reconstruction+after+pancreaticoduodenectomy+reduces+severity+of+postoperative+pancreatic+fistula+in+high-risk+patients%5BTitle%5D)+AND+%22HPB+%28Oxford%29%22%5BJournal%5D)">A modified single-loop reconstruction after pancreaticoduodenectomy reduces severity of postoperative pancreatic fistula in high-risk patients.</a> HPB (Oxford). 20 (7), 676-683 (2018).</li>
<li>Marangoni, G., Morris-Stiff, G., Deshmukh, S., Hakeem, A., Smith, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+modern+approach+to+teaching+pancreatic+surgery%3A+stepwise+pancreatoduodenectomy+for+trainees%5BTitle%5D)+AND+%22Journal+of+Gastrointestinal+Surgery%22%5BJournal%5D)">A modern approach to teaching pancreatic surgery: stepwise pancreatoduodenectomy for trainees.</a> Journal of Gastrointestinal Surgery. 16 (8), 1597-1604 (2012).</li>
<li>Sülberg, D. U. W. Pyloruserhaltende Duodenohemipankreatektomie nach Traverso-Longmire mit T-Drainage (pp-Whipple). , Available from: 
 <a target="_blank" href="https://www.webop.de/Allgemein-und-Viszeralchirurgie/Pankreas-und-Milz/Pyloruserhaltende-Duodenohemipankreatektomie-nach-Traverso-Longmire-mit-T-Drainage-pp-Whipple">https://www.webop.de/Allgemein-und-Viszeralchirurgie/Pankreas-und-Milz/Pyloruserhaltende-Duodenohemipankreatektomie-nach-Traverso-Longmire-mit-T-Drainage-pp-Whipple</a> (2019).</li>
<li>Machado, M. C., Machado, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Systematic+use+of+isolated+pancreatic+anastomosis+after+pancreatoduodenectomy%3A+Five+years+of+experience+with+zero+mortality%5BTitle%5D)+AND+%22European+Journal+of+Surgical+Oncology%22%5BJournal%5D)">Systematic use of isolated pancreatic anastomosis after pancreatoduodenectomy: Five years of experience with zero mortality.</a> European Journal of Surgical Oncology. 42 (10), 1584-1590 (2016).</li>
<li>Pescio, G., Cariati, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+new+reconstructive+method+after+pancreaticoduodenectomy%3A+the+triple+Roux+on+a+%22P%22+loop.+Rationale+and+radionuclide+scanning+evaluation%5BTitle%5D)+AND+%22HPB+Surgery%22%5BJournal%5D)">A new reconstructive method after pancreaticoduodenectomy: the triple Roux on a "P" loop. Rationale and radionuclide scanning evaluation.</a> HPB Surgery. 9 (4), 223-227 (1996).</li>
<li>Kingsnorth, A. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Safety+and+function+of+isolated+Roux+loop+pancreaticojejunostomy+after+Whipple%27s+pancreaticoduodenectomy%5BTitle%5D)+AND+%22Annals+of+the+Royal+College+of+Surgeons+of+England%22%5BJournal%5D)">Safety and function of isolated Roux loop pancreaticojejunostomy after Whipple's pancreaticoduodenectomy.</a> Annals of the Royal College of Surgeons of England. 76 (3), 175-179 (1994).</li>
<li>Jester, A. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+Impact+of+Hepaticojejunostomy+Leaks+After+Pancreatoduodenectomy%3A+a+Devastating+Source+of+Morbidity+and+Mortality%5BTitle%5D)+AND+%22Journal+of+Gastrointestinal+Surgery%22%5BJournal%5D)">The Impact of Hepaticojejunostomy Leaks After Pancreatoduodenectomy: a Devastating Source of Morbidity and Mortality.</a> Journal of Gastrointestinal Surgery. 21 (6), 1017-1024 (2017).</li>
<li>Funovics, J. M., Zoch, G., Wenzl, E., Schulz, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Progress+in+reconstruction+after+resection+of+the+head+of+the+pancreas%5BTitle%5D)+AND+%22Surgery+Gynecology+Obstetrics%22%5BJournal%5D)">Progress in reconstruction after resection of the head of the pancreas.</a> Surgery Gynecology Obstetrics. 164 (6), 545-548 (1987).</li>
<li>Jover, J. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Results+of+defunctionalized+jejunal+loop+after+pancreaticoduodenectomy%5BTitle%5D)+AND+%22Cirurgia+Espanola%22%5BJournal%5D)">Results of defunctionalized jejunal loop after pancreaticoduodenectomy.</a> Cirurgia Espanola. 80 (6), 373-377 (2006).</li>
<li>Albertson, D. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pancreaticoduodenectomy+with+reconstruction+by+Roux-en-Y+pancreaticojejunostomy%3A+no+operative+mortality+in+a+series+of+25+cases%5BTitle%5D)+AND+%22The+Southern+Medical+Journal%22%5BJournal%5D)">Pancreaticoduodenectomy with reconstruction by Roux-en-Y pancreaticojejunostomy: no operative mortality in a series of 25 cases.</a> The Southern Medical Journal. 87 (2), 197-201 (1994).</li>
</ol>

The authors have nothing to disclose.

To date, POPF contributes significantly to the postoperative morbidity following PD1.
A mixture of bile and pancreatic juice can lead to mutual activation of both secretions, increasing their adverse effects on the PJ or the HJ9,13,14,15,16. Cytotoxic activity of activated phospholipase A2, which converts bil...

Pancreaticoduodenectomy (PD) is considered a sophisticated surgical procedure. While mortality has decreased over the last decades, morbidity still remains high1. The most frequent and feared complication is the postoperative pancreatic fistula (POPF), which occurs in over 20% of operations2,3,4,5. POPF can lead to subsequent complications such as postpancreatectomy hemorrhage, delayed gastric emptying, intraabdominal abscess and sepsis. Increased hospital costs, prolonged hospital stay, and delayed initiation of chemotherapy in cancer patients have a dramatic socioeconomic impact2,3,4.
Different surgical approaches have been introduced in the last decades to decrease the frequency and severity of POPF. One of those is the double-loop reconstruction (DLR) with isolated Roux-en-Y loops for the biliary and pancreatic anastomoses. Separating pancreatic juice from bile is thought to decrease the detrimental effects of mutually activated secretions on the pancreaticojejunostomy (PJ). Results in the literature have been encouraging6,7,8. However, operative time is significantly prolonged with DLR4,9.
We here introduce the technique of modified single-loop reconstruction (mSLR) during PD to separate pancreatic secretion from bile compared to the conventional single-loop reconstruction (SLR, Figure 1). In this method, a single long small-bowel loop is used for the construction of the hepaticojejunostomy (HJ) and PJ. A side-to-side anastomosis between the afferent and efferent limb of the HJ facilitates isolated flow of bile and pancreatic secretions. The first promising results confirming decreased mortality and morbidity in patients with high-risk pancreata were reported by our group in 201810.
This method reduces the severity of POPF by separating pancreatic fluid and bile without prolonging the duration of surgery significantly compared to the double-loop reconstruction.

<table><tbody><tr><td>Alexis O XXL</td><td>Applied medical</td><td>C8405</td><td></td></tr><tr><td>Bauchtuch Gr&amp;uuml;n 10x90</td><td>Nobatrast</td><td>603219</td><td>abdominal compress</td></tr><tr><td>Bauchtuch Gr&amp;uuml;n 45x45</td><td>Nobatrast</td><td>607544</td><td>abdominal compress</td></tr><tr><td>GIA 60mm-3.8mm</td><td>Covidien/Medtronic</td><td>GIA6038S</td><td></td></tr><tr><td>GIA Loading Unit</td><td>Covidien/Medtronic</td><td>GIA6038L</td><td></td></tr><tr><td>OP-Flex Yankauer</td><td>Unomedical</td><td>34094182</td><td>suction device</td></tr><tr><td>Pr&amp;auml;pariertupfer-Set</td><td>Fuhrmann</td><td>32019</td><td>sterile swab</td></tr><tr><td>Schlinggazetupfer 30x40</td><td>Fuhrmann</td><td>32016</td><td>sterile swab</td></tr><tr><td>Telescopic Smoke Pencil</td><td>LiNA Medical</td><td>SHK-TSP-CL</td><td>electro cautery</td></tr><tr><td>Thermocover ECO</td><td>PEMAX</td><td>TC43-75EC2</td><td>bowel cover</td></tr><tr><td>Whipple-Set</td><td>M&amp;ouml;lnlycke</td><td>97016042-00</td><td></td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td>&lt;strong&gt;Drainages:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Drainagebeutel</td><td>Coloplast</td><td>?</td><td>drainagebag</td></tr><tr><td>Silikon-Kapillardrainage</td><td>AsidBonz</td><td>551012</td><td>capillary drainage</td></tr><tr><td>Trichteransatz f&amp;uuml;r T-Rohr</td><td>R&amp;uuml;sch</td><td>333169-000025</td><td>2,5 mm</td></tr><tr><td>T-Rohr nach Kehr</td><td>R&amp;uuml;sch</td><td>423600-000025</td><td>t-tube 2,5 mm</td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td>&lt;strong&gt;Sutures:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Ethiloop 2mm 2x45cm</td><td>Ethicon</td><td>EH387</td><td>loop</td></tr><tr><td>Mersilene 0 FSL</td><td>Ethicon</td><td>EH7637</td><td>fixation of the drainage</td></tr><tr><td>PDS 1 CT</td><td>Ethicon</td><td>PDP9234</td><td>suturing of the fascia</td></tr><tr><td>Vicryl 2-0 , 6x45cm</td><td>Ethicon</td><td>VCP1226</td><td>for ligature</td></tr><tr><td>Vicryl 2-0 SHplus, 8x70</td><td>Ethicon</td><td>VCP7850</td><td>for ligature</td></tr><tr><td>Vicryl 3-0 MH-1plus</td><td>Ethicon</td><td>VCP245</td><td>subcutaneous suture</td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td>&lt;strong&gt;Pancreatic anastomoses:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Prolene 5-0 c1</td><td>Ethicon</td><td>8890</td><td>6 x</td></tr><tr><td>PDS 5.0 RB-1plus</td><td>Ethicon</td><td>X1153</td><td>2 x Multipack</td></tr><tr><td>Prolene 4-0 RB-1</td><td>Ethicon</td><td>8871</td><td>2 x holding sutures</td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td>&lt;strong&gt;Hepaticojejunostomy:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Prolene 5-0 c1</td><td>Ethicon</td><td>8890</td><td>2 x holding sutures</td></tr><tr><td>PDS 5-0 c1</td><td>Ethicon</td><td>PDP1013</td><td>7 x</td></tr><tr><td>PDS 6-0 c1</td><td>Ethicon</td><td>PDP1012</td><td>1 x mucosa fixation sutures</td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td>&lt;strong&gt;Gastrojejunostomy:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>PDS 4-0 SH-1 plus</td><td>Ethicon</td><td>X1154</td><td>1 x Multipack</td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td>&lt;strong&gt;Jejuno-Jejunostomy&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Ligasure</td><td>Covidien</td><td>LS1520</td><td></td></tr><tr><td>PDS 5-0 RB-1 plus</td><td>Ethicon</td><td>X1153</td><td>1 x Multipack</td></tr><tr><td>Prolene 2-0 SH</td><td>Ethicon</td><td>8833</td><td>Vessel-suture, etc.</td></tr><tr><td>Prolene 3-0 SH</td><td>Ethicon</td><td>8832</td><td>Cystic duct, cystic artery</td></tr><tr><td>Prolene 4-0 RB-1</td><td>Ethicon</td><td>8871</td><td>2 mal suturing of the slit in the meso</td></tr></tbody></table>

modified single-loop reconstruction for pancreaticoduodenectomy

Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic remnants to reduce the severity of postoperative pancreatic fistulas and moreover the overall postoperative morbidity. This reconstruction technique is characterized by an extra-long jejunal loop for the construction of the pancreaticojejunostomy and hepaticojejunostomy. The longer distance between these anastomoses and an additional jejuno-jejunostomy between the afferent and efferent limb of the hepaticojejunostomy separate the fluids and prevent backflow of bile towards the pancreaticojejunostomy. Thus, the secretions cannot activate each other and aggravate an existing anastomotic leakage. We observed a reduced rate of severe postoperative pancreatic fistulas after modified single-loop reconstruction compared to conventional single loop reconstruction. The technique is easy to perform, safe, and less time-consuming than a traditional double-loop reconstruction.

Every patient undergoing PD underwent an investigation of the pancreatic tissue to evaluate the indication for mSLR. High-risk pancreatic remnants (i.e., soft pancreatic tissue and a tiny main pancreatic duct) were reconstructed using a modified single loop whenever possible.
We identified 50 patients with high risk pancreatic tissue and a small main pancreatic duct. All of them underwent mSLR. The mean age was 63 ± 13 years old. The male/female ratio was 17:33. Indications for surgery were ma...

The technique of modified single-loop reconstruction following pancreaticoduodenectomy separates pancreatic secretion from bile, thus reducing the severity of POPF without prolonging the duration of surgery.

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic ...

modified-single-loop-reconstruction-for-pancreaticoduodenectomy

Research

JoVE Journal

Medicine

Laparoscopic pancreatoduodenctomy (LPD) may offer advantages over open pancreatoduodenectomy, including early postoperative mobilization, less delayed gastric emptying and a shorter hospital stay. However, LPD is technically challenging and not well-standardized, especially regarding the pancreatic anastomosis. We describe a standardized technique for the pancreatic anastomosis during LPD: modified Blumgart pancreaticojejunostomy.

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Robotic pancreatoduodenctomy (RPD) has been highly standardized in recent years and may be used in selected patients with pancreatic head cancer, including those with a replaced right hepatic artery. This case report describes a standardized and reproducible technique for RPD, which includes the approach of the Dutch LAELAPS-3 training program to an aberrant vasculature.

Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Complete resection of the uncinate process and mesopancreas is one of the most important and difficult processes in laparoscopic pancreatoduodenectomy (LPD). This article presents a method for managing the uncinate process in no-touch LPD using the median-anterior and left-posterior approaches to the superior mesenteric artery (SMA).

Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy

This article provides a whole technical process of laparoscopic duodenum-preserving pancreatic head resection via an inferior infracolic approach. This is a surgical approach for benign tumors without intraoperative fluorescence image guidance.

Laparoscopic Duodenum-Preserving Pancreatic Head Resection via Inferior Infracolic Approach: A Surgical Approach for Benign Lesions

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.

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

This protocol presents robotic duodenum-preserving total pancreatic head resection (R-DPPHRt) for intraductal papillary mucinous neoplasms (IPMNs). A video demonstrates the technique in a patient with main duct-IPMN, highlighting its feasibility as a minimally invasive, organ-preserving alternative to pancreaticoduodenectomy.

Robotic Duodenum-preserving Total Pancreatic Head Resection for Intraductal Papillary Mucinous Neoplasms

The surgical procedure used to induce experimental myocardial infarction in mice begins with left thoracotomy between the third and the fourth ribs in order to visualize the anterior surface of the heart and left lung. The left coronary artery is ligated, the chest is closed and the mouse is allowed to recover spontaneously.

Modified Technique for Coronary Artery Ligation in Mice

A technique is demonstrated for the microsurgical procedure for heterotopic transplantation of hearts in mice, including simplified methods for donor harvesting and recipient vessel anastomosis.

A Modified Method for Heterotopic Mouse Heart Transplantion

Learn modified single-loop reconstruction for pancreaticoduodenectomy to reduce postoperative pancreatic fistula severity. This surgical technique separates pancreatic secretion from bile without extending operative time.

Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

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