Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

Separation of pancreatic secretion from bile decreases detrimental effects of mutually activated secretions on the pancreaticoduodenostomy. This reduces the severity, but not the incidence, of postoperative pancreatic fistula. The single-loop reconstruction is a frequently performed reconstruction technique in pancreaticoduodenectomy.

The double-loop reconstruction has been introduced first in 1976. It realizes the theory of separation of pancreatic fluid and bile. However, this procedure is significantly more time-consuming than the conventional single-loop reconstruction.

The modified single-loop reconstruction aims to separate pancreatic fluid from bile with a long jejunal limb and an additional jejunal anastomosis between the afferent and efferent limb of the hepaticojejunostomy. This picture demonstrates the finished reconstruction phase of a pancreaticoduodenectomy with a modified single-loop reconstruction. The green arrows demonstrate the pancreaticojejunostomy, the hepaticojejunostomy, and the jejunojejunostomy.

The extra long jejunal limb can be seen clearly in this picture. The study protocol of this study involving human surgery only was approved by the Ethics Committee at the Ruhr-University of Bochum. Written informed consent was obtained from all patients.

This is the preparation of a teres ligament patch. It will be wrapped around the hepatic artery after completion of the anastomosis to reduce the risk of erosion bleeding in cases of anastomotic leakages. Begin the reconstruction phase with immobilization of a long, mobile jejunal loop.

Resect the first 10 inches of the jejunum to provide enough length of the mesentery. Reposit the jejunal loop in right upper abdominal quadrant. Perform a double-layered intersite duct-to-mucosa pancreaticojejunostomy.

Use interrupted polydioxanone 5-0 sutures for the outer layer and interrupted polypropylene 5-0 sutures for the inner layer. Stents or sealants are not required. This sequence shows the suture of the inner layer of the pancreaticojejunostomy with an interrupted polypropylene 5-0 suture.

Place the sutures close to each other to avoid an insufficiency of the anastomosis. Don't place the sutures too close to each other to avoid necrosis of the suture tissue. Here we see the construction of the outer layer of the pancreaticojejunostomy with an interrupted polydioxanone 5-0 suture.

The sutures are prepared as demonstrated in this sequence. Once again, don't place the sutures too close to each other. This is the finished double-layer into the duct-to-mucosa pancreaticojejunostomy.

Construct the outer wall of the jejunojejunostomy before constructing the hepaticojejunostomy. This facilitates the construction of the hepaticojejunostomy. Now we can clearly see how the long jejunal limb is going to be placed.

The jejunal loop between hepaticojejunostomy and pancreaticojejunostomy measures 25 to 35 centimeters instead of 10 centimeters. This creates distance between the anastomosis for diversion of the secretions. It further facilitates construction of an additional jejunojejunostomy between the afferent and efferent limb of the hepaticojejunostomy.

Perform a single-layer interrupted polydioxanone 5-0 suture for the hepaticojejunostomy. Split thin-walled and tiny common bile ducts with a T-tube. Begin the hepaticojejunostomy with four mucosa fixation sutures.

Two polypropylene 5-0 holding sutures facilitate construction of the hepaticojejunostomy. Begin the construction of the hepaticojejunostomy with a Roux-en-Y using interrupted polydioxanone 5-0 sutures. Prepare the surgical knots but don't tie them at the beginning.

The prepared surgical knots are tied afterwards to enable an equal tension on each suture. Here we can see clearly the extra long jejunal limb for a modified single-loop reconstruction. Here we see the construction of the anterior wall of the hepaticojejunostomy.

The jejenojejunostomy is a 1.5 centimeter measuring double-layered jejunal anastomosis performed with a polydioxanone 5-0 suture. Construct the anastomosis at the lowest point between the efferent and afferent limb of the hepaticojejunostomy. Construct this anastomosis of the pancreaticojejunostomy and the hepaticojejunostomy because they are most sophisticated.

Use monopolar cautery to open the jejunum for construction of jejunojejunostomy. Perform a continuous suture with a polydioxanone 5-0 suture for the inner layer of the rear wall of the jejunojejunostomy. The continuous suturing allows equal distribution of tension on the anastomosis.

Here we see the construction of the inner layer of the anterior wall of the anastomosis. This is the construction of the outer layer of the anterior wall. Here we see the pancreaticojejunostomy, the jejunojejunostomy, and the hepaticojejunostomy in the background.

Close the gap in the mesocolon after transposition of the jejunal limb to avoid internal hernia. Every patient with a soft pancreatic tissue and a tiny main pancreatic duct underwent modified single-loop reconstruction whenever possible. Mobilization of the long jejunal limb was usually no problem.

In rare cases, mobilization was limited due to extreme visceral obesity or severe adhesions due to past surgical history. Small patients come along with naturally smaller space in the upper abdomen, impeding the preparation as well. The continuous double-layer reconstruction of the jejunojejunostomy was performed without difficulties in all patients.

No anastomotic insufficiency occurred postoperatively. This method reduces the incidence of severe postoperative pancreatic fistula in all patients with high risk pancreatic remnants. The number of postpancreatectomy hemorrhages and reoperations was significantly lower with modified single-loop reconstruction.

In comparison to the double-loop reconstruction, this procedure is significantly less technically demanding and less time-consuming. The modified single-loop reconstruction is a simple technique to separate pancreatic secretion from bile for reduction of postoperative morbidity. It is safe and less time-consuming than the double-loop reconstruction.