Robotic-assisted Lateral Pancreaticojejunostomy for Chronic Pancreatitis

[Narrator] Here, we present a robotic-assisted lateral pancreatic jejunostomy in a patient with chronic pancreatitis. Our patient is a 39-year-old male with no significant past medical history. He presented to our institution with several episodes of pancreatitis requiring multiple hospitalizations over approximately five years. He had undergone a laparoscopic cholecystectomy several years prior to presentation for a diagnosis of gallstone pancreatitis, however, episodes persisted after surgery and increased in frequency over time. During his workup, he underwent ERCP and endoscopic ultrasound, where he was diagnosed with pancreatic divisum. Additionally, he was found to have a pancreatic duct stricture at the neck, which was unable to be traversed for an attempted pancreatic duct stent placement. On the left is a pancreatogram showing stricturing at the pancreatic duct at the neck with distal dilation. On the right is MRCP showing irregularly dilated pancreatic duct in the body and tail of the pancreas. Given no significant disease of the head of the pancreas or involvement of biliary structures, the patient was deemed a candidate for a drainage procedure. Listed are the steps of the operation, as well as a schematic with suggested port placement for a robotic-assisted lateral pancreatic jejunostomy. At this point in the operation, the lesser sac has been entered. and the stomach is retracted anterior and cephalad, along with the liver. Intraoperative ultrasound is used to identify the dilated pancreatic duct, locate the stricture, and track the course of the duct along the body of the pancreas. The body of the pancreas is incised using cauterized scissors along the anterior surface of the duct. Pancreatic duct fluid is expressed as the duct is entered. A four-French hob stent is used to track the pancreatic duct as it is opened. Identify the ligament of Trietz and proximal jejunum. Approximately 20 centimeters distal to this, a looped jejunum is identified, and using bipolar electrocautery, a mesenteric window is created and the bowel is divided with a 60 millimeter purple load Endo GIA stapler. A retrocolic tunnel in the transverse colon mesentery is created using blunt dissection, and the Roux limb is then subsequently passed through this space into the lesser sac, ensuring that the jejunum reaches the pancreas without tension. A longitudinal enterotomy is created on the antimesenteric aspect of the jejunum using electrocautery and sharp dissection to match the length of the incision along the pancreas. The anastomosis begins at the tail of the pancreas, where two 3-0 V-Loc sutures are anchored at the distal end of the ductotomy and the enterotomy. Each V-Loc suture is run along either side of the anastomosis. A four-French hop stent is used to ensure the duct remains patent at the beginning of the anastomosis. The inferior aspect of the anastomosis is being completed. The anastomosis is completed when the V-Loc sutures meet at the neck of the pancreas, where they are tied together. Here is the completed anastomosis. To complete the operation, GI continuity is reestablished. Small enterotomies are created near the previous stapled edge of the jejunum in a segment of jejunum approximately 50 centimeters distal to the Roux limb. A 60 millimeter purple load Endo GIA staple fire is used to create a side-to-side jejunojejunostomy. The common enterotomy is closed with running 3-0 V-Loc sutures, followed by interrupted 3-0 silk Lembert sutures. 3-0 silk Lembert sutures are again used to close the colon mesenteric defect created around the Roux limb. Two 19-French drains are placed using the robotic port sites. One drain is passed posterior to the pancreatic jejunal anastomosis, and the other anterior to the anastomosis. Here again is the completed anastomosis. His postoperative course was largely unremarkable. He had drained amylase studies indicative of no pancreatic leak. His drains were removed on the day of discharge from the hospital. On his postoperative clinic visit, he reported resolution of preoperative symptoms. Here is a table demonstrating his postoperative outcomes. In this video, we demonstrate that a robotic-assisted modified bestow is a safe and effective option for the treatment of chronic pancreatitis. When used for appropriately selected patients, this option results in symptom control and spares resection of pancreatic parenchyma.