We thank Anne M Sill, MSHS, GME Research Coordinator and Department Statistician for careful review of the statistics, and acknowledge Xihua Yang, MD, Pouya Aghajafari, MD, and Pouya Aghajafari, MD, for their contributions as co-authors on the original paper reporting this technique9.

This study was approved by the Ethics Committee (Institutional Review Board) of Saint Agnes Hospital (No. 2016-020).
1. Preparations
<ol>
	<li>Preoperatively, give&#160;5,000 units of heparin subcutaneously to prevent deep venous thrombosis prophylaxis, and give antibiotics per the hospital&#39;s surgical care improvement project (SCIP) policy, such as&#160;2 g of cefazolin and 500 mg of metronidazole.</li>
	<li>Place an epidural as discussed with the anesthesia team for optimal postoperative pain control and to promote enhanced recovery after surgery (ERAS).</li>
	<li>Intraoperatively, perform a classic or pylorus-preserving PD in a standard fashion.7</li>
</ol>
2. Transection of the Pancreatic Neck
<ol>
	<li>Prior to transection of the pancreatic neck, place four full-thickness, transpancreatic, 3-0 silk, stay sutures on the superior and inferior edges of the pancreas and then divide the pancreatic neck between these stay sutures. Place a Crile clamp on each of the four silk sutures.</li>
	<li>Proceed to completion of the PD resection in standard fashion.</li>
</ol>
3. Preparing the Jejunum and Pancreas for Anastomosis
<ol>
	<li>After removal of the specimen, dissect the posterior surface of the pancreas free from the retroperitoneum for several centimeters.</li>
	<li>Bring the stapled end of the jejunum into position in preparation for anastomosis.</li>
</ol>
4. Suture Placement:
NOTE: The following sutures are placed in the following order to create the anastomosis (as shown in Figure 1).
<ol>
	<li>Two 3-0 silk CW sutures (cw)
	<ol>
		<li>For each of these, take a full-thickness bite through the pancreas a few centimeters from the cut surface, one at the superior border and one at the inferior border of the pancreas, each passing through a generous seromuscular bite of jejunum, as shown in Figure 1. The bites through the jejunum should be approximately 6 cm from each other (to allow for 2 cm of jejunum on either side of the jejunotomy, which is typically ~2 cm in length, but will vary with the thickness of the pancreatic neck).</li>
		<li>Leave these sutures untied, as they will later join the inferior border of the pancreas to the antimesenteric border of the proximal jejunum, and the superior border to the more distal antimesenteric border of the jejunum, wrapping the jejunum around the sides of the pancreatic remnant covering the corners of the anastomosis and giving the final appearance of a colonial wig (Figure 1).</li>
	</ol>
	</li>
	<li>Two 3-0 absorbable (e.g., VicrylTM) U-sutures (u)
	<ol>
		<li>Place these two stitches with a straight(ened) needle. For the first one, starting at the proximal aspect of the jejunotomy and traveling anterior to posterior, take a full-thickness bite through the anterior wall of the jejunotomy, then a full thickness bite through the pancreas, about 1 cm from the cut surface, and just a few mm from the superior border, and then take&#160;a full-thickness bite through the posterior wall of the proximal jejunotomy.</li>
		<li>Now the needle is at the bottom of the &#34;U,&#34; so turn 180 degrees and reverse the path, travelling posterior-to-anterior, taking a full-thickness bite through the posterior jejunum, then pancreas, then anterior wall of the jejunum (Figure 1A, 1B). These U-stitches are used to compress the small ducts (similar to the Blumgart anastomosis11) and to keep the pancreas securely invaginated in the jejunotomy (similar to the &#34;dunking PJ&#34; anastomosis8).&#160;Place the second U-suture in a similar fashion, but at the distal half of the jejunotomy and inferior to the pancreatic duct (Figure 1A, 1B).</li>
		<li>Place a metallic probe (e.g., a Garrett dilator) in the pancreatic duct while taking the pancreatic bites close to the main pancreatic duct, to make sure that the suture does not go through the duct. Each of these should encompass most of the width of pancreatic parenchyma on either side of the&#160;pancreatic duct.</li>
	</ol>
	</li>
	<li>Two silk 3-0 stay sutures (s)
	<ol>
		<li>Attach a French-eye needle to the previously placed stay stitches on the pancreatic remnant, and take a full-thickness bite, in-to-out, through the jejunum 1 cm away from the jejunotomy. The purpose of these stitches is to secure the invagination of the corners of the pancreatic remnant deep into the jejunotomy.</li>
		<li>After placing stitches #1-3, pull taut on the s and u stitches to invaginate the pancreatic remnant into the jejunotomy, then proceed with tying them in the following order: u then s then cw (Figure 1C, 1D). The jejunum should now look much like a Colonial wig fitted snugly around the sides of a Colonial Whig&#39;s head.</li>
	</ol>
	</li>
	<li>Several interrupted 3-0 silk sutures provide a final, outer layer (o)
	<ol>
		<li>Place these stitches very closely together in a vertical fashion between the anterior border of the pancreatic remnant and the cut edge of the jejunum to hermetically seal the redundant cuff of jejunum remaining after tying the u sutures to pancreatic capsule (Figure 1). Two of these stitches may be placed posteriorly as well, typically in a horizontal fashion, either now or earlier, e.g., after&#160;placing the sutures in steps 1.2 above.</li>
	</ol>
	</li>
</ol>
5. Placement of Omental Wrap
<ol>
	<li>Wrap the PJ anastomosis with a harvested tongue of healthy omentum. Place two, 19-F, round, fluted (e.g., Blake) drains near, but not touching, the anastomosis (the omental flap serves in part to protect the PJ from the drains).</li>
	<li>Perform the remainder of the reconstruction, viz., the hepaticojejunostomy and the gastro- or duodenojejunostomy, as previously described.7</li>
</ol>
6. Optional Adjuncts
<ol>
	<li>In cases with high-risk features, such as soft pancreas parenchyma, consider decompressing the bilopancreatic limb, e.g., with the creation of a Braun enteroenterostomy between the afferent and efferent limbs of the gastro- or duodenojejunostomy or between the afferent and efferent limbs of the hepaticojejunostomy. The administration of somatostatin analogues is also recommended and is supported by prospective, randomized data.</li>
</ol>
7. Postoperative Management
<ol>
	<li>Postoperatively, extubate the patient once stable from a hemodynamic and respiratory standpoint. Admit patients to the intensive care unit for overnight close monitoring, and follow local ERAS pathways.</li>
	<li>Initiate enteric feeds via an intraoperatively placed nasojejunal tube immediately postoperatively at a rate of 10 mL/h and advance to goal once there is evidence of return of small-bowel function. If starting somatostatin analogues pre- or intraoperatively, continue postoperatively.</li>
	<li>For high-risk cases, use pasireotide at 900 &#181;g twice daily for a week. For medium-risk cases and some low-risk cases, use octreotide at 100 &#181;g three times daily until the day of discharge.</li>
	<li>Check serum and drain amylase daily to evaluate for the presence of POPF. Remove drains on postoperative day #3, depending on the amylase level.</li>
</ol>

<ol>
	<li>DeOliveira, M. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessment+of+complications+after+pancreatic+surgery:+A+novel+grading+system+applied+to+633+patients+undergoing+pancreaticoduodenectomy.">Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy.</a> Annals of Surgery. 244, 931-939 (2006).</li><li>Grobmyer, S. R., Kooby, D., Blumgart, L. H., Hochwald, S. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+pancreaticojejunostomy+with+a+low+rate+of+anastomotic+failure-related+complications.">Novel pancreaticojejunostomy with a low rate of anastomotic failure-related complications.</a> Journal of the American College of Surgeons. 210, 54-59 (2010).</li><li>Fuji, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Modified+Blumgart+anastomosis+for+pancreaticojejunostomy:+Technical+improvement+in+matched+historical+control+study.">Modified Blumgart anastomosis for pancreaticojejunostomy: Technical improvement in matched historical control study.</a> Journal of Gastrointestinal Surgery. 18, 1108-1115 (2014).</li><li>Bassi, C., Marchegiani, G., Dervenis, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+2016+update+of+the+international+study+group+(ISGPS)+definition+and+grading+of+postoperative+pancreatic+fistula:+11+years+after.">The 2016 update of the international study group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after.</a> Surgery. 161, 584-591 (2016).</li><li>Callery, M. P., Pratt, W. B., Kent, T. S., Chaikof, E. L., Vollmer, C. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+prospectively+validated+clinical+risk+score+accurately+predicts+pancreatic+fistula+after+pancreatoduodenectomy.">A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy.</a> Journal of the American College of Surgeons. 216, 1-14 (2013).</li><li>Miller, B. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+multi-institutional+external+validation+of+the+fistula+risk+score+for+pancreatoduodenectomy.">A multi-institutional external validation of the fistula risk score for pancreatoduodenectomy.</a> Journal of Gastrointestinal Surgery. 18, 172-179 (2014).</li><li>Goussous, N., Patel, S. T., Cunningham, S. C., Cameron, J. L., Cameron, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bile-Duct+Cancer.">Bile-Duct Cancer.</a> Current Surgical Therapy, 12th ed. , (2016).</li><li>Cho, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Performing+simple+and+safe+dunking+pancreaticojejunostomy+using+mattress+sutures+in+pure+laparoscopic+pancreaticoduodenectomy.">Performing simple and safe dunking pancreaticojejunostomy using mattress sutures in pure laparoscopic pancreaticoduodenectomy.</a> Surgical Endoscopy. 28, 315-318 (2014).</li><li>Yang, X., Aghajafari, P., Goussous, N., Patel, S. T., Cunningham, S. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+"Colonial+Wig"+pancreaticojejunostomy:+zero+leaks+with+a+novel+technique+for+reconstruction+after+pancreaticoduodenectomy.">The "Colonial Wig" pancreaticojejunostomy: zero leaks with a novel technique for reconstruction after pancreaticoduodenectomy.</a> Hepatobiliary and Pancreatic Disease International. 16 (5), 545-551 (2017).</li><li>Cameron, J. L., Sandone, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Atlas of Gastrointestinal Surgery, Vol 2/Edition 2. , (2014).</li><li>Grobmyer, S. R., Kooby, D., Blumgart, L. H., Hochwald, S. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+pancreaticojejunostomy+with+a+low+rate+of+anastomotic+failure-related+complications.">Novel pancreaticojejunostomy with a low rate of anastomotic failure-related complications.</a> Journal of the American College of Surgeons. 210 (1), 54-59 (2010).</li></ol>

The authors have nothing to disclose.

There are many descriptions of novel PJs reported in the literature. It is generally true that the more ways that exist to perform a given task, the less likely there is a single perfect way to do it. This is likely accurate for PJ reconstruction as well. Each of the multiple different PJ techniques reported reports a low incidence of POPF. Nevertheless, POPF continues to be considered the &#34;Achilles heel&#34; of PD and more work is therefore needed to find a better way to construct this anastomosis.
Our current design for PJ reconstruction developed after studying widely used anastomoses and evaluating the likely technical sources of failure of the PJ anastomosis, such as leaks from the small ducts on the cut surface of the pancreatic neck, from the corners of the PJ anastomosis, and from the suture lines on the anterior and posterior surfaces of the PJ.
Failure to address these potential leak points likely increases the risk of POPF. In two of the most widely used PJ reconstruction methods, Cameron&#39;s duct-to-mucosa invaginating PJ and the Blumgart&#39;s PJ, some compression of the small ducts on the pancreatic cut surface is provided, but these techniques do not provide hermetic sealing of the corners of the anastomosis. This is provided by the cw sutures in the CW anastomosis. Our reconstruction also addresses the potential for leak from small ducts on the cut surface of the pancreatic by further compressing the parenchyma using the U-stitches, which further decreases the leak risk by also serving to deeply invaginate the pancreas within the jejunotomy. The s sutures ensure that the corners of the pancreatic remnant, which are prone to slip out to the jejunotomy, instead stay securely fixed within the jejunum. The o sutures provide further protection by providing a hermetic&#160;coverage of the anterior and posterior aspect of the PJ.
To mitigate the risk of POPF even further, the anastomosis is treated with several adjunctive measures. First, the PJ is wrapped with a vascularized omental pedicle, which was used universally when available. Second, in high-risk patients a Braun enteroenterostomy was created between the afferent and efferent loop to decompress the pancreaticobiliary limb.&#160; This limb may also be decompressed with a tube or with an enteroenterostomy between the afferent and efferent limb of the hepaticojejunostomy. Finally, as described above, somotostatin analogues are selectively used. Our low incidence of leak could be explained by the combination of all these measures, as well as simply by reduced tension across the anastomosis owing to the effect of the cw sutures.
Future applications of this technique may include comparison to other techniques in prospective randomized trials.
In conclusion, the existence of many PJ anastomotic techniques suggests none is ideal for all surgeons. Therefore, the best technique for now may be the one most familiar to the surgeon. However, this novel &#34;Colonial Wig&#34; anastomosis is easy to learn and may be a safe and effective way to lower POPF rates after PD.

Postoperative pancreatic fistula (POPF) is described as the Achilles&#39; heel of pancreaticoduodenectomy (PD) with an incidence rate ranging between 4&#8211;36%1,2,3. The goal of the presently described method of pancreaticojejunostomy (PJ), termed the &#34;Colonial Wig&#34; (CW), is to lower the rate of POPF following PD.
The morbidity of POPF is variable and it can range from being asymptomatic (Grade A, or clinically insignificant biochemical leak) to being symptomatic, causing deviation in the postoperative management, requiring percutaneous, endoscopic or angiographic interventions (Grade B) or requiring operative interventions, causing organ failure or death (Grade C)4. Multiple risk factors have been described to be associated with increased&#160;POPF, including soft pancreatic texture, small diameter of pancreatic duct, and increased intraoperative blood loss, and a&#160;validated 10-point scoring&#160;system has been described to predict the risk of POPF in patients undergoing PD5,6.
To reduce the incidence and mitigate the severity of POPF, several PJ reconstruction techniques have been described in the literature with a variable POPF incidence and severity. In this paper, we describe a novel PJ reconstructive technique, the CW PJ, which has the advantage of combining what we assess to be the best aspects of the best and most common techniques of the PJ. We compared the risk factors and outcomes of patients undergoing the new CW PJ technique versus standard techniques.

<table><tbody><tr><td>French eye needle, tapered</td><td>Anchor Products Co Inc, Addison, IL</td><td>1861-2dc&amp;nbsp;</td><td></td></tr><tr><td>Garrett dilator</td><td>Medline, Northfield, IL</td><td>MDS2040030</td><td></td></tr><tr><td>Octreotide</td><td>Sagent, Schaumburg, IL</td><td>2055879</td><td></td></tr><tr><td>Pasireotide</td><td>Curascript SD, Grove City , OH</td><td>246492</td><td></td></tr></tbody></table>

colonial wig pancreaticojejunostomy

Postoperative pancreatic fistula (POPF) is one of the most problematic complications after pancreaticoduodenectomy (PD). We describe a series of 48 pancreatic-head resections from our institution, in which we compare a new technique to create the pancreaticojejunostomy (PJ) reconstruction with standard techniques. The goal is to achieve a lower rate of POPF. This new PJ is termed the &#34;Colonial Wig&#34; (CW) PJ due to the novel appearance of the jejunum wrapping around the pancreas, resembling a Colonial wig wrapping around the head of a Colonial Whig (e.g.,&#160;George Washington). In our consecutive series, 22 cases were performed using the new CW technique to perform the PJ and were compared to 26 traditional PDs with traditional reconstruction. There was an incidence of clinically relevant POPF of 0% in the CW group, compared to 15% in 26 conventional PJs. Our proposed CW PJ reconstruction is&#160;associated with a lower the incidence of POPF following PD, and hence may be a way to improve outcomes after PD.

Perioperative data are found in our original publication on this procedure.9&#160;Briefly, the POPF rate for the first 26 (control) PDs was 27%. There were 3 (12%) grade-A (clinically insignificant) fistulas, 4 (15%) grade-B, and 0 grade-C fistulas. This clinically relevant POPF (CR-POPF) rate (grade B + grade C) was 15%. In the next 22 CW PJs, however, the CR-POPF rate was 0 (P = 0.052, by Chi-square test) among eligible cases. There was one grade-A POPF in the CW group (5%, Table 1).
The lower POPF rate in the CW group was not due to the presence of lower-risk glands in the CW group (Table 2). Similarly, the two groups were similar regarding important parameters such as gland texture, pancreatic duct diameter, distribution of pathologies, and estimated blood loss.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/58142/58142fig1.jpg" /> 
Figure 1: Schematic of suture placement. (A)&#160;The U sutures (u) are used to secure the invagination of the pancreatic remnant deep in the jejunotomy, while the stay sutures (s), which were placed before division of the pancreatic neck, are used to secure the corners of the remnant pancreas. (B-D)&#160;&#34;Colonial Wig&#34; sutures (cw) are used to bury the corners of the PJ under the jejunal serosa, which makes the jejunum resemble a traditional Colonial wig, which covers the tops of the ears like the jejunum covers, protects, and seals the corners of the PJ. Finally, the outer-layer sutures (o) are placed to provide a more hermetic anastomosis (D). This figure has been reproduced from our original publication on this procedure9. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/58142/58142fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td>ISGPS grade</td>
			<td>Conventional PD</td>
			<td>CWPJ</td>
		</tr>
		<tr>
			<td>None</td>
			<td>19 (73%)</td>
			<td>19 (95%)</td>
		</tr>
		<tr>
			<td>A</td>
			<td>3 (12%)</td>
			<td>1 (5%)</td>
		</tr>
		<tr>
			<td>B</td>
			<td>4 (15%)</td>
			<td>0</td>
		</tr>
		<tr>
			<td>C</td>
			<td>0</td>
			<td>0</td>
		</tr>
	</tbody>
</table>
Table 1: Comparison of conventional PD and CWPJ cases by occurrence and grade of POPF. PD = pancreaticoduodenectomy; CWPJ = &#34;Colonial Wig&#34; pancreaticojejunostomy; POPF = postoperative pancreatic fistula; ISGPS = International Study Group of Pancreatic Surgery.
<table fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td>FRS parameter</td>
			<td>Conventional PD</td>
			<td>CWPJ</td>
			<td>P value</td>
		</tr>
		<tr>
			<td>Soft pancreas texture (n)</td>
			<td>14/24* (58%)</td>
			<td>10/20 (50%)</td>
			<td>0.58</td>
		</tr>
		<tr>
			<td>Pancreatic duct diameter (mm)</td>
			<td>3 &#177; 2.3</td>
			<td>4 &#177; 2.5</td>
			<td>0.28</td>
		</tr>
		<tr>
			<td>PDAC/pancreatitis (n)</td>
			<td>12/26 (46%)</td>
			<td>10/20 (50%)</td>
			<td>0.8</td>
		</tr>
		<tr>
			<td>Estimated blood loss (mL)</td>
			<td>500 &#177; 539</td>
			<td>500 &#177; 316</td>
			<td>0.33</td>
		</tr>
	</tbody>
</table>
Table 2: Comparison of conventional PD and CWPJ cases by FRS parameter shows that the groups were similar regarding other known risk factors for POPF. *Two cases were missing data for gland texture. Two deaths early in the postoperative period were excluded since they precluded assessment of POPF. PD = pancreaticoduodenectomy; CWPJ = &#34;Colonial Wig&#34; pancreaticojejunostomy; FRS = fistula risk score; POPF = postoperative pancreatic fistula; PDAC = pancreatic ductal adenocarcinoma.

Watch this Scientific Journal Video about Colonial Wig Pancreaticojejunostomy at JoVE.com

Colonial Wig Pancreaticojejunostomy

We describe a new technique for pancreaticojejunostomy reconstruction after pancreaticoduodenectomy that is associated with a very low rate of postoperative pancreatic fistula.

Postoperative pancreatic fistula (POPF) is one of the most problematic complications after pancreaticoduodenectomy (PD). We describe a series of 48 ...

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Medicine

11.9K Views.  Saint Agnes Hospital. We describe a new technique for pancreaticojejunostomy reconstruction after pancreaticoduodenectomy that is associated with a very low rate of postoperative pancreatic fistula.

Video: Colonial Wig Pancreaticojejunostomy

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis.
The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index &#62;35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers.
The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy.
The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

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.

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal ...

Cancer Research

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

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several studies have described the safety of RPD in case of a replaced or aberrant right hepatic artery, but detailed video descriptions of the approach are lacking. This case report describes a step-&#173;by-&#173;step technical video in case of a replaced right hepatic artery. A 58-year-old woman presented with an incidental finding of a 1.7 cm pancreatic head mass. RPD was performed using the da Vinci Xi system and involves a robotic-assisted pancreatico- and hepatico-jejunostomy and open gastro-jejunostomy at the specimen extraction site. The operation time was 410 min with 220 mL of blood loss. The patient had an uncomplicated postoperative course and was discharged after 5 days. Pathology revealed a pancreatic head cancer. RPD is a feasible and safe procedure in case of a replaced hepatic artery when performed in selected patients in high-volume centers by experienced surgeons.

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 (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several ...

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body. With technological development, the robotic surgical system has shown its advantage in minimally invasive surgery and been increasingly applied in central pancreatectomy. However, reconstruction of the continuity of pancreas with end-to-end anastomosis after robotic central pancreatectomy has not been applied. In this study, we report surgical techniques for robotic central pancreatectomy with end-to-end anastomosis. The pancreas is reconstructed by duct-to-duct anastomosis of the pancreatic duct with a pancreatic stent inserted in the two stumps of pancreatic duct, and by end-to-end anastomosis of the pancreatic parenchyma. Compared with traditional central pancreatectomy with pancreaticoenteric anastomosis, this approach decreases the operative injury to the patient, and also conserves the integrity and continuity of the digestive duct and pancreatic duct. The robotic surgical system integrated with multiple instruments with flexible and precise movement is particularly suitable for the dissection and reconstruction of the pancreatic duct. We found that robotic central pancreatectomy with end-to-end anastomosis is safe and feasible, and we need more experience to evaluate its best indications and long-term outcomes.

The robotic central pancreatectomy with end-to-end anastomosis is feasible and safe for tumor in the pancreatic neck and proximal portion of pancreatic body. The operative techniques of this operation are presented.

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of ...

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.

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 ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

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

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

Robotic lateral pancreaticojejunostomy (RLPJ) may be used in patients with painful, morphine dependent, chronic pancreatitis and a dilated main pancreatic duct. We describe a standardized and reproducible technique for RLPJ, which includes transection of the gastroduodenal artery.

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of the pancreas. The aim of central pancreatectomy is to prevent postoperative life-long endocrine and exocrine insufficiency. The downside of central pancreatectomy is the high rate of postoperative pancreatic fistula, which is the main reason that many surgeons do not routinely use central pancreatectomy in eligible patients. Most studies report open or laparoscopic central pancreatectomy with a pancreatico-gastrostomy anastomosis in adults. This is the first description of a standardized approach to robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy reconstruction in an adolescent (16-year-old boy) with a pseudopapillary tumor in the body of the pancreas. The operation time was 248 min with 20 mL of blood loss. The postoperative course was uneventful except for the short-term medical treatment for a grade B pancreatic fistula. Robotic central pancreatectomy can be safely applied in selected patients in experienced centers.

Robotic central pancreatectomy may be used in selected patients in experienced centers. This protocol presents all steps and the feasibility of a robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy in a 16-year-old adolescent patient.

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of ...

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

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation 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 (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy

Laparoscopic pancreatoduodenectomy (LPD) is a demanding abdominal operation that necessitates meticulous surgical skills and teamwork. The management of the pancreatic uncinate process is one of the most important and difficult processes in LPD because of its deep anatomical location and difficult exposure. Complete resection of the uncinate process and mesopancreas has become the cornerstone of LPD. In particular, it is even more difficult to avoid positive surgical margins and incomplete lymph node dissection when the tumor is located in the uncinate process. No-touch LPD, which is an ideal oncological operation process fitting the "tumor-free" principle, has been reported by our group previously. This article introduces the management of the uncinate process in no-touch LPD. Based on the multi-angle arterial approach, in this protocol, the median-anterior and left-posterior approaches to the SMA are used to correctly deal with the important vascular structure, the inferior pancreaticoduodenal artery (IPDA), in order to ensure the safe and complete excision of the uncinate process and mesopancreas. For the achievement of the no-touch isolation technique in LPD, the pancreatic head and the blood supply to the duodenal region must be severed at the very early stage of the operation; after that, the tumor can be isolated intact, resection can be performed in situ, and finally, the tissue can be removed en bloc. This paper aims to show the distinctive ways to manage the uncinate process in no-touch LPD and investigate the viability and safety of this approach. Moreover, the technique may increase the R0 resection rate.

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).

Laparoscopic pancreatoduodenectomy (LPD) is a demanding abdominal operation that necessitates meticulous surgical skills and teamwork. The management of ...

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

Minimally invasive pancreatic resections are gaining popularity despite being technically demanding. However, in contrast to laparoscopic pancreatoduodenectomy (LPD), laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has not yet obtained wide acceptance. This could be attributed to the technical challenges involved in preserving the blood supply of the duodenum and bile duct.
This study describes and demonstrates all the steps of LDPPHR. A 48-year-old woman was diagnosed with a 3.0 cm x 2.5 cm pancreatic head cystic mass, which was detected unexpectedly. The surgery was performed using the 3D laparoscopy via an inferior infracolic approach. The operation lasted approximately 310 min with 100 mL of blood loss. Postoperatively, the patient experienced no complications and was discharged 5 days later. Pathology revealed intraductal papillary mucinous neoplasms.
LDPPHR via an inferior infracolic approach is feasible and safe when performed by experienced surgeons in selected patients with thin mesenteric fat layers. The described technique for LDPPHR via inferior infracolic approach should be well standardized and performed at high-volume centers with experienced surgeons in both open and laparoscopic pancreatology.

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.

Colonial Wig Pancreaticojejunostomy

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Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

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

Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy

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