Pancreatogastrostomy - general and visceral surgery

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  • Placing stay sutures on the pancreatic remnant

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    Note: The video joins the partial duodenopancreatectomy after completion of the resection phase.

    The reconstruction phase now starts with the pancreatic anastomosis. For this purpose, first place stay sutures in circular fashion on the pancreatic remnant. For the deepest telescope-type invagination of the pancreatic remnant possible, mobilize the latter some 3-4 cm distad.

    At the end of the resection phase, the portal vein arising from the confluence of the splenic vein and the superior mesenteric vein posterior to the pancreatic head is exposed.

  • Posterior gastrotomy

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    After checking for an appropriate location, place a purse-string suture (PDS 2-0) on the posterior gastric wall. Divide the posterior wall of the stomach within the purse-string suture such that the opening is smaller than the diameter of the pancreas. The trick is to best balance pancreas consistency, diameter and gastrotomy opening. Select the site of implantation such that the implantation will make the pancreatic remnant stand up and "hook" into the posterior gastric wall, as it were. The best seal possible is achieved when the pancreatic body is tightly enclosed by the gastric serosa.

  • Anterior gastrotomy

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    Next, perform a limited gastrotomy on the opposite anterior gastric wall between stay sutures.

  • Telescope-type invagination of the pancreatic remnant

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    With the stay sutures now pull the pancreatic remnant at least 3-4 cm into the stomach. With only slight traction on the pancreas slip the luminal mucosa over the pancreas with two forceps.

  • Suture fixation on the posterior gastric wall

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    Anchor the invaginated pancreas to the posterior wall of the stomach with interrupted sutures (PDS 3-0), taking extraductal deep parenchymal pancreatic and full- thickness gastric bites. Watch out for the pancreatic duct!

    Note: This offers the benefit of a wholly intragastric anastomosis including the needle tracts, which, unlike in pancreato- or pancreaticojejunostomy, drains the entire cut surface of the pancreas into the lumen. Another benefit is the option of endoscopic inspection of the anastomosis, e.g., for hemostasis, at any time.

  • Tying the purse-string suture, closing he gastrotomy, drainage

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    Tying the purse-string suture at the posterior gastrotomy site protects the anastomosis against traction. After placing a moist abdominal towel on the still-open stomach, fashion the other anastomoses (hepaticojejunostomy; duodenojejunostomy) first (neither shown). Next, place the gastric tube and close the anterior gastrotomy with a running suture, interrupted sutures, or with a 60 mm stapler (not demonstrated in the video). Finish by placing a ( lavage) drain to the pancreatic anastomosis posterior to the stomach.

    Note: After surgery, it is essential to watch for adequate gastric emptying (gastric tube, clinical monitoring!).