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Distal duodenectomy extended to first loops of jejunum. (A) Kocher maneuver; (B) tattoo identifications and transection at distal margin; (C) jejunum dissection; (D)Treitz ligament dissection.
Source publication
Angiodysplasia of the duodenum is a rare disorder, often requiring surgical resection. Technical difficulties have made the use of the minimally invasive approach uncommon. Herein, we present a subtotal pancreas-preserving duodenectomy using robotic assistance.
The patient is a 60-y-old female with a long medical history including chronic gastroint...
Contexts in source publication
Context 1
... was done using the monopolar hook and the Harmonic device (Ethicon Endo-Surgery, Inc; Cincinnati, OH). A Kocher maneuver was then performed to assess the duodenum and pan- creas ( Figure 2A). The transverse colon was then re- tracted upward and the ligament of Treitz was exposed. ...
Context 2
... transverse colon was then re- tracted upward and the ligament of Treitz was exposed. The Indian ink tattoo placed earlier on the jejunum was identified approximately 1 m distally from the Treitz (Figure 2B), demarcating the distal portion of the dis- eased segment of the bowel. Using an Endo GIA (Co- vidien, Norwalk CT) stapler, the small bowel was tran- sected distally to the tattoo. ...
Context 3
... an Endo GIA (Co- vidien, Norwalk CT) stapler, the small bowel was tran- sected distally to the tattoo. Using the Harmonic device (Ethicon Endo-Surgery Inc, Cincinnati OH), the proxi- mal jejunum was dissected, detaching it from the mes- entery ( Figure 2C). The ligament of Treitz ( Figure 2D) was then taken down and the duodenojejunal flexure and first jejunal loops were retracted on the right side of the transmesocolon posteriorly to the superior mesen- teric vessels. ...
Context 4
... the Harmonic device (Ethicon Endo-Surgery Inc, Cincinnati OH), the proxi- mal jejunum was dissected, detaching it from the mes- entery ( Figure 2C). The ligament of Treitz ( Figure 2D) was then taken down and the duodenojejunal flexure and first jejunal loops were retracted on the right side of the transmesocolon posteriorly to the superior mesen- teric vessels. The third portion of the duodenum was then detached from the uncinate process and ventral portion of the head of the pancreas using a monopolar hook. ...
Citations
... Nevertheless, PPTD is a relatively novel technique with an early adoption learning curve that appears to already be comparable to Whipple PD. Rare case reports of laparoscopic and robotic procedures bring the promise that newer technologic advances will reduce the technical challenges associated with the meticulous dissection necessary when separating the duodenum from the pancreas [8, 9]. In experienced hands and centers, PPTD may provide an additional tool in the armamentarium of surgeons for the resection of benign duodenal lesions. ...
Pancreas sparing total duodenectomy (PSTD) is an exceedingly rare procedure that is performed mostly for benign disease, widely involving the duodenum, that cannot be treated otherwise. PSTD requires meticulous dissection as well as reconstruction of both biliary and pancreatic drainage. Despite these technical aspects appear to be ideal for robotic assistance, robotic PSTD has not been described yet.
Robotic PSTD was successfully performed in two patients. In both patients biliary and pancreatic drainage were reconstructed on the second jejunal loop, which was pulled in the duodenal bed. In the first patient, gastro-jejunostomy was performed on the blind end of the neo-duodenum (Billorth I type gastric reconstruction). In the second patient, gastro-jejunostomy was achieved in an antecolic position, 40 cm downstream the neo-ampulla in the second patient (Billorth II type gastric reconstruction). In both patients, indication to PSTD was duodenal polyps not amenable to endoscopic removal. The first patient suffered from prolonged delayed gastric emptying, but she is currently doing well 5 years and beyond after the procedure. The second patient complained of mild delayed gastric emptying that resolved spontaneously. He is now doing well 5 months after surgery.
We have shown the feasibility of robotic PSTD in what we believe to be a world premiere. Further experience is required to refine the procedure and improve outcomes.
Background:
Although organ-preserving operations are regarded as effective strategies for duodenal gastrointestinal stromal tumors (GISTs), laparoscopic partial sleeve duodenectomy (lap PSD) has not been fully evaluated. The aims of this study were to evaluate the effectiveness and technical feasibility of lap PSD.
Study design:
Between January 2011 and March 2016, we reviewed 13 patients who underwent laparoscopic approach among 22 patients who underwent PSD. PSD for the infra-ampullary lesions was defined as infra-ampullary duodenal resection including the first portion of the jejunum. After resection, all patients underwent reconstruction via side-to-side duodenojejunostomy.
Results:
The total mean operation time was 273 min (range 160-346 min), and estimated mean blood loss was 80 ml (range scanty-200 ml). One patient was converted to open laparotomy because of mesocolonic tumor involvement. The median postoperative hospital stay was 10.5 days (range 4-36 days). There were no postoperative mortalities. Postoperative complications included 2 instances of delayed gastric emptying (DGE), 1 duodenojejunostomy stricture, and 2 intestinal obstructions. No patient was treated with adjuvant therapy. One patient experienced hepatic metastasis 28 months after surgery during a mean follow-up period of 48.6 months.
Conclusion:
Lap PSD might be an oncologically effective strategy for duodenal GIST, and the laparoscopic approach is a technically feasible and appealing surgical modality in terms of safety and perioperative results. However, DGE and anastomosis strictures are concerns for postoperative complications, which need to be further investigated.
