Technique description
  • Technique Description
    • The two layer, mucosa-to-mucosa without stent technique is one of many techniques that can be used to perform the pancreaticojejunostomy.
    • The principle of the mucosa-to-mucosa anastomosis is intended to reduce the risk of post-operative stricture, and the two layer technique is intended to reduce the risk of post-operative anastomotic leaks. Even for very small pancreatic ducts and normal pancreatic parenchyma, a stent is not 'necessary' for post-operative patency or leaks.
    • Absorbable sutures are important for the inner layer; non-absorbable sutures would be acceptable for the outer layer.
    • Surgical operating loupes with magnification of 2.5X to 4X greatly facilitates the precise placement of the fine sutures. In addition to adequate OR lighting, a bright headlight helps define the actual anatomy.
    • The full length Whipple case where this technique is utilized can be found here.
  • Key Points
    • The jejunostomy should be kept as small as possible to accommodate the pancreatic duct.
    • To avoid tearing or cracking of the parenchyma, sutures are placed following the curve of the needle and avoiding torquing; knots are tied with sufficient but not excessive tension.
    • The discrepancy between the small circumference of the pancreatic duct, and the relatively large circumference of the cut surface of the pancreas, requires that the pancreatic sutures be placed in a radial fashion.
    • An instrument to demonstrate the lumen can be helpful in the placement of sutures (i.e. a pancreatic duct probe or right-angled instrument).
    • Adjunctive measures such as stents (internal or externalized) or biologic glues or drains should not be necessary with a well-constructed two layer mucosa-to-mucosa pancreaticojejunostomy.

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