Laparoscopic Puestow’s for chronic pancreatitis in children

Chronic pancreatitis is a sequelae characterized by recurrent attacks of pancreatitis leading on to fibrosis and calcification of both ductal and parenchymal elements of pancreas. Most of these if left untreated at the right time will lead on to burnt out pancreas with complete atrophy of the parenchyma leading on to endocrine/exocrine insufficiency. The pain in such patients is most likely due to ductal hypertension, parenchymal hypertension and head mass causing perineural inflammation.

Puestows procedure (longitudinal pancreaticojejunostomy) is the surgery of choice in select patients with ductal hypertension where decompression of the duct provides symptomatic relief. Performance of such procedures in children by minimal access laparoscopic method is still evolving.

Operative technique

Under General anesthesia, supine position with legs spread out and the primary operating surgeon standing between the legs. With a slight reverse trendlenberg tilt, 10mm optical port in the umbilicus is made and two 5mm lateral working Para-rectal ports slightly above the level of umbilicus in the mid clavicular line is introduced. Pneumoperitoneum using carbondioxide is created at 10-12mm Hg.

As a first step, lesser sac was entered by opening the gastrocolic omentum with harmonic scalpel. A silk stitch was taken on the posterior aspect of stomach and is anchored to the anterior abdominal wall to facilitate retraction. Following which the anterior, superior and inferior surface of the pancreas was bared of all attachments and soft tissues. Localization of the pancreatic duct (PD) is the rate-limiting step in the entire procedure. The pancreatic duct is completely laid open with electrocautery from head region till tail. The pancreatic duct is flushed with saline after removing all the intra-ductal stones.

A 40 cm roux limb is taken retro-colic and ostomy on the jejunum corresponding to the length of the duct length using monopolar hook is made extracorporeally. A single layer side-to-side Pancreatico-jejunostomy is done using 3-0 mersilk from pancreatic head to tail.

Further Reading:

Meehan JJ, Sawin R.Robotic lateral pancreaticojejunostomy (Puestow).J Pediatr Surg. 2011 Jun;46(6):e5-8.

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