Laparoscopic Pancreaticoduodenectomy / Whipple of Duodenal GIST
This video was presented at International Hepatopancreatobiliary Association World Congress 2024 Cape Town South Africa.
- This case highlights a surgical removal of a duodenal Gastrointestinal stromal tumour(GIST). A duodenal GIST invading the pancreas is an uncommon tumour. Surgical resection is required as part of curative treatment.
- The technical difficulty in this case is the reconstruction of the pancreaticojejunostomy (pancreas to small intestine) where the soft pancreas and small pancreatic duct increases the risk of a joint leak. Note that Dr Thng uses a double handed technique to overcome angle limitations of laparoscopic surgery.
- The hepaticojejunostomy (bile duct to small intestine) was also performed in a small caliber bile duct. Note that Dr Thng uses an interrupted technique to reduce stricture/tightening of the joint.
Transcript
0:00 This video showcases a laparoscopic
0:02 reverse procedure performed for dual
0:04 gist.
0:06 The patient is a 73 year old female who
0:08 was previously well. She presented with
0:11 fever and abdominal pain secondary to a
0:13 liver abscess.
0:15 CT scan showed an incidental 5.4 cm
0:18 heterogeneous lesion in the pancreatic
0:20 doino groove. The case was discussed at
0:22 tumor board and recommended for reverse
0:24 resection.
0:27 The operating theater is set up with the
0:29 patient in French position.
0:32 A 10 mm per umbilical port is used to
0:35 gain entry into the abdomen. Additional
0:37 10 mm ports are placed in the flanks and
0:40 5 mm pots in the hypochondrium.
0:44 The gastrocolic ligament is divided to
0:47 enter the lesser sack. The right
0:49 gastroepipolic vessels are divided
0:51 followed by the right gastric artery.
0:55 D1 is transacted with a surgical
0:57 stapler.
0:59 A cautious maneuver is performed by
1:01 dividing the paronial attachments along
1:03 the lateral border of the dordinum.
1:12 The gastro trend of Henley is divided.
1:16 Dissection is continued along the
1:18 inferior border of the pancreas.
1:22 Station 8A lymph node is identified
1:24 above the command hypatic artery and
1:26 dissected off. The gastro artery is
1:29 divided.
1:36 The hippetto dorina ligament is
1:38 dissected.
1:51 The common buck is clammed and divided.
2:08 A retropancetic tunnel is created
2:10 between the pancreas and the portal
2:12 vein.
2:23 The pancreas neck is translated anterior
2:25 to the portal vein using a harmonic
2:26 scapo.
2:35 The pancreatic duct is transacted with
2:37 scissors.
2:39 The junum is put through to the
2:41 retroletic compartment and divided about
2:43 20 cm from the DJ flexure.
2:47 Further retroparitinal dissection is
2:49 performed and the superior mentric
2:51 artery skeleton knife.
2:59 The pancreatical joinostomy is performed
3:01 using proline 4 for the anterior and
3:03 posterior sosa.
3:39 Deduct to mucosal layer is performed
3:41 using PDS50. F4.
4:07 A six French infant feeding tube is used
4:09 to stand the pancreatic duct.
5:36 The hippetto jinostomy is performed
5:38 using PDS50.
7:20 Novial and TCL glue is applied over the
7:22 PG and HJ an estimis.
7:25 The falsif ligament and t- cell glue is
7:27 placed over the GDS thumb.
7:29 The permilical incision is extended and
7:32 the specimen delivered. The
7:34 gastroenostomy is accelerized and
7:36 performed with PDS 40. The abdominal
7:38 fasia is closed with loop PDS followed
7:40 by skin closure with monochril.
7:44 Histologology showed a 5.4 cm PT3 dorino
7:47 G with a low motic rate. 11 leaf nodes
7:50 and resection margin were not involved
7:52 by tumor. This is a stage two g and the
7:55 patient is on followup with medical
7:56 oncology for adjuvenate.
0:02 reverse procedure performed for dual
0:04 gist.
0:06 The patient is a 73 year old female who
0:08 was previously well. She presented with
0:11 fever and abdominal pain secondary to a
0:13 liver abscess.
0:15 CT scan showed an incidental 5.4 cm
0:18 heterogeneous lesion in the pancreatic
0:20 doino groove. The case was discussed at
0:22 tumor board and recommended for reverse
0:24 resection.
0:27 The operating theater is set up with the
0:29 patient in French position.
0:32 A 10 mm per umbilical port is used to
0:35 gain entry into the abdomen. Additional
0:37 10 mm ports are placed in the flanks and
0:40 5 mm pots in the hypochondrium.
0:44 The gastrocolic ligament is divided to
0:47 enter the lesser sack. The right
0:49 gastroepipolic vessels are divided
0:51 followed by the right gastric artery.
0:55 D1 is transacted with a surgical
0:57 stapler.
0:59 A cautious maneuver is performed by
1:01 dividing the paronial attachments along
1:03 the lateral border of the dordinum.
1:12 The gastro trend of Henley is divided.
1:16 Dissection is continued along the
1:18 inferior border of the pancreas.
1:22 Station 8A lymph node is identified
1:24 above the command hypatic artery and
1:26 dissected off. The gastro artery is
1:29 divided.
1:36 The hippetto dorina ligament is
1:38 dissected.
1:51 The common buck is clammed and divided.
2:08 A retropancetic tunnel is created
2:10 between the pancreas and the portal
2:12 vein.
2:23 The pancreas neck is translated anterior
2:25 to the portal vein using a harmonic
2:26 scapo.
2:35 The pancreatic duct is transacted with
2:37 scissors.
2:39 The junum is put through to the
2:41 retroletic compartment and divided about
2:43 20 cm from the DJ flexure.
2:47 Further retroparitinal dissection is
2:49 performed and the superior mentric
2:51 artery skeleton knife.
2:59 The pancreatical joinostomy is performed
3:01 using proline 4 for the anterior and
3:03 posterior sosa.
3:39 Deduct to mucosal layer is performed
3:41 using PDS50. F4.
4:07 A six French infant feeding tube is used
4:09 to stand the pancreatic duct.
5:36 The hippetto jinostomy is performed
5:38 using PDS50.
7:20 Novial and TCL glue is applied over the
7:22 PG and HJ an estimis.
7:25 The falsif ligament and t- cell glue is
7:27 placed over the GDS thumb.
7:29 The permilical incision is extended and
7:32 the specimen delivered. The
7:34 gastroenostomy is accelerized and
7:36 performed with PDS 40. The abdominal
7:38 fasia is closed with loop PDS followed
7:40 by skin closure with monochril.
7:44 Histologology showed a 5.4 cm PT3 dorino
7:47 G with a low motic rate. 11 leaf nodes
7:50 and resection margin were not involved
7:52 by tumor. This is a stage two g and the
7:55 patient is on followup with medical
7:56 oncology for adjuvenate.