“Tricks of the Trade” robotic pancreaticojejunostomy

Background: Several methods of pancreaticojejunostomy (PJ) have been shown to decrease complications after whipple. With the increased utilization of the robotic platform, it is important to refine the technique. Herein, we discuss variations in technical aspects of robotic PJ. Methods: Multiple methods of PJ that are employed depending on the particular anatomy of the patient, gland texture, and size of the pancreatic duct. One of the most common techniques utilized in both open and robotic PJ is the modified Blumgart technique. Three 3-0 silk mattress sutures (cut to 7cm) are placed through the gland and tied down before the duct to mucosa is performed. This approximates the jejunum to the pancreas and effectively alleviates tension off the inner duct-to-mucosa layer. The middle mattress suture is placed straddling the pancreatic duct (technique 1, figure) or can be eliminated altogether (technique 2). Care must be taken not to cause narrowing of the pancreatic duct when tying this suture. To facilitate exposure for small pancreatic ducts, a 1-millimeter cardiac vascular probe is used to locate, expose, and dilate the pancreatic duct. Typically, all ducts can be dilated to accommodate a four-french pancreatic stent, if desired. Other methods such as running and dunking methods for the outer capsule-to-serosa layer (technique 3) can be used as appropriate. We've found these method to result in equivalent grade B/C fistula rate even with a higher proportion of soft glands (n=70). Conclusion: We've found these techniques of PJ to be useful in minimizing fistula rates and optimizing outcomes.