THE USE OF BARBED SUTURE WITHOUT FASHIONING THE “CLASSIC” WIRSUNG-JEJUNOSTOMY IN A MODIFIED ROBOTIC END-TO-SIDE INVAGINATED PANCREATOJEJUNOSTOMY

Aims: The treatment of the pancreatic stump is a critical step of pancreaticoduodenectomy (PD) because leaks from this anastomosis incur major morbidity and mortality. Robotic technologies can facilitate minimally invasive surgery in challenging abdominal procedures such as pancreato-jejuunostomy, increasing their widespread. However, one of the major limitations of this application could be the lack of a tactile feedback, that can lead to pancreatic parenchyma laceration during knots ligation, or during traction in the continuous suturing techniques. Moreover, a Wirsung-jejunostomy is not always easy to be fashioned, especially in case of very small diameter of the duct. We herein describe the technical details of a robotic modified end-to-side, invaginated robotic pancreatojejunostomy (RmPJ) with the use of barbed suture and without fashioning the “classic” Wirsung-jejunostomy. Methods: The RmPJ technique consists of a particular double layer suture: the outer layer is a monofilament absorbable running barbed suture (using 3-0 V-Loc) to reach the invagination of the pancreatic stump; then a small enterotomy is made in the jejunum exactly opposite respect to the location of the pancreatic duct, and a stent (usually 5 Fr) is inserted inside the duct. The internal layer is another row of 3-0 V-Loc running suture, placed between the pancreatic capsule/parenchyma and the seromuscular layer of the jejunum. Results: With this technique, we have experienced that the two layers of running barbed suture are at lower risk of parenchymal damage because they maintain the suture’s tension at any passage, avoiding the need of tractions and of multiple knots tying. Furthermore, the absence of a “classic” Wirsung-jejunostomy, as the duct and the enterotomy are only faced and stented, allows to easily reproduce this technique in every kind of pancreas and in Wirsung ducts of every size. The post-operative course was uneventful and the patient was discharged on POD 7th, without developing any fistula. Conclusions: In our experience the RmPJ technique resulted to be fast, safe and reproducible in any kind of pancreatic duct and parenchyma. Its application on a large number of patients is needed to draw conclusions.