Puestow procedure [Case 22]

Post-op Debrief

Watch the following videos for the operating surgeon's summary of the case.

Key points from this case

Key points from this case

When the pancreatic duct is very dilated, be sure you have correctly identified the correct structures. While 6-cm is the suggested length of longitudinal opening for the duct, always exercise judgment to determine what is appropriate for each situation.

Show Summary +

The key moments that the surgeons collectively identified preoperatively:

  • Preserve gastroepiploic vessels
  • Finding pancreatic plane, avoid splenic vein, artery, duodenojejunal flexure
  • Locating pancreatic duct
  • Adequate longitudinal ductotomy
  • Selecting length of jejunum for Roux loop
  • Pancreaticojejunostomy side-to-side anastomosis
  • Closing mesenteric defect

And that's what we performed. We did it through an open operation. Relatively small incision. I'm sure it could be tackled through a minimally invasive approach as well.

Her pancreatic duct was definitely very dilated. It can be a bit tricky but in this case it was very easy because it was really bulging through the pancreas and lesser sac. And in this case it was easy to open up the pancreas for about six or seven centimeters just with cautery. Out came a lot of pancreatic juice we looked inside the duct and saw nothing untoward or worrisome. Certainly there was nothing neoplastic looking. Most people suggest that the pancreaticojejunostomy should be large and or wide so that it doesn't recur, a stricture does not recur. And onto a Roux limb we created a side-to-side pancreaticojejunostomy in the lesser sac. We brought the Roux limb through a defect in the mesocolon and the operation went smoothly and this patient actually has done well. We'll have to see long term if it helps resolve her symptoms.

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Acknowledgements
Thank you to the HPB Surgeons who contribute their time and expertise. This content is made possible through educational grants from:
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Views and opinions expressed in all videos and module content are those of the individual surgeon and solely intended for surgical education purposes. We do not endorse any product, treatment or therapy.

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