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232 Atlas of Gastrointestinal Surgery: Pancreas
The operative procedure can be done either through a midline or bilateral subcostal
incision. Once the abdomen is entered, the pancreas is exposed by removing the
greater omentum from the transverse colon (2). This means of entering the lesser sac is
preferred over that in which the omentum is just divided in its midportion. The entire
pancreas is exposed and palpated through the lesser sac. The duodenum is then kocherized, and the head and uncinate process carefully palpated. Once the tail, body, neck,
head, and uncinate process of the pancreas have been exposed, the dilated pancreatic duct frequently can be identified by finger palpation along the anterior surface of the
gland. Its position is confirmed by aspirating with a 20-gauge needle and a 10-ml
syringe (3). At times, it may be surprisingly difficult to identify a dilated pancreatic
duct, which has been demonstrated preoperatively by computed tomography (CT)
scan or endoscopic retrograde cholangiopancreatography. Intraoperative ultrasound will
be of help in these situations.
Omentum
2
Transverse colon
Longitudinal Pancreaticojejunostomy: Puestow Procedure 233
3
Aspiration of
dilated duct
Once clear pancreatic
secretions are obtained, using
Dilated pancreatic duct
Divided omentum
Spleen
Stomach
the electrocautery a pancreatotomy is made along the needle
down into the dilated pancreatic
duct. The needle is then
removed and a right-angle
clamp is inserted into the
dilated duct. The duct is
filleted open for the entire
length using the electrocautery (4).
Pancreas
Dilated pancreatic duct
4
234 Atlas of Gastrointestinal Surgery: Pancreas
Several studies have demonstrated that the pancreaticojejunostomy needs to be at least 6 cm in length to maximize good,
long-term results. Once the duct is filleted open, an attempt
should be made to pass a Bakes dilator carefully into the proximal pancreatic duct, through the ampulla, and into the duodenum (5). If this is not possible, some surgeons recommend
performing a duodenotomy and a sphincteroplasty. Other
surgeons feel strongly that this is an indication for either the
Frey or Beger procedures. (See “Local Pancreatic Head
Resection with Lateral Pancreaticojejunostomy” and
“Duodenal Preserving Pancreatectomy for Chronic Pancreatitis”
respectively.) If the gall bladder is still in place, most pancreatic
surgeons feel that a cholecystectomy should be performed at the
same time a Puestow procedure is carried out, even though definite
5
Bakes dilator in
pancreatic duct
gall bladder pathology may not have been demonstrated.
A Roux-en-Y jejunal loop 60 cm in length is constructed. The jejunum is divided just distal to the
ligament of Treitz (6). The mesentery is then further divided to provide for mobility in the Roux-
en-Y loop. Following division of the bowel, the distal end of the jejunum, which will become
Linear stapler
the proximal end of the Roux-en-Y loop, is closed with an inverting layer of 3-0 silk
sutures (7).
Mesentery
6
7
Longitudinal Pancreaticojejunostomy: Puestow Procedure 235
8
Opening in
transverse
mesocolon
Middle colic a.
Transverse colon
Roux-en-Y
jejunal loop
The loop is then brought up into the lesser sac through a rent in the transverse mesocolon, either
to the right or to the left of the middle colic artery (8).
236 Atlas of Gastrointestinal Surgery: Pancreas
9
Staple line
Roux-en-Y
jejunal loop
Enteric continuity is reestablished by an end-to-side
jejunojejunostomy.
The end of the proximal jejunum is anastomosed to the side
of the Roux-en-Y loop, approximately 60 cm from the closed end
of the loop. The small bowel anastomosis is performed in the classic
Inner layer of
posterior row
Outer layer of
posterior row
inner layer using a Connell type stitch (11).
fashion with an outer interrupted layer of 3-0 silk and an inner continu-
ous layer of 3-0 synthetic absorbable sutures. After the outer interrupted
posterior row of silk sutures is placed, the previously placed staple line is excised
using the electrocautery (9). The inner posterior layer of the anastomosis is then
placed using a continuous locking suture (10). This suture is continued as the anterior
Inner layer of
anterior row
10
11
The anastomosis is completed with an outer row
of silk sutures on the anterior layer of the anastomosis
(12). The rent in the small bowel mesentery can be
closed with either interrupted 4-0 silk sutures, or with a
continuous suture of 4-0 silk (13).
Once the Roux-en-Y loop has been delivered into the
lesser sac via the retrocolic approach, the longitudinal
side-to-side pancreaticojejunostomy is performed.
When there is a very large dilated duct, 1 cm or greater
Longitudinal Pancreaticojejunostomy: Puestow Procedure 237
Outer layer of
anterior row
in diameter, demonstrated here, the anastomosis is performed in two layers—an outer interrupted layer of 30 silk and an inner continuous layer of 3-0 synthetic
absorbable sutures. If the duct is dilated, but is less than
1 cm in diameter, the anastomosis is generally performed
with only the outer interrupted layer of 3-0 silk, without placing an inner continuous layer. The two-layer anastomosis is started by placing the outer layer of interrupted 3-0 silk sutures
between the antimesenteric surface of the jejunal loop and the
inferior margin of the pancreatotomy (14).
Pancreatic duct
epithelium
12
Roux-en-Y
jejunal loop
Mesenteric
defect
Pancreatic
parenchyma
Roux-en-Y
jejunal loop
14
Spleen
End-to-side
jejunojejunostomy
13
238 Atlas of Gastrointestinal Surgery: Pancreas
15
Two-layer anastomosis
Outer layer
The sutures of the outer layer on the pancreatic side come out in pancreatic
parenchyma adjacent to the duct epithelium
(15). Once this layer has been completed, an enterotomy is made in the jejunal
loop (16). The inner layer is then started,
utilizing an over-and-over locking stitch of
synthetic absorbable material (17). This
stitch passes through the pancreatic duct
epithelium (15, 17).
16
Enterotomy
Inner layer
17
18
Longitudinal Pancreaticojejunostomy: Puestow Procedure 239
Pancreas
Inner layer
The inner layer can
then be continued
along the superior line
of the anastomosis utiliz-
ing either an over-and-
over stitch as pictured here
(18), or the Connell stitch.
This layer ensures good mucos-
al-to-mucosal approximation
Roux-en-y
jejunal loop
between the pancreatic duct and the
jejunal loop (19). The anastomosis is com-
pleted by placing the outer row of silk sutures along the
superior aspect of the pancreaticojejunostomy (19, 20).
Two-layer anastomosis
Outer layer
19
20
240 Atlas of Gastrointestinal Surgery: Pancreas
This anastomosis ensures excellent decompression of the pancreatic duct into the jejunal loop with good approximation of
the dilated pancreatic duct and the jejunal lumen (21).
When the pancreatic duct is less than 1 cm in diameter,
only a single layer of interrupted silk sutures is used to perform the anastomosis. The interrupted silk suture layer passes through the ductal epithelium. One has to place the inferior layer, however, in such a fashion that the silk suture knots
are on the outside (22).
Pancreas
Alternate: Duct less than 1 cm in diameter
21
Jejunum
Duct
22
Liver
Stomach
Omentum
Sagittal section
23
Pancreas
Duct
Duodenum
Transverse
mesocolon
Duodenum
Longitudinal Pancreaticojejunostomy: Puestow Procedure 241
Spleen
Stomach
Roux-en-Y
jejunal loop
Pancreas
Roux-en-Y
Transverse
colon
jejunal loop
The procedure is
completed by tacking
the jejunal loop to the
rent in the transverse
mesocolon with interrupted 4-0 silk sutures.
The Puestow procedure
ensures excellent dependent
drainage of the pancreatic duct
into a defunctionalized jejunal loop
that resides nicely in the lesser sac
passing down through the trans-
Transverse
colon
24
Transverse
mesocolon
tacked to
jejunal loop
verse mesocolon to rejoin the
enteric pathway (23, 24).
The anastomosis is drained
with two, closed-suction
Silastic drains. Leakage from this
anastomosis is very unusual.
End-to-side
jejunojejunostomy