Robotic Laparoscopic Transgastric Pseudocystogastrostomy and Necrosectomy
May 26, 2012
Pier C. Giulianotti (Chicago – USA) Subhashini Ayloo (Newark – USA)
Disease: Infected pancreatic pseudocyst after acutenecrotizing pancreatitis.
Age: 34
ASA score: 1
History: a 34-year-old gentleman with the past medical history of alcoholism complicated by acute pancreatitis, which is of the severe type further complicated by infected pseudocyst. The patient after an acute necrotizing pancreatitis developed a pseudocyst suspected for infection, and endoscopy was attempted to drain endoscopically transgastrically, putting a small stent through the opening in the stomach, but the persistence of the pseudocyst and signs of infection showed that probably the endoscopic treatment failed.
Description: Trocars: Open Hasson technique through the umbilicus. Once the pneumoperitoneum is established, we are looking around with the scope. There are some minor adhesions but we can place more trocars for the procedure, two 8-mm size trocars are placed in the right upper quadrant and then one in the left upper quadrant, and another assistant port is placed on the right side of the umbilicus.
Steps:
1 – The stomach is displaced anteriorly for the presence of the pseudocyst that is compressing. An ultrasound scanning of the pancreas with a laparoscopic probe is performed.
2 – The anterior aspect of the stomach is opened robotically, and the small stents that were positioned endoscopically are removed.
3 – Purulent material is evident. The opening is enlarged with a longitudinal stapler, in order to endure communication between the posterior wall of the stomach and the pseudocyst.
4 – The necrotic material that is placed into an endobag and extracted. After repeated procedure, debridement is achieved. Pseudocyst is checked and Now with irrigation, we are checking inside the pseudocyst.
The procedure allowed a satisfactory including debridement and creation of a larger communication between the stomach and the pseudocyst.
Blood loss has been no more than 50 cc.
