Robotic Cyst Gastrostomy and Roux-en-Y Cyst Jejunostomy for a Bilobed Walled-Off Pancreatic Necroma.

backgroundWalled-off pancreatic necrosis (WON) represents delayed sequelae of necrotizing pancreatitis, generally developing in 5-15% of cases 4 weeks after the initial attack (Boškoski and Costamagna Ann Gastroenterol 27(2):93-94, 2014). They are characterized by a well-circumscribed, encapsulated collection of necrotic parenchyma with variable degree of gland liquefaction (Boškoski and Costamagna Ann Gastroenterol 27(2):93-94, 2014, Khreiss et al. J Gastrointest Surg 19(8):1441-1448, 2015). Although a significant number of WONs are asymptomatic and resolve spontaneously, some will ultimately require endoscopic or surgical intervention (Costa et al. Br J Surg 101(1):e65-e79, 2014). In this video, we demonstrate a robotic cyst gastrostomy and Roux-en-Y cyst jejunostomy performed for two simultaneous and complex WONs.

methodsA 71-year-old female presented with a history of drug-induced necrotizing pancreatitis 2 years prior to surgical referral. This was complicated by the development of two separate WONs in the head and the body of the pancreas measuring 6.5 × 6.5 cm and 9.7 × 7.3 cm respectively, with significant necrotic debris. Due to the continued growth of both WONs and progressive discomfort, the decision was made to pursue simultaneous internal surgical drainage of both lesions using a minimally invasive approach. The procedure was performed using the DaVinci Si HD robotic Surgical System (Intuitive Surgical Inc.) and lasted 180 min with a total blood loss of approximately 25 ml. A cyst gastrostomy and a Roux-en-Y cyst jejunostomy were performed for the body and head WONs respectively following debridement of the necrotic tissue. The patient tolerated the procedure well, had an uneventful postoperative course, and was discharged on post-operative day 7.

conclusionThis case demonstrates that the robotic approach can be a safe and effective modality for the management of technically challenging and complex WONs. Although endoscopic or video-assisted retroperitoneal drainage procedures are alternative treatment modalities for WON, the complexity and size of this bilobed WON, coupled to the significant amount of necrotic debris and the need for a concomitant cholecystectomy, made this case ideal for internal surgical drainage via the robotic approach, since it allowed for definitive treatment with fewer reinterventions (Khreiss et al. J Gastrointest Surg 19(8):1441-1448, 2015).