Pancreaticojejunostomy (PJ) is a pivotal procedure in pancreaticoduodenectomy (PD), often fraught with complications such as postoperative pancreatic fistula (POPF). This brief report introduces a novel robotic PJ technique that incorporates a self-expandable metallic stent, demonstrating its application through video reports. The method utilises the Da Vinci Xi robotic system and the WallFlex™ Biliary RX Stent, aimed at enhancing anastomotic support, particularly in high-risk cases associated with soft pancreatic texture and narrow duct diameter (less than 3 mm).

Technique Overview

The innovative approach employs a modified Seldinger technique for the deployment of the stent and completes the anastomosis using barbed sutures. The self-expandable stent adapts dynamically to the pancreatic duct, reducing tension and improving ductal drainage during the crucial postoperative phase, without the need for balloon expansion or fluoroscopy. This technique presents an advantage over traditional stenting methods, particularly in minimally invasive settings.

Study Design and Patient Selection

The study targeted patients with resectable tumours in the pancreatic head, periampullary region, or duodenum, who had no contraindications for anaesthesia or minimally invasive surgery. The Huscher-modified anastomosis was applied to all high-risk PD cases as classified by the International Study Group of Pancreatic Surgery (ISGPS), specifically targeting patients with soft pancreatic glands and duct diameters under 3 mm.

Surgical Instrumentation and Procedure

Using the Da Vinci Xi robotic system, the surgical setup involves a standard port placement with four robotic ports and two laparoscopic ports. The WallFlex™ RX Biliary Fully Covered Stent was utilized, featuring a multi-wire braid construction that ensures flexibility, radial force, and full-length radiopacity for improved visibility.

The surgical technique comprises several key steps:
1. A continuous running suture is made between the inferior side of the pancreatic stump and the jejunum.
2. The WallFlex™ stent is introduced via a modified Seldinger wire technique.
3. A guidewire is advanced through a needle inserted into the abdomen, followed by the placement of a blunt cannula.
4. The stent is then deployed into the Wirsung duct, ensuring adequate depth and securing it in place.
5. The anastomosis is completed with a continuous running barbed suture, and in certain cases, a layer of U-shaped stitches is added for additional security.

Postoperative Outcomes

The mean time for completing the PJ was reported at 50 minutes, with no signs of pancreatic leaks observed in the two cases evaluated. Patients were discharged by the tenth postoperative day, and follow-up scans at three months confirmed the stent’s presence in situ.

Discussion and Conclusion

The use of self-expandable stents is highlighted as a promising innovation for reducing POPF rates. Unlike traditional methods, the self-expandable stent provides dynamic adaptability, minimizing anastomotic tension and potentially lowering intraductal pressure, which is crucial for preventing complications. The technique’s reliance on robotic advantages—such as enhanced dexterity and visualisation—improves anastomotic precision while addressing the limitations associated with conventional stenting.

Overall, this report emphasizes the feasibility and benefits of integrating advanced robotic surgery with novel stenting techniques to optimize outcomes in Pancreaticojejunostomy. Future studies with larger patient populations are necessary to validate the effectiveness of this innovative approach.

READ MORE… https://link.springer.com/article/10.1007/s11701-025-02216-5

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