Introduction

According to revised Atlanta criteria, pancreatic pseudocyst (PP) is a chronic (>4 weeks) fluid collection within pancreatic parenchyma or adjacent space of pancreas which has no solid debris [1]. Pancreatic pseudocyst is consequence of acute pancreatitis in most cases. However, it may be consequence of chronic pancreatitis, pancreatic trauma, or pancreatic operation [2].

There are variety of clinical manifestations from asymptomatic to appearance of complications. Symptoms can be pain, nausea, and vomiting. Sometimes we can see upper gastrointestinal bleeding. Infection, hemorrhage, and rupture of cyst are the most common complications of PPs [3, 4].

Surgery has been main treatment method for PP for nearly a century from the first surgically internal drainage in 1921 [5]. Endoscopic internal drainage emerged from 1975. After being modified and developed, the latter shows that its efficacy of PP resolution was similar to that of surgery and this technique’s complications were comparable to surgery. In addition, endoscopic therapy had benefits of hospitalization, mental health, and cost when compared with surgery [6,7,8]. Currently, surgery still plays an important role in the management of PP. Typically, surgical treatment includes surgical drainage (internal and external) and excision. Both can be done by open or laparoscopic surgery. This chapter focuses on technically laparoscopic internal drainage.

Patient Selection

Because of the benefits of nonoperative intervention, such as endoscopic internal drainage and percutaneous external drainage, indication of surgical internal drainage is limited at present. This technique is indicated when other drainage procedures are a failure or cannot perform. Patients with recurrent pseudocyst are also suitable for this technique and patients with enteric obstruction or biliary obstruction are suitable as well.

One important thing we need to check carefully before doing surgical internal drainage is the matureness of PP’s wall. Appropriate time for this technique is usually after 6 weeks and thickness is more than 3 mm as well.

Procedure

Operating Room Setup, Patient Positioning, and Surgical Team

Like other laparoscopic surgery, a flexible table is required to change the patient’s position during the operation. This is necessary because it can help creating better exposure owing to gravity. Cautery system should be prepared while energy system such as harmonic scalpel or ligasure is rarely needed. Ideally, there are two monitors located at the head of the bed over both shoulders’ side. One is for the surgeon and scrub nurse and another is for assistants. When lack of facility, given just one monitor, the placement should be on the left side of the patient.

Patient’s position is decubitus with slight head up. As mentioned, head up help us having better view resulting from gravity retraction. Patient’s legs may be split to make space for camera man or kept close to each other. Arms are usually tucked to create free spaces for surgeon, assistants, and scrub nurse’s activities. Team is set up as in Fig. 1.

Fig. 1
An image of a set up of personnel in a surgical procedure. The nurse is behind the surgeon and the camera man stays between the thighs of the patient. The monitor is placed above the head.

Personnel setup

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Technique

Trocar Placement

First trocar is 12 mm in size which is placed at infra-umbilicus by close technique or Hasson technique. However, consequence of intra-abdominal inflammation usually presents, we prefer to use Hasson technique. One more 12 mm trocar and two 5 mm trocars are placed as in Fig. 2.

Fig. 2
An image of the trocar position of a patient in a surgical operation.

Trocar position

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Exposure of Pancreatic Pseudocyst

There are two ways to enter the lesser sac to expose PP. One is dividing gastrocolic ligament below gastroepiploic vessels. We have to free enough space for PP’s wall for anastomosis. In this way, we can do either cystogastrostomy or cystojejunostomy. When inflammation does not present, exposure of PP’s wall is usually performed easily. However, when inflammation still exists, this will confront with difficulties. In this situation, we should change to the second approach. Second way is transmesenteric approach. Transverse colic mesentery usually adheres to PP’s wall. Hence, one additional advantage of second way is thicker wall which will form a better anastomosis. In second way, we only open transverse colic mesentery to enter PP. With respect to transmesenteric approach, we only do cystojejunostomy.

Insight inspection of pancreatic pseudocyst and cyst wall biopsy.

Purpose of insight inspection of PP is exploring signs of bleeding and pancreatic necrosis which may lead to postoperative complications. These complications can cause consequences including reoperation or mortality. Because differentiation between PP and other types of pancreatic cysts is a challenge, cyst wall biopsy is necessary. Misdiagnosis as PP was reported in up to one-third of pancreatic cyst lesions [9].

Cystogastrostomy or Cystoduodenostomy or Cystojejunostomy

Surgical internal drainage includes cystogastrostomy, cystoduodenostomy, and cystojejunostomy depending on PP’s location. Cystogastrostomy and cystoduodenostomy are performed when PP’s wall is close to posterior wall of stomach. The former usually happens when PP is located in body or tail of pancreas. In contrast, the latter usually occurs when PP is located in head of pancreas. With regard to cystojejunostomy, the procedure can be done with any position of PP. Among them, pseudocystoduodenostomy seems to be rarely applied in laparoscopic drainage [10].

Technically, all surgical internal drainages have the same method. That is anastomosing PP’s wall with lumen of alimentary tract such as posterior wall of stomach, wall of duodenum, and wall of small intestine. For laparoscopic drainage, anastomosis can be done by stapler or suturing. However, stapler is preferred due to saving operating time. In cystogastrostomy, there are some types of techniques such as endogastric, exogastric, and transgastric approaches [10, 11]. To pseudocystojejunostomy, Roux en Y anastomosis is usually fashioned [12]. Below, we describe technically cystojejunostomy with Roux en Y anastomosis by stapler.

After exposing, inspecting, and biopsy PP, below steps will be done one after another:

  • Approaching cyst via incising through transverse mesocolon or through gastrocolic ligament. The choice of approach depends on certain case. In case of through transverse mesocolon, opening should be just left of middle colic vessels. Sometimes puncturing or ultrasonography is used before opening cyst.

  • Transecting jejunum at level 25–30 cm from ligament of Treitz by a linear stapler.

  • Making a Y anastomosis between Y limb (proximal limb) and Rous limb (distal limb). Jejunojejunostomy is performed side to side by a linear stapler too. Distance from anastomosis to stump of distal limb is approximate 60–70 cm. we prefer to close enterotomy with continuous suture. Mesenteric defect should be closed.

  • Enterotomy is performed close to the end cut of Roux limb. Cystojejunostomy is fashioned by one more linear stapler and defect of enterotomy and cyst are closed by continuous suture as well.

  • Placing a drain is usually not necessary.

  • Closure of trocar incision.

Outcomes

Effect of laparoscopic drainage was reached in 98% cases and recurrence rate was 2.5% in a systematic review [13].

It was also reported associating with low morbidity (<2%) [13]. Postoperative morbidities can be infection or bleeding. Most of the cases with morbidities were conservatively treated.

Summary

Laparoscopic internal drainage is technically feasible. It was associated with high rate of success and low morbidity. However, this technique should be performed when endoscopic or percutaneous drainage is failed or in case of recurrent pancreatic pseudocyst because endoscopic or percutaneous procedure is less invasive than it and has had benefits of hospitalization and mental health as well.