Laparoscopic Transgastric Cystogastrostomy in a 10-Year-Old Child

Abstract

Introduction:

Pancreatic pseudocysts are uncommonly seen in children. ¹ Trauma, most often injury by a cycle handle bar ^{2 –4} accounts for about 60% ² of these pseudocysts. Pancreatic pseudocysts are treated by internal drainage—either surgical (cystogastrostomy, cystojejunostomy) or endoscopically with stenting. ⁵ Laparoscopic cystogastrostomy is safe and effective in the treatment of pediatric pancreatic pseudocysts and are performed by intragastric ^2,6 or transgastric routes. ⁷ We report the technique of a successful laparoscopic transgastric cystogastrostomy in a 10-year-old boy with a post-traumatic pancreatic pseudocyst.

Materials and Methods:

This 10-year-old boy presented with a large lump in the upper abdomen. He had received treatment for traumatic pancreatitis sustained by a bicycle handle bar injury 2 months ago. A contrast CT abdomen revealed a 12×8-cm retrogastric pseudocyst of the pancreas.

Operative Technique:

The child was placed in a supine position after general anesthesia. A 10 F nasogastric tube was placed and the stomach was emptied. Pneumoperitoneum was established by the open technique. Three 5-mm ports were used: one in the umbilical region and one each in the midclavicular line on either side just above the level of the umbilicus. The stomach was visualized, stretched, and draped over the pseudocyst. An operating space was created by transgastric aspiration (750 mL) of the pseudocyst using a 22G spinal needle. The anterior wall of the stomach, in line for the gastrotomy, was held up by two 4-0 Prolene stay sutures, which were brought out of the anterior abdominal wall. The anterior wall of the stomach was opened longitudinally for a length of 4 cm by the hook monopolar cautery between the sutures, which now held the gastrotomy open. The pseudocyst and posterior stomach walls were transfixed with a 3-0 Prolene stay suture, which was brought out through the anterior abdominal wall. Using this stay suture for traction, a wad of tissue 2.5 cm in diameter consisting of the posterior wall of the stomach and the adjacent pseudocyst wall was then excised using KLS Martin maxium^™ vessel sealing bipolar diathermy and scissors. The vessel sealing bipolar prevented bleeding and caused a temporary fusion of the layers, and helped complete the cystotomy. The edge of the opening in the posterior stomach and the adjacent pseudocyst walls were then sutured to each other with continuous 3-0 Vicryl sutures. The anterior gastrotomy was then closed with continuous 3-0 Vicryl sutures. The excised piece of tissue was bagged and removed. The laparoscopic port wounds closed with 3-0 Vicryl for muscles and bioadhesive (Amcrylate) glue for skin. The total blood loss was less than 10 mL. The child made a quick recovery. He was started on oral feeds by 48 hours and was discharged at 72 hours. An ultrasound abdomen at 2 weeks postprocedure showed no residual pseudocyst. He has remained well at follow up of 2 months.

Conclusions:

Laparoscopic transgastric cystogastrostomy is a safe and feasible option to treat children with pseudocysts of the pancreas.

No competing financial interests exist.

Runtime of video: 7 mins 12 secs