RU2747418C1 - Method of formation of invagination pancreatojejunal anastomosis - Google Patents

Abstract

FIELD: medicine; surgery; oncology.

SUBSTANCE: enterotomy and the diameter of the long axis of the cut of the stump of the pancreas are conditionally divided into three equal sections, and then a single U-shaped suture is applied in the central part. To do this, an injection is performed in front of the enterotomy, an atraumatic thread is carried out in the submucosal layer of the jejunum and the injection is performed before reaching the edge of the enterotomy. Next, the stump of the pancreas is pierced through from front to back perpendicular to its anterior surface, then an injection is performed behind the enterotomy, an atraumatic thread is carried out in the submucosal layer of the jejunum parallel to the enterotomy and the injection is performed. The stump of the pancreas is pierced through from behind to front perpendicular to its posterior surface, then in front of the enterotomy, retreating from the edge, an injection is performed, an atraumatic thread is carried out in the submucosal layer of the jejunum wall and an injection is performed, completing the U-shaped suture. In the upper and lower corners of the anastomosis, one semi-mesh suture is applied with one through puncture of the pancreatic tissue, carrying out a suture thread in the submucosal layer of the jejunum wall.

EFFECT: method allows restoring the continuity of the digestive tract, preventing development of secondary complications by creating an adaptive and sealed anastomosis of the stump of the pancreas and jejunum with a minimum number of punctures and without eruption of the pancreatic tissue.

1 cl, 14 dwg, 1 ex

Description

The proposed invention relates to the field of medicine, namely to surgery.

P., Tarifa A., Eguaras I., Lera J.M. Feasibility, morbidity and mortality in two hundred consecutive cases of pan-creaticogastrostomy after pancreaticoduodenectomy. Cir Esp.2019 Jun 7. pii: S0009-739X(19)30122-8. doi: 10.1016/j.ciresp.2019.04.010. [Epub ahead of print] English, Spanish. PubMed PMID: 31182218).The anastomosis between the pancreatic stump and the intestinal tube is the "Achilles heel" of pancreatoduodenal resection; pancreatic fistula remains the main complication and is 5.8-57.6% (Lao M., Zhang X., Guo C., Chen W., Zhang Q., Ma T., Bai X., Liang T. External validation of alternative fistula risk score (a-FRS) for predicting pancreatic fistula after pancreatoduodenectomy. HPB (Oxford). 2019 Jul 1. pii: S1365-182X (19) 30546-5. doi: 10.1016 / j.hpb.2019.05.007. [ Epub ahead of print] PubMed PMID: 31272847). The evaded pancreatic secretion from the anastomotic zone damages the surrounding tissues, causing the development of secondary complications, as a result, the bed-day and the cost of treatment increase. These secondary complications (arrosive intra-abdominal bleeding, abdominal abscesses, peritonitis) are the main cause of postoperative mortality, which reaches 4% (Herrera J., Zazpe S.,

P., Tarifa A., Eguaras I., Lera JM Feasibility, morbidity and mortality in two hundred consecutive cases of pan-creaticogastrostomy after pancreaticoduodenectomy. Cir Esp. 2019 Jun 7. pii: S0009-739X (19) 30122-8. doi: 10.1016 / j.ciresp.2019.04.010. [Epub ahead of print] English, Spanish. PubMed PMID: 31182218).

Various methods are known for connecting the stump of the pancreas and the intestinal tube.

One of the most commonly used pancreatodigestive anastomoses is a two-row invaginating pancreatojejunostomy according to C.G. Child (Child CG Pancreaticojejunostomy and other problems associated with the surgical management of carcinoma involving the head of the pancreas: report of five additional cases of radical pancreaticoduodenectomy. Ann Surg. 1944 Jun; 119 (6): 845-55. PubMed PMID: 17858411 ; PubMed Central PMCID: PMC1617983).

This anastomosis is performed "from the end of the pancreas to the end of the jejunum." After removal of the organo-complex, the proximal end of the jejunum is moved to the stump of the pancreas through the window into the mesocolumn. The posterior surface of the pancreas is freed from the surrounding tissues for 2 cm. Departing 1.5-2 cm from the edge of the displaced area of the jejunum, the wall of the posterior semicircle of the intestine with the posterior semicircle of the pancreas is sewn with separate extramucosal interrupted sutures (in the amount of 4-6). The capsule and pancreatic tissue (the first row of sutures) are captured into the suture. Then, the posterior edge of the pancreatic stump section is sutured with the posterior edge of the displaced jejunum section with separate through interrupted sutures, in the amount of 4-6 (second row of sutures). The "lost" drainage is placed in the lumen of the pancreatic duct and fixed. The front edge of the pancreatic stump cut is sutured to the front edge of the displaced area of the jejunum with separate through interrupted sutures, in the amount of 4-6 (third row of sutures). The stump of the pancreas is immersed in the lumen of the displaced part of the jejunum. The fourth row of sutures is used to sew the wall of the anterior semicircle of the jejunum with the anterior semicircle of the pancreas as well as the first row of sutures. If the diameter of the stump of the pancreas does not correspond (when it is larger) to the diameter of the jejunum, this anastomosis is formed "the end of the pancreas to the side of the jejunum."

The disadvantages of this method include the complexity and multistage formation of the anastomosis, trauma to the pancreas due to significant mobilization of its edges, a large number of punctures (about 24 punctures) of the pancreas during suture formation, eruption of interrupted sutures when tying them. In turn, a large number of puncture holes, the cutting of interrupted sutures on the tissue of the pancreas increase the likelihood of developing a pancreatic fistula and secondary complications.

The closest in technical essence to the proposed one is the method of invagination pancreatojejunostomy with U-shaped transpancreatic through sutures according to C.G. Chen (Chen H.R., Huang ZY, Lau JW, Zhang BX, Zhang ZW, Chen YF, Zhang WG, Zhu P., Zhang B. Chen's U-suture technique for end-to-end invaginated pancreaticojejunostomy following pancreaticoduodenectomy. Ann Surg Oncol. 2014 Dec; 21 (13): 4336-41. Doi: 10.1245 / s10434-014-3823-2. Epub 2014 Jul 23. PubMed PMID: 25052245).

When forming this anastomosis, a two-needle atraumatic thread is used.

The known method is performed in the following sequence. After removal of the organo-complex, the proximal end of the jejunum is moved to the stump of the pancreas through the window into the mesocolon. The "lost" drainage is placed in the lumen of the pancreatic duct and fixed. The formation of the anastomosis begins from the posterior wall of the displaced jejunum. To do this, 1.5 cm from the edge of the jejunum, the first needle punctures the posterior wall of the intestine from outside to inside (through puncture of the intestinal wall). Then with the same needle pierce through the pancreas from the back in front of 1.5 cm from the edge of the cut of the stump of the pancreas, then puncture the opposite wall of the displaced section of the jejunum from the inside out (through puncture of the intestinal wall) 1.5 cm from the edge of the jejunum. The second needle repeats the movement of the first needle, i.e. 1.5 cm from the edge of the jejunum with a second needle, puncture the posterior wall of the intestine from outside to inside, pierce through the pancreas from the back in front, 1.5 cm from the edge of the cut of the stump of the pancreas. Then the second needle puncture the opposite intestinal wall from the inside out, 1.5 cm from the edge of the jejunum. The insertion distance between the first and second needles is 1 cm. This method requires three U-sutures to form an anastomosis. If necessary - a large diameter of the pancreatic stump, the number of U-sutures is increased. After all the U-seams have been completed, they are pulled at the same time in a metered fashion. As a result, the stump of the pancreas freely "automatically" enters the lumen of the displaced portion of the jejunum. The seams are tied sequentially. If the diameter of the stump of the pancreas exceeds the diameter of the intestine, the anastomosis is formed "the end of the pancreas to the side of the jejunum."

The disadvantages of the known method include through piercing of the walls of the jejunum and leaving large gaps between the seams in the upper and lower corners of the pancreatojejunoanastomosis, since from the lumen of the intestine through through punctures and large gaps in the corners of the pancreatojejunoanastomosis, the intestinal contents and the space surrounding the anastomosis leave the intestinal contents and microflora. They (pancreatic secretion, intestinal contents and microflora) damage (destroy, digest, rot) the surrounding connective tissue, blood vessels, nerves. As a result of this damage, secondary complications develop - arrosive bleeding, abdominal abscesses, peritonitis.

In addition, with this option of immersion (invagination), the capsule of the pancreatic stump comes into contact with the jejunal mucosa, which implies the healing of the anastomosis only along the wound edge of the jejunal wall. As a result, the healing area (scar formation) of the stitched surfaces will be narrow; such an anastomosis will be "weak" for a long time during the healing phase.

The objective of the proposed technical solution is to develop a method for forming an invagination anastomosis of the stump of the pancreas and jejunum with transancreal through sutures.

The technical result of the proposed method is to prevent secondary complications by creating an adapted and hermetic anastomosis of the pancreatic stump and the jejunum with a minimum number of punctures and without eruption of the pancreatic tissue.

The technical result is achieved by the fact that the method of forming an invagination pancreatojejunostomy involves removing the organo-complex, moving the proximal end of the jejunum to the pancreatic stump and stitching them with transancreal through sutures.

Distinctive techniques of the proposed method are that the enterotomy and the diameter of the long axis of the cut of the pancreatic stump are conventionally divided into three equal sections, then one U-shaped suture is applied in the central part, for which an injection is performed in front of the enterotomy, an atraumatic thread is carried out in the submucosal layer jejunum and perform a puncture before reaching the edge of the enterotomy. Next, the stump of the pancreas is pierced through from front to back perpendicular to its front surface. Then, behind the enterotomy, an injection is performed, an atraumatic thread is carried out in the submucous layer of the jejunum in parallel with the enterotomy, and an injection is performed. Next, the stump of the pancreas is pierced through from the rear to the front perpendicular to its posterior surface, then in front of the enterotomy, stepping back from the edge, an injection is made, an atraumatic thread is drawn in the submucosal layer of the jejunal wall and an injection is performed, completing the U-shaped suture.

The differences of the proposed method also lie in the fact that then along the lower-posterior third of the enterotomy, stepping back from the edge, perform two stitches, passing the second atraumatic thread in the submucosal layer of the jejunal wall. Then, stepping back from the edge of the cut of the stump of the pancreas, pierce through the stump of the pancreas from back to front perpendicular to its posterior surface, after which, along the lower-anterior third of the enterotomy, stepping back from the edge, perform two stitches, passing an atraumatic thread in the submucosa of the layer of the jejunal wall, completing the first half in the lower corner of the anastomosis; then along the upper-posterior third of the enterotomy, departing from the edge, two stitches are performed, passing the third atraumatic thread in the submucosal layer of the jejunal wall. Then, stepping back from the edge of the cut of the stump of the pancreas, pierce through the stump of the pancreas from behind to front perpendicular to its posterior surface, then along the upper anterior third of the enterotomy, departing from the edge, perform two stitches, holding an atraumatic thread in the submucosal layer of the wall of the jejunum, complete the stitches in the upper half the corner of the anastomosis.

Comparative analysis with the prototype showed that the proposed method differs from the known one by the above methods, namely, when forming an invaginated pancreatojejunoanastomosis, only one U-shaped suture is applied in the central part of the anastomosis, and in the upper and lower corners of the anastomosis, a semi-purulent suture with one through puncture of the pancreatic tissue. The difference also lies in the fact that the suture thread is carried out in the submucosal layer of the jejunum, i.e. the walls of the sutured jejunum are not pierced through. Therefore, the claimed method meets the criterion of patentability of the invention "novelty".

The search for solutions known in medicine showed that the distinctive features of the proposed method were not found in the known solutions for the formation of invagination pancreatojejunostomy.

Distinctive techniques of the proposed method make it possible to form an invagination pancreatojejunostomy with a minimum number of punctures and without eruption of the pancreatic tissue, to exclude the release of intestinal contents, microflora, pancreatic secretion into the space surrounding the anastomosis, to match (adapt) the pancreatic capsule with the serous membrane of the jejunum anastomosis in a short time.

Thus, the use of transancreal through sutures in the formation of an invagination pancreatojejunostomy according to the proposed method allows to reduce the number of punctures in the pancreatic tissue and to exclude the eruption of the pancreatic tissue when tying sutures.

Carrying out the suture thread in the submucosal layer of the walls of the jejunum excludes the release of intestinal contents, microflora and pancreatic secretions (through the puncture channels) into the space surrounding the anastomosis.

Likewise, the imposition of a half-string suture with one through puncture of the pancreatic tissue in the upper and lower corners of the anastomosis eliminates the presence of an inter-suture gap in the upper and lower corners of the pancreatojejunoanastomosis and, therefore, prevents the release of intestinal contents, microflora and pancreatic secretion into the space surrounding the anastomosis.

Holding the suture thread in the submucosal layer of the sutured walls of the jejunum and transpancreally (through puncturing of the pancreatic stump) during tightening allows you to match (adapt) the pancreatic capsule with the serous membrane of the jejunum. As a result, the healing of the anastomosis proceeds not only along the wound edge of the jejunal wall, but also over the entire contact surface of the pancreatic capsule with the serous membrane of the jejunum. The large healing area of the stitched surfaces ensures the strength of the anastomosis in a short time.

The inventive method ensures the achievement of the technical result seen by the applicant, namely, the prevention of secondary complications (pancreatic fistula, arrosive intra-abdominal bleeding, abdominal abscesses, peritonitis) by creating an adapted and hermetic anastomosis of the pancreatic stump and the jejunum. The foregoing allows us to conclude that the technical solution meets the “inventive step” criterion.

The method constituting the claimed invention is intended for use in healthcare. The possibility of its implementation is confirmed by the methods and means described in the application, which corresponds to the criterion of the invention "industrial applicability".

The inventive method of invagination pancreatojejunostomy is illustrated by Figures 1-14, which reflect the stages of its formation, where: 1 - "lost drainage", 2 - a stomy section of the jejunum, 3 - enterotomy, 4 - the diameter of the long axis of the pancreatic stump, 5 - the first atraumatic thread, 6 - second atraumatic thread, 7 - third atraumatic thread.

The inventive method for the formation of invagination pancreatojejunostomy is carried out as follows.

Placed in the lumen of the pancreatic duct "lost drainage" 1, fixed with a U-shaped suture atraumatic suture PDS 5/0 (Fig. 1). The stoma section of the jejunum 2 is stretched along its length. On the antimesenteric edge of the ostomy area of the jejunum 2, enterotomy 3 is made, the length of which corresponds to the diameter of the long axis of the pancreatic stump 4 (Fig. 1). Enterotomy 3 is divided by two conditional perpendicularly drawn lines (A and B) into three equal sections (Fig. 1). The diameter of the long axis of the section of the stump of the pancreas 4 is also divided by two conditional perpendicularly drawn lines (A1 and B1) into three equal sections (Fig. 1). In front of enterotomy 3, at a distance of 1.0-1.5 cm from the edge (along line A), an injection is performed (Fig. 1), the first atraumatic thread 5 is carried out in the submucosal layer of the jejunal wall and an injection is performed (along line A) before reaching 2 -3 mm to the edge of enterotomy 3 (Fig. 2). Next, an atraumatic thread 5, 1.0-1.5 cm away from the edge of the pancreatic stump cut (along line A1), pierce the pancreas stump from front to back perpendicular to its front surface (Fig. 3). Then with an atraumatic thread 5 behind the enterotomy 3, at a distance of 1.0-1.5 cm from the edge (along line A), an injection is made, an atraumatic thread 5 is carried out in the submucosal layer of the jejunal wall parallel to the enterotomy 3 and an injection is performed (along line B) in 1 , 0-1.5 cm from the edge of enterotomy 3 (Fig. 4). Next, with an atraumatic thread 5, 1.0-1.5 cm away from the edge of the cut of the pancreatic stump (along line B1), pierce the pancreas stump from behind to front perpendicular to its posterior surface (Fig. 5). In continuation of this atraumatic thread 5 in front of enterotomy 3, 2-3 mm apart from the edge (along line B), an injection is made, an atraumatic thread 5 is carried out in the submucosal layer of the jejunal wall and an injection is performed (along line B) in 1.0-1 , 5 cm to the edge of enterotomy 3 (Fig. 6). The U-shaped transpancreatic through suture of the formed anastomosis is completed.

Along the lower-posterior third of the enterotomy 3, at a distance of 1.0-1.5 cm from the edge, two stitches are performed, passing the second atraumatic thread 6 in the submucosal layer of the jejunal wall (Fig. 7). Then, retreating 1.0-1.5 cm from the edge of the cut of the pancreatic stump (3 mm from the line A1), pierce the atraumatic thread 6 through the stump of the pancreas from behind to front perpendicular to its posterior surface (Fig. 8). In continuation along the lower anterior third of the enterotomy 3, at a distance of 1.0-1.5 cm from the edge (3 mm from line A), two stitches are performed, passing the atraumatic thread 6 in the submucosal layer of the jejunal wall (Fig. 9). The first semi-string suture with a through puncture of the pancreatic tissue in the lower corner of the anastomosis is completed.

Along the upper-posterior third of the enterotomy 3, at a distance of 1.0-1.5 cm from the edge, two stitches are performed, passing the third atraumatic thread 7 in the submucosal layer of the jejunal wall (Fig. 10). Then, retreating 1.0-1.5 cm from the edge of the cut of the stump of the pancreas (3 mm from the line B1), pierce the atraumatic thread 7 through the stump of the pancreas from behind to front perpendicular to its posterior surface (Fig. 11). In continuation along the upper anterior third of the enterotomy 3, at a distance of 1.0-1.5 cm from the edge (3 mm from line B), two stitches are performed, passing the atraumatic thread 7 in the submucosal layer of the jejunal wall (Fig. 12). The second semi-string suture with a through puncture of the pancreatic tissue in the upper corner of the anastomosis is completed.

After all the seams have been made, they are pulled at the same time in a metered fashion (Fig. 13). As a result, the stump of the pancreas is unimpeded "automatically" immersed in the lumen of the jejunum. The seams are sequentially tied (Fig. 14).

The proposed method is illustrated by an example of a specific implementation.

Patient S., 63 years old, was admitted to the oncological dispensary on 09.08.2018. with a diagnosis: Cancer of the head of the pancreas IIA stage (T3 N0 M0), II class gr. Medical history within 2 months.

A comprehensive treatment plan was drawn up - extended gastropancreato-duodenal resection, chemotherapy based on the results of morphological examination.

08/15/18. the operation was performed: Extended gastropancreatoduodenal resection.

After treatment of the operating field with a solution of skin antiseptic bonderm three times, under endotracheal anesthesia, access to the upper mid-mid-laparotomy, the abdominal cavity was opened. There are no ascites, carcinomatosis, liver metastases in the abdominal cavity. During the revision there is a tumor of the head of the pancreas (RV), 4 × 3 cm in size. The lymph nodes No. 8, 9, 12, 16 groups are enlarged. The situation was recognized as resectable. The greater omentum is separated from the transverse colon, and access to the omental bursa is made. Projectionally, access to the superior mesenteric vessels (VBS) is made at the root of the mesentery of the small intestine. The superior mesenteric vein (SMV) and superior mesenteric artery (SMA) were isolated, taken on handles. VPS skeletonized to the lower edge of the pancreas. In the course of mobilization, the first and second small intestinal arteries, the middle colon-intestinal artery, and at the base of the gastro-intestinal venous trunk were tied and crossed at the mouth. The group of lymph nodes No. 14 was removed. The duodenum (DNA) is mobilized according to Kocher. Dissection of the inter-aortocaval space was performed, group of lymph nodes No. 16 was removed. The infra-pan-creative segment of the PMV is highlighted and marked. The lower pancreatoduodenal vessels are ligated and transected. The hepato-duodenal ligament was dissected, number 12 of the group of lymph nodes was removed. The bundle elements are marked. The common bile duct is dilated, 12 mm in diameter, the wall is 2 mm, dense. The common bile duct (common bile duct) is cut distal to the cystic duct by 1.5 cm. The latter flows into the common bile duct high in the confluence projection. Tied and crossed the gastroduodenal, right gastric arteries. Dissection along the common hepatic and splenic arteries, No. 8, 9, 7, 11 groups of lymph nodes were removed. The upper pancreatoduodenal vein was ligated and transected. The stomach is transected in the antrum. The small curvature is formed by the hardware seam UO-60 (staples 0.3 × 4.0 × 4.8 mm). The seam is treated with povidone iodine. The pancreas is crossed at the body-tail border. The pancreas is fibrously changed. The diameter of the pancreatic duct is 4-5 mm. The wound surface of the pancreas was sutured with precision sutures with atraumatic thread PDS 5/0, hemostasis was achieved. The small intestine is crossed 15 cm from the duodenojejunal junction. The intrinsic ligament of the uncinate process of the pancreas was transected in portions. The preparation of the greater and lesser omentum-antrum part of the stomach-duodenum-part of the small intestine-head with tumor and the body of the pancreas-part of the common bile duct was removed.

Then, according to the claimed method, a posterior colic invagination pancreatojejunoanastomosis (PJA) is formed end-to-side: a U-shaped suture in the central part of the anastomosis, a half-string suture with one through puncture of the pancreas in the upper and lower corners of the anastomosis, the suture thread is held in the submucosa of the intestine. Anterior colon hepatic anastomosis is single row, atraumatic thread PDS 5/0. Then formed an interintestinal anastomosis, anterior colic gastrojejunostomy and a second interintestinal anastomosis. Digestive anastomoses were performed with a single-row continuous suture with atraumatic suture PDS 3/0, treated with povidone iodine. The hemostasis is satisfactory. The abdominal cavity was sanitized with an aqueous solution of chlorhexidine antiseptic in a volume of 1.5 liters. Drainages (blake, 24fr) on the right: the first - under the left lobe of the liver (along the upper edge of the NAP), the second - along the mesocolon (along the lower edge of the NAP). Counting tampons by the operating nurse. The wound was sutured tightly in layers. Aseptic dressing.

The postoperative period was uneventful. The patient was discharged in satisfactory condition on the 12th day after the operation.

At present, 52 patients have been operated on according to the claimed method. In 47 cases, there were no complications associated with evasion of pancreatic secretion from the pancreatojejunostomy zone (arrosive intra-abdominal bleeding, abdominal abscesses, peritonitis). In 5 cases, a local accumulation of fluid was found in the anastomotic area (under the left lobe of the liver), removed by puncture under USS navigation.

Thus, the proposed method for the formation of pancreatojejunostomy allows you to restore the continuity of the digestive tract, to prevent the development of secondary complications, by ensuring the tightness of the anastomosis.

The advantages of the proposed method in comparison with the known ones are that:

- invagination of the entire wound surface of the pancreatic stump, including the pancreatic duct into the lumen of the jejunum;

- the minimum number of punctures (4) of the pancreatic tissue;

- transpancreatic through suture (the reason for the eruption of the pancreatic tissue when tying the sutures is excluded);

- carrying out the suture thread in the submucosal layer of the sutured walls of the jejunum;

- semi-string suture with one through puncture of the pancreatic tissue in the upper and lower corners of the anastomosis (the inter-suture spaces in the upper and lower corners of the pancreatojejunoanastomosis are eliminated);

- comparison of the capsule of the pancreas with the serous membrane of the jejunum when tightening the sutures (one of the conditions for rapid healing of the anastomosis).

In addition, the method is simple to execute, low-traumatic, does not take much time, and does not require special tools.

Claims (1)

A method for the formation of an invagination pancreatojejunostomy, including removal of the organocomplex, moving the proximal end of the jejunum to the pancreatic stump and stitching them with trans-pancreatic through sutures, characterized in that the enterotomy and the diameter of the long axis of the cut of the pancreatic stump are conventionally divided into three equal sections parts impose one U-shaped suture, for which an injection is made in front of the enterotomy, an atraumatic thread is drawn in the submucosal layer of the jejunum and an injection is performed without reaching the edge of the enterotomy, then the stump of the pancreas is pierced through from front to back perpendicular to its front surface, then from behind from enterotomies perform an injection, conduct an atraumatic thread in the submucosal layer of the jejunum parallel to the enterotomy and perform an injection, then pierce through the stump of the pancreas from behind to front perpendicular to its posterior surface, then in front of the enterotomy, stepping back from the edge, perform an injection, an atraumatic thread is drawn in the submucosal layer of the jejunal wall and an incision is made, completing the U-shaped suture, then along the lower-posterior third of the enterotomy, stepping back from the edge, two stitches are performed, passing the second atraumatic thread in the submucosal layer of the jejunal wall, then, stepping back from the edges of the cut of the stump of the pancreas, pierce through the stump of the pancreas from behind to front perpendicular to its posterior surface, after which two stitches are performed along the lower anterior third of the enterotomy, stepping back from the edge, passing an atraumatic thread in the submucosal layer of the wall of the jejunum, completing the first semiaxis the lower corner of the anastomosis, after which two stitches are performed along the upper-posterior third of the enterotomy, stepping back from the edge, passing the third atraumatic thread in the submucosal layer of the jejunal wall, then, departing from the edge of the cut of the pancreatic stump, pierce through the perpendicular stump of the pancreas from the back to the front its posterior surface, after along the upper the anterior third of the enterotomy, stepping back from the edge, perform two stitches, passing an atraumatic thread in the submucosal layer of the jejunal wall, completing the second semi-string suture in the upper corner of the anastomosis.

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