Specific indications include a pseudocyst in the head of the pancreas anatomically placed so that only a cystoduodenostomy is possible.
The same approach/setup as for cystogastrostomy above.
The pseudocyst is visualized and palpated.
The cyst is aspirated with a 22-gauge needle.
A clear, opalescent, or brownish fluid should be obtained; mucoid fluid suggests a cystic neoplasm.
The syringe is removed from the needle, and a #11 blade knife is used to enter the cyst along the needle.
A right-angled clamp is inserted to elevate the cyst wall, for enlarging the opening to at least 2-3 cm of longer; a biopsy is taken of the cyst wall.
The duodenum is well Kocherized.
In this depiction, a lateral-to-lateral or side-to-side cystoduodenostomy is shown.
Creation of an anterior vertical duodenotomy of at least 2-3 cm is carried out (A-1).
Posterior sutures between the cyst and the duodenum are placed in a single interrupted layer using 3-0 silk (A-2).
Sutures are placed from the duodenum to the cyst to create an anterior wall using a single layer of interrupted 3-0 silk (A-3).
If a transduodenal cystoduodenostomy can be used, it is similar to cystogastrostomy. However, pseudocyst drainage into the posterior duodenum is done into the first or third portion of the duodenum to avoid injuring the common duct; staying in the midline of the posterior duodenal wall avoids injury to the gastroduodenal and pancreaticoduodenal vessels. Intraoperative ultrasonography can be used to identify the common bile duct and vessels if necessary.
Abdominal incision closed as for cystogastrostomy.
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