Access: incision, midline or bilateral subcostal depending on patient habitus (see Sect. 1, chapter "Positioning and Accesses").

The first step involves exposure to the lesser sac and installation of the mechanical retractor (see Sect. 1, chapter "Positioning and Accesses").

The preoperative fistulogram helps to locate the disrupted pancreatic duct.

Carefully trace the external drainage catheter into the lesser sac; dissection continues through the peripancreatic inflammatory tissue to the anterior surface of the pancreas (A-1).

It is often possible to directly visualize the fistulous tract as it exits the pancreas parenchyma.

Intraoperative secretin (SecreFlo, ChiRhoClin, Inc. Silver Springs, MD, USA) 0.2 mg/kg (after a 0.2-pg test dose) given intravenously stimulates pancreatic secretion and assists identification of the ductal disruption when it is not visualized clearly (A-2).


If possible, a catheter or probe is passed through the fistulous tract into the pancreatic duct.

If the pancreatic duct is identified, opening the anterior wall (spatulating the duct) increases the effective diameter of the anastomosis and facilitates the conduct of the anastomosis.

Pancreatography can be obtained if not done already.

The pancreatic duct should be imaged proximally and distally.

The jejunum is transected about 15 cm distal to the ligament of Treitz.

The blind end of the jejunum is closed by a stapling device or sutures.

Enteric continuity is reestablished by end-to-side jejunojejunostomy at least 60 cm from the closed end of the Roux limb.

The anastomosis is constructed by suturing the side of the jejunum to the pancreatic duct or the rim of scarred tissue at the fistulous tract at its point of origin on the pancreas. For details of construction of the Roux-en-Y limb see Sect. 2, chapter "Subtotal Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision in Complicated Gastric Ulcers."

Total Gastrectomy Billroth


A posterior row of Lembert-type sutures is placed using 4-0 silk.

Next a row of absorbable sutures (4-0 or 5-0 polyglycolic acid) are placed full thickness through the pancreatic duct and the jejunum.

A catheter can be left as a stent through the anastomosis and brought out of the anterior abdominal wall, allowing the anastomosis to be studied postoperatively through the catheter if indicated.


If the pancreatic duct cannot be identified definitively, the jejunum can be sewn over the fistulous tract as an onlay anastomosis to the pancreatic parenchyma; it would be optimal to keep a stent across this onlay anastomosis.

A soft closed suction drain is placed adjacent to the anastomosis.

Billroth Mit Roux Anastomose

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