Tricks of the Senior Surgeon

Open internal drainage of pseudocysts:

■ Always make sure that the cyst contents are that of a pseudocyst; i. e., clear, opalescent or brownish and not mucoid as in a cystic neoplasm.

■ Leave the aspirating needle in place to enter the cyst with a knife alongside the needle.

■ Use a right-angled clamp to elevate the cyst wall to make an adequate sized opening.

■ Virtually always biopsy the cyst wall.

■ If the cyst contents appear purulent, send the fluid for gram stain. If only white cells are seen, then internal drainage can be done; however, if numerous bacteria are seen and the fluid is purulent, external drainage is preferable.

■ Use intraoperative ultrasonography liberally, because it can identify and locate more than one cyst. It can also locate the common bile duct and pancreatic duct. Finally, it can reveal the relationship of the pseudocyst to adjacent visceral and vascular structures.

Laparoscopic cystogastrostomy:

■ This laparoendoscopic approach recapitulates the open transgastric cystogas-trostomy. While others have described a side-to-side cystogastrostomy via a laparoscopic approach using a linear endoscopic stapler, the risk of an intraperitoneal "anastomotic leak" is avoided by the approach we have described.

■ The initial short cystogastrostomy can be lengthened using an endoscopic linear stapler or even the harmonic scalpel, but we have not found this necessary and these techniques just increase the cost of the procedure.

■ Carefully inspect the site of the cystogastrostomy; if there is any bleeding, the incision can either be reefed/oversewn intragastrically via the two trocars using a 2-0 silk suture or further controlled with electrocautery.

■ Beware of the patient with a large "pseudocyst" of the pancreatic body after an episode of necrotizing pancreatitis. Be certain to exclude the presence of splenic vein compression/occlusion and gastric varices; these varices can be quite large and lead to severe hemorrhage during the cystogastrostomy.

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