Overview
Definition:
Laparoscopic cystogastrostomy is a minimally invasive surgical procedure where a direct connection is created between a pancreatic pseudocyst and the stomach to allow for drainage
This technique is typically employed when pseudocysts are symptomatic or at risk of complications and are located in close proximity to the stomach.
Epidemiology:
Pancreatic pseudocysts are a common complication of acute and chronic pancreatitis, occurring in approximately 15-40% of patients with pancreatitis
While many resolve spontaneously, a significant proportion may require intervention, with laparoscopic cystogastrostomy becoming a preferred approach for suitable cases.
Clinical Significance:
Pancreatic pseudocysts can cause significant morbidity due to pain, mass effect, infection, or hemorrhage
Laparoscopic cystogastrostomy offers a less invasive alternative to open surgery, potentially leading to reduced hospital stays, faster recovery, and fewer surgical complications for patients requiring drainage, making it a crucial skill for surgical residents preparing for DNB and NEET SS examinations.
Indications
Indications For Procedure:
Symptomatic pseudocysts (e.g., abdominal pain, early satiety, vomiting)
Large pseudocysts (>5-6 cm) that are unlikely to resolve spontaneously
Pseudocysts causing complications such as gastric outlet obstruction, biliary obstruction, or vascular compression
Infected pseudocysts or pseudocysts with risk of rupture.
Patient Selection:
Careful patient selection is crucial
Pseudocysts must be mature (well-defined wall, typically >4 weeks old) and favorably located adjacent to the stomach
Absence of significant inflammation or fibrosis in the gastrocolic ligament and stomach wall is desirable
Patients with severe comorbidities may still be better candidates for endoscopic drainage.
Preoperative Preparation
Imaging Assessment:
Contrast-enhanced CT scan is essential to delineate the pseudocyst size, location, wall thickness, and relationship to surrounding organs (stomach, duodenum, pancreas, major vessels)
MRI/MRCP may be useful for complex cases or to assess ductal anatomy.
Laboratory Tests:
Complete blood count (CBC) to assess for infection/inflammation (elevated WBC count)
Liver function tests (LFTs) to rule out biliary involvement
Amylase and lipase levels (may be elevated but not diagnostic)
Coagulation profile (PT/INR, aPTT).
Anesthesia Considerations:
General anesthesia with endotracheal intubation is required
Careful fluid management is necessary due to potential third-spacing
Patients with pancreatitis may have respiratory compromise, requiring diligent perioperative respiratory care.
Bowel Preparation:
Routine bowel preparation is not typically required for elective laparoscopic cystogastrostomy, but clear liquid diet adherence is important.
Procedure Steps
Trocar Placement:
Typically, 3-4 trocars are used: a 10-12 mm umbilical trocar for the telescope and instruments, and two 5 mm or 10 mm working trocars placed in the supraumbilical or left upper quadrant region
Optimal port placement depends on the surgeon's preference and the pseudocyst location.
Identification Of Pseudocyst:
The surgeon identifies the pseudocyst, often by palpating a fluctuant mass
The gastrocolic omentum is meticulously dissected using electrocautery or ultrasonic devices to expose the anterior wall of the stomach overlying the pseudocyst.
Gastric Access And Anastomosis:
A small gastrotomy is created in the anterior stomach wall
The pseudocyst wall is then carefully incised, and a wide communication is established between the pseudocyst cavity and the gastric lumen
Diligent suctioning of pseudocyst contents is performed
Avoidance of excessive dissection into pancreatic tissue is paramount.
Drainage And Irrigations:
A nasogastric tube is usually placed for gastric decompression
A large-bore drainage catheter (e.g., Pleur-evac or Foley catheter) may be placed across the anastomosis into the pseudocyst cavity, though often the gastrotomy itself provides adequate drainage
The operative field is irrigated, and hemostasis is confirmed.
Closure:
The gastrotomy is closed with a running suture or stapling device
Trocars are removed, and the fascial defects are closed
A drain may be placed in the splenorenal pouch if significant contamination or dissection was encountered.
Postoperative Care
Pain Management:
Adequate analgesia is crucial, often requiring patient-controlled analgesia (PCA) or epidural anesthesia
Opioids should be used cautiously due to potential for ileus.
Nutritional Support:
Initially, patients are kept NPO (nil per os)
Oral intake is gradually advanced as tolerated, starting with clear liquids and progressing to a regular diet
Enteral feeding via nasojejunal tube may be considered if oral intake is delayed.
Monitoring:
Close monitoring of vital signs, urine output, and abdominal examination for signs of complications like bleeding, infection, or anastomotic leak
Serial CBC and LFTs may be performed.
Drain Management:
If a drain is placed, output should be monitored for volume, color, and consistency
The drain is typically removed when output is minimal and serosanguinous.
Complications
Early Complications:
Bleeding from the pseudocyst wall or gastrotomy site
Anastomotic leak leading to peritonitis or intra-abdominal abscess
Pancreatitis or worsening of existing pancreatitis
Gastric outlet obstruction due to edema or blood clots
Infection of the pseudocyst or abdominal cavity.
Late Complications:
Recurrence of pseudocyst due to inadequate drainage or incomplete resolution
Pancreatic fistula formation
Stricture of the gastro-gastrostomy anastomosis
Hemosuccus pancreaticus (hemorrhage into the GI tract from the pseudocyst).
Prevention Strategies:
Meticulous surgical technique to ensure adequate anastomosis and hemostasis
Careful patient selection
Judicious use of drains
Early recognition and management of complications
Adequate preoperative and postoperative nutritional support.
Key Points
Exam Focus:
Key indications for drainage of pseudocysts
Comparison of laparoscopic vs
open cystogastrostomy
Management of complications like bleeding and infection
Criteria for pseudocyst maturation.
Clinical Pearls:
A mature pseudocyst (typically > 4 weeks) with a well-defined wall is essential for successful cystogastrostomy
Always aim for a wide-mouthed anastomosis to ensure adequate drainage
Recognize that laparoscopic surgery requires careful visualization and manipulation, especially in inflammatory fields.
Common Mistakes:
Attempting drainage of immature pseudocysts
Creating too small an anastomosis, leading to obstruction
Disruption of the pancreatic ductal system
Inadequate hemostasis, leading to postoperative bleeding
Failure to recognize and manage intra-abdominal infections promptly.