Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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524 Section VII • Pancreas

◆ Some element of biliary stricture results either in jaundice, which is rare, or in some ele-

ment of bile duct dilation. This can be conﬁ rmed by extremely high circulating levels of

alkaline phosphatase in the blood.

◆ Poor nutrition and inability to adequately process nutrients because of exocrine or endo-

crine insufﬁ ciency, as well as the pain associated with eating, is an additional indication for

surgery.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ It is vital to establish the signiﬁ cance of the pain associated with chronic pancreatitis to be

certain that this person’s pain is of sufﬁ cient magnitude to warrant major operation.

◆ The patient must be carefully scrutinized for current nutritional status, as well as the

proper medical management of either exocrine or endocrine dysfunction, which is often

associated with this disease. Surgery should be delayed until nutritional status has been

stabilized.

◆ Some amount of counseling regarding narcotic dependence should be initiated preopera-

tively in these patients.

◆ Speciﬁ c discussion should be made regarding the goals of resuming normal activities,

stopping ethanol abuse, and resuming employment. It is incumbent upon the pancreatic

surgeon to participate in this form of rehabilitation of these patients to ensure satisfactory

outcomes for the goals of this operation.

◆ If a patient has ﬁ nally reached very high narcotic requirements to manage his or her pain

preoperatively, the management of the postoperative pain in these patients can be a daunt-

ing task. We have found signiﬁ cant improvements when we perform this procedure with

an epidural catheter in place. We have found that even high doses of intravenous narcotics

failed to properly manage the pain in these patients in the postoperative period.

◆ We have experience with improving narcotic effectiveness by placing patients on epidural

access some days ahead of surgery and using a pure bupivacaine analgesic. If this can be

achieved, the patient may have some freedom of his or her endorphin receptors by the

time surgery is undertaken.

◆ We perform bowel preparation and colonic cleansing in all patients preoperatively.

◆ A single dose of preoperative intravenous antibiotic prophylaxis is administered using a

second-generation cephalosporin.

CHAPTER 48 • Beger and Frey Procedures 525

STEP 3: OPERATIVE STEPS

1. INCISION

◆ We prefer a midline incision for this procedure. The incision is taken from the xiphoid pro-

cess to just above the umbilicus. Self-retaining retractors are used to establish exposure

(Figure 48-1).

Incision

FIGURE 48 –1

526 Section VII • Pancreas

2. DISSECTION

◆ The gastrocolic omentum is separated from its attachments along the transverse mesocolon

in the avascular plane by using electrocautery. We ﬁ nd it easiest to enter this plane begin-

ning well to the left of the spine. After entering the lesser sac, the omentum is dissected free

of its attachments to the hepatic ﬂ exure of the colon and toward the cecum if necessary.

This permits access to the lesser sac, and any adhesions between the posterior wall of the

stomach and the anterior surface of the body and head of the pancreas are carefully dis-

sected (Figure 48-2).

◆ Any of the fatty tissues or adhesions overlying the body and head of the pancreas are care-

fully cleared to visualize the anterior surface of the pancreas. You will see a bundle of fatty

tissue inferior to the pylorus. The right gastroepiploic vessels are within this bundle. These

should not be divided at this time. Often a branch can be seen traversing between this bun-

dle and vessels on the inferior border of the pancreas. These can be divided safely between

clamps.

◆ At this point, the duodenum and the head of the pancreas are mobilized from their poste-

rior attachments in the retroperitoneum by dividing the peritoneum lateral to the C-loop of

the duodenum. This dissection is then carried out toward the left beneath the head of the

pancreas. The superior vena cava and the aorta can be identiﬁ ed posteriorly during the dis-

section. After adequate dissection, you may bimanually palpate the head of the pancreas

(Figure 48-3).

CHAPTER 48 • Beger and Frey Procedures 527

Omentum

Transverse colon

FIGURE 48 –2

Duodenum

Kocherized

Duodenum

Kidney

FIGURE 48 –3

528 Section VII • Pancreas

BEGER PROCEDURE

◆ Both the Beger and Frey procedures will use all of the previous steps. The steps unique to

each one will now be reviewed, with the Beger procedure ﬁ rst. In many ways the Beger pro-

cedure can be viewed as a modiﬁ cation of a resection (pancreaticoduodenectomy)—in other

words, a lesser resection. The Frey procedure can be looked upon as a modiﬁ cation of a

drainage procedure (Puestow)—in other words, an extended drainage. By virtue of this fact,

the two procedure are surprisingly similar.

◆ The inferior border of the pancreas is mobilized beginning to the left of the spine and work-

ing toward the head of the pancreas. This is categorized as a vascular plane; however, as the

dissection carries toward the insertion of the superior mesentery vein, one must exercise

considerable caution because of the variable number of venous tributaries to the mesenteric

vein or even piercing beneath the pancreas to the splenic vein (Figure 48-4).

◆ The third and fourth portions of the duodenum are carefully dissected, and as one approaches

the terminal portions of the C-loop of the duodenum as it courses beneath the mesenteric ves-

sels, the superior mesenteric vein can be easily identiﬁ ed as it courses along the root of the

mesentery. A plane can now be established posterior to the head of the pancreas and anterior

to the superior mesenteric vein directed toward the hepatoduodenal ligament.

Dilated duct

Omentum dissected

Stomach reflected

Inferior border of

pancreas mobilized

FIGURE 48 –4

CHAPTER 48 • Beger and Frey Procedures 529

Common bile duct

Portal vein

Gastroduodenal

artery

Common hepatic

artery

◆ The peritoneum overlying the hepatoduodenal ligament is next dissected and the common bile

duct is encircled with a

⁄4-inch Penrose drain. Similarly, the proper hepatic artery is encircled

by a vessel loop. Place traction laterally on the bile duct and medially on the hepatic artery. In

this fashion, you will visualize the portal vein between these two structures, but in a deeper

plane. It is now possible to establish a plane between the previously dissected superior mesen-

teric vein on the inferior border of the pancreas and the portal vein in the hepatoduodenal

ligament (Figure 48-5).

◆ Carefully divide the vascular attachments along the superior border of the pancreas to the left

of the portal vein. Follow the hepatic artery to the point that it diverts in a right angle. At just

this point, you will identify the gastroduodenal artery. Divide between clamps, tie, and suture

ligate (Figure 48-6).

FIGURE 48 –5

Proper hepatic artery

Gastroduodenal artery

Common hepatic artery

Splenic artery

Portal vein

Vascular attachments to

splenic artery divided

FIGURE 48 –6

530 Section VII • Pancreas

◆ Division of the gastroduodenal artery permits skeletonization of a perhaps 2-to 3-cm area

along the superior border of the head of the pancreas. A line drawn between this plane and

the area of dissection along the superior mesenteric vein constitutes the planned line of di-

vision of the neck of the pancreas (Figure 48-7).

◆ Place 2-0 Prolene sutures on the superior and inferior border of the body of the pancreas,

both to the left and the right of the anticipated incision site. This is useful both for manipu-

lation of the head of the pancreas during the remaining dissection and to control some of the

intraparenchymal vessels. Divide the pancreas using a scalpel and obtain a margin of tissue

for biopsy, because chronic pancreatitis may harbor an associated carcinoma (Figure 48-8).

◆ Then place 2-0 Prolene sutures in a circular fashion on the inner border of the C-loop of

the duodenum between the duodenum and the head of the pancreas. These are placed

essentially in a continuous fashion, although they are interrupted. These continue from the

pylorus on the superior aspect around to the region of the superior mesenteric vein. Both

the anterior superior and the anterior inferior vessels are ligated (Figure 48-9). After gain-

ing signiﬁ cant control of hemorrhage with these 2-0 Prolene sutures, one can now begin to

excavate the head of the pancreas.

Gastroduodenal

artery divided

FIGURE 48 –7

CHAPTER 48 • Beger and Frey Procedures 531

Pancreas divided

Dilated duct

FIGURE 48 –8

Circumferential line of

2-0 Prolene sutures

FIGURE 48 –9

532 Section VII • Pancreas

◆ Electrocautery or cold knife is used to carefully divide the mass in the head of the pancreas,

all the while using bimanual palpation to ensure a thickness in the posterior plane of 5 to

10 mm (Figures 48-10 and 48-11).

◆ Carefully examine the area at the second portion of the duodenum during the excavation to

identify the intrapancreatic portions of the bile duct. Optimally, any encasement of the bile

duct by the inﬂ ammatory mass can be released. This may be sufﬁ cient to resolve a bile duct

stricture and thereby negate the need for a separate bilioenteric anastomosis (see Figure 48-10).

◆ At times, there may be entry into the bile duct during this dissection, and in this case, either

perform a hepaticojejunostomy or simply include the bile duct within the anastomosis to the

jejunum in the excavated head of the pancreas.

◆ Care should be taken when encountering hemorrhage, which can be quite brisk during this

dissection. Apply 3-0 silk suture ligature at all times to control this hemorrhage. Postopera-

tive bleeding is a known complication of this procedure. Once the mass is excised, palpate

once again to conﬁ rm the thickness of the posterior shell. Complete the placement of the

2-0 Prolene sutures along the border of the uncinate process beneath the superior mesenteric

vein/portal vein complex (see Figure 48-11).

◆ In the case of patients with a dilated main pancreatic duct, one may then perform a longitu-

dinal incision along the main pancreatic duct, as is often done in a Puestow type of proce-

dure. It should be noted that the original description of the Beger procedure did not include

this longitudinal pancreaticojejunostomy, but it is now commonplace to combine this por-

tion of the procedure. This addition further exempliﬁ es the similarities between the Beger

and the Frey procedures.

CHAPTER 48 • Beger and Frey Procedures 533

Head of pancreas

excavated

Dilated duct

incised

FIGURE 48 –10

Duodenum

Uncinate process

Superior mesenteric

vein

Palpation of head

of pancreas

FIGURE 48 –11