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

Подождите немного. Документ загружается.

554 Section VII • Pancreas

◆ Dissect the gallbladder free of the gallbladder bed, and dissect the cystic duct/common duct

conﬂ uence. The gallbladder will be included in the en bloc specimen. If it is tense with bile

it may be decompressed to maximize visualization.

◆ Divide the common hepatic duct just proximal to the insertion of the cystic duct. In an

operation for malignancy, send a margin of bile duct for frozen section examination. Place

a medium clip on the actual (proximal) margin (Figure 49-8).

◆ Divide and suture ligate the gastroduodenal artery. Soft tissue attachments between the

superior aspect of the head of the pancreas and the retroperitoneal structures are quite

dense. Several broad, ﬂ at lymph nodes overlie the arterial structures (the celiac trunk,

common hepatic artery, and splenic artery root). Include the lymph nodes with the spec-

imen (see Figure 49-8). The head of the pancreas will ﬁ nally be freely mobile for a trans-

verse distance of 3 to 5 cm. The medial aspect of the portal vein is visualized. The antic-

ipated dividing line for most resections approximates the line nearly vertical along the

medial border of the superior mesenteric vein/portal vein conﬂ uence (Figure 49-9).

◆ Dissect and divide/ligate the right gastroepiploic arteriovenous bundle approximately 3 cm

proximal to the pylorus along the greater curvature. This will include an important lymph

node region. Dissect the lymphovascular bundle distally until it separates from the pylorus

and remains a part of the specimen (see Figure 49-9).

◆ Ligate and divide the right gastric artery.

◆ After skeletonizing the proximal duodenum, divide the duodenum using the gastrointestinal

anastomosis (GIA) stapler and reﬂ ect the stomach superiorly. This permits a broad, unob-

structed view of the entire operative ﬁ eld including the entire pancreas (Figure 49-10).

Gastroduodenal artery stump

Gallbladder dissected

Penrose drain

Proper hepatic artery

Portal vein

FIGURE 49 –8

CHAPTER 49 • Pylorus-Saving Pancreaticoduodenectomy 555

Penrose drain

Proper hepatic artery

Gastroduodenal artery

stump

Right gastroepiploic artery,

vein, and bundle

Pancreaticoduodenal

artery and vein

Splenic artery

and vein

Celiac trunk

Right gastric artery ligated

FIGURE 49 –9

Gastroduodenal artery

stump

Divided duodenum

Reflect stomach

superiorly

Common hepatic duct

Penrose drain

Pyloric canal

FIGURE 49 –10

556 Section VII • Pancreas

◆ Having established a horizontal plane along the superior and the inferior border of the pan-

creas, now place 2-0 Prolene sutures on the inferior and superior border of the body of pan-

creas to the left and right of the anticipated line of resection of the body of the pancreas. Use

a large needle such as CT-1. These sutures are intended to occlude the intraparenchymal

arteries, which course longitudinally along the superior and inferior borders of the pancreas.

Hemorrhage during the division of the pancreas may thereby be prevented (Figure 49-11).

◆ Divide the pancreas with a scalpel and send a 2-mm margin for frozen section analysis.

Mark the “actual” margin by placing a medium clip on the pancreatic duct on the side of

the divided pancreas oriented toward the tail of the pancreas.

◆ Reﬂ ect the divided body and head of the pancreas toward the right, revealing the superior

mesenteric vein/portal vein conﬂ uence. Divide the short tributaries between the uncinate

process and the superior mesenteric vein and portal vein in continuity using 3-0 silk suture

(Figure 49-12).

◆ Divide the ﬁ nal attachment between the uncinate process and the superior mesenteric artery

between clamps and ligate after visualizing the course of the superior mesenteric artery. From

superior to inferior, the superior mesenteric artery courses downward and toward the right.

Thus, if one carries the dissection in a strictly vertical direction, there is a risk that the

superior mesenteric artery may be inadvertently divided (Figure 49-13).

Duodenum divided

Divide pancreas with scalpel

Sutures around anticipated

line of resection of pancreas

Intrapancreatic vessels

FIGURE 49 –11

CHAPTER 49 • Pylorus-Saving Pancreaticoduodenectomy 557

Portal vein

Splenic vein

Superior mesenteric

vein tributaries

Superior mesenteric artery

Superior mesenteric vein

FIGURE 49 –12

Superior mesenteric

vein tributaries

Portal vein

Superior mesenteric

artery and vein

Superior mesenteric

artery branches

FIGURE 49 –13

558 Section VII • Pancreas

◆ Redirect attention to below the transverse mesocolon. Divide the mesentery of the jeju-

num between clamps beginning approximately 15 cm distal to the ligament of Treitz

and extending the ligation proximally. Divide the jejunum using the GIA stapling device

(Figure 49-14). Divide the avascular elements of the ligament using electrocautery. When

the vascular attachments between the duodenojejunal junction and the superior mesen-

teric artery and vein have been divided, pass the limb of jejunum beneath the artery and

vein through the prior site of the ligament of Treitz. This places the jejunum in the same

plane in which all prior dissection has taken place (see Figure 49-14, inset).

◆ Divide the ﬁ nal vascular attachments between the duodenojejunal junction and the superior

mesenteric artery between clamps and ligate. Remove the specimen (Figure 49-15).

CHAPTER 49 • Pylorus-Saving Pancreaticoduodenectomy 559

Distal end of jejunum

Superior mesenteric artery and vein

Ligament of Treitz dissected

FIGURE 49 –14

Former Ligament of Treitz

Specimen

Superior mesenteric

artery and vein

Distal end of jejunum

Vena cava

Superior mesenteric

artery branches

Superior mesenteric

vein tributaries

FIGURE 49 –15

560 Section VII • Pancreas

3. RECONSTRUCTION

◆ Pass the distal divided limb of jejunum beneath the prior site of the ligament of Treitz, and

position it directly opposite the pancreatic remnant oriented from the divided end of the

pancreas to the side of the jejunal limb. The limb will fall into the right upper quadrant in

the area where the hepaticojejunostomy will be performed (Figure 49-16).

◆ Identify the pancreatic duct. Make an incision from the anterior surface of the pancreas

down to the duct (1.5 cm in length).

◆ Perform an end-to-side pancreaticojejunostomy in a single layer using interrupted 3-0 silk

suture. The anterior surface of the jejunum will drape over the 1.5-cm incision in the

duct. Place the sutures in the pancreatic parenchyma using a broad passage of the needle

to ensure adequate “purchase” and to avoid tearing parenchyma while tying the sutures

(see Figure 49-16).

◆ Perform an end-to-side hepaticojejunostomy using a single layer of interrupted 4-0

polydioxanone (PDS) suture on an RB-1 needle. Use absorbable suture (see Figure 49-16).

◆ Fix the limb of jejunum in place as it passes beneath the prior site of the ligament of Treitz

using an interrupted 3-0 silk stitch.

◆ Perform a duodenojejunostomy in an antecolic fashion 40 cm distal to the hepaticojejunos-

tomy. The anastomosis is performed in two layers with an outer layer of interrupted 3-0 silk

suture and an inner layer of running locking 3-0 Vicryl suture posteriorly, which is con-

verted to a Connell type of stitch anteriorly (Figure 49-17).

◆ Irrigate the peritoneal cavity with warm, sterile saline.

◆ Place two 10-mm Jackson-Pratt drains:

◆ Place one through a stab wound on the left side of the abdomen, and position it posterior

to the pancreaticojejunostomy and posterior to the hepaticojejunostomy.

◆ Place the other through a stab wound on the right side of the abdomen, and position it

anterior to the hepaticojejunostomy and anterior to the pancreaticojejunostomy.

◆ The drains are ﬁ xed in place using drain ﬁ xation sutures of 2-0 silk stitch.

CHAPTER 49 • Pylorus-Saving Pancreaticoduodenectomy 561

Pancreaticojejunostomy

Hepaticojejunostomy

Superior mesenteric

artery and vein

FIGURE 49 –16

Pancreaticojejunostomy

Duodenojejunostomy

Hepaticojejunostomy

Superior mesenteric artery and vein

FIGURE 49 –17

562 Section VII • Pancreas

4. CLOSING

◆ Reapproximate the fascia using heavy-gauge Vicryl suture. We favor the Smead-Jones tech-

nique. Reapproximate the skin and apply dressings. Place drains to close and bulb suction.

STEP 4: POSTOPERATIVE CARE

◆ In the ﬁ rst 24 hours, the primary concerns are hemorrhage (including monitoring coagula-

tion status) and hyperglycemia. Unexpected glucose intolerance after resection and after the

stress of surgery may manifest only as brisk urine output and be interpreted as a sign of

euvolemia. Hemoglobin stability must be documented before close, and interval evaluations

may be stopped.

◆ Delayed gastric emptying is common, and one must establish low nasogastric tube output

before removal (⬍150 mL per 8 hours). Most can be removed on postoperative day 1.

◆ Drains must be monitored for volume and character. On postoperative day 3, these should

be tested for amylase and bilirubin content. Evidence of biliary or pancreatic ﬁ stula is man-

aged by continued drainage.

◆ Intravenous antibiotics are stopped after 24 hours.

◆ Diet is resumed as tolerated. If diet is tolerated and drain output is low and devoid of

enzymes or bile, the drains may be removed.

◆ Pain control progresses from epidural to patient-controlled analgesia versus oral narcotics.

◆ Once the patient is tolerating diet, is ambulating, and has pain controlled by oral agents, he

or she is discharged home.

◆ We rarely require more than 1 day in a critical care setting.

CHAPTER 49 • Pylorus-Saving Pancreaticoduodenectomy 563

STEP 5: PEARLS AND PITFALLS

◆ It is best to understand the potential for challenging anatomy. These circumstances include

patients with prior pancreatic surgery, patients with chronic inﬂ ammation (chronic pancre-

atitis), patients with prior acute pancreatitis (seen in 37% of patients with IPMN), and

patients with tumor close to or invading the superior mesenteric vein and artery.

◆ If severe hemorrhage is encountered beneath the head of the pancreas in the superior mes-

enteric vein/portal vein or if it is encountered after division of the pancreas, several mea-

sures should be considered:

◆ Call for experienced help.

◆ Isolate and control the portal vein, superior mesenteric vein, and splenic vein, and place

either vessel loops or vascular clamps.

◆ Compression should always offer time to establish control and obtain help.

◆ Mobilize the pancreas to achieve the best exposure available.

◆ One potentially useful maneuver is to pass Fogarty catheters into the lumen of each

vein.

◆ If some length of vein is lost, it is possible to mobilize the vein to permit as much as a

3-cm defect to be repaired primarily.

SELECTED REFERENCES

1. Katz MH, Wang H, Fleming J, et al: Long-term survival after multidisciplinary management of resected

pancreatic adenocarcinoma. Ann Surg Oncol 2009;16:836-847.

2. Kow AW, Chan SP, Earnest A, et al: Striving for a better operative outcome: 101 pancreaticoduodenecto-

mies. HPB (Oxford) 2008;10:464-471.

3. Katz MH, Fleming JP, Pisters PW, et al: Anatomy of the superior mesenteric vein with special reference to

the surgical management of ﬁ rst order branch involvement at pancreaticoduodenectomy. Ann Surg

2008;248:1094-1102.