Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

5 3 2 S E C T I O N V I I • PA N C R E A S

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 inflammatory mass can be released. This may be sufficient 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. Postoperative bleeding is a known complication of this procedure. Once the mass is excised, palpate once again to confirm 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 longitudinal incision along the main pancreatic duct, as is often done in a Puestow type of procedure. 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 portion of the procedure. This addition further exemplifies the similarities between the Beger and the Frey procedures.

Dilated duct incised

Head of pancreas excavated

FIGURE 48–10

Duodenum

Superior mesenteric vein

Uncinate process

Palpation of head of pancreas

FIGURE 48–11

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If the bile duct has been opened, a separate anastomosis with this jejunal limb to the opened bile duct can be performed using interrupted 4-0 Vicryl sutures. We prefer a separate hepaticojejunostomy over an attempt at this type of closure within the head of the pancreas.

The rent in the transverse mesocolon where the limb of jejunum traverses is fixed in place using interrupted 3-0 silk stitch. Next, approximately 40 cm distal to the pancreaticojejunostomy, a side-to-side jejunojejunostomy is performed in two layers, using an outer layer of interrupted 3-0 silk stitch and an inner layer of running locking 3-0 Vicryl stitch posteriorly, which converts to a Connell type of stitch anteriorly. If the bile duct has been entered or sewn, a closed suction drain is placed in the foramen of Winslow and brought out in a separate stab wound on the right side of the abdomen. We do not place a drain across the pancreaticojejunostomy (see Figure 48-14).

FREY PROCEDURE

Once again, the procedure description begins after mobilization of the head of the pancreas and bimanual palpation. Once again, the lesser sac is entered and the Kocher maneuver performed (Figures 48-15 and 48-16).

Palpate the anterior surface of the body of the pancreas, searching for the dilated main pancreatic duct. This is typically easily done by palpating along the very hard texture of the pancreas usually seen in chronic pancreatitis and searching for an area of softer tissue with a feel not unlike that of a palpable vein under the skin. Often the duct seems to be oriented more toward the superior aspect of the body. This is an acquired skill, and even an experienced pancreatic surgeon will at times be challenged to find the duct (see Figure 48-15). After adequately determining the presence of the main pancreatic duct, a 20-gauge angiocatheter is passed into the duct where crystal clear fluid should be encountered.

5 3 8 S E C T I O N V I I • PA N C R E A S

At this point, we often place a catheter using water manometry; we measure the pressure within the main pancreatic duct. Electrocautery is then used to follow the tract of the angiocatheter down into the main pancreatic duct where a larger amount of clear fluid should be encountered. A long narrow hemostat such as a tonsil clamp is used to probe the duct to demonstrate the proper direction to continue the longitudinal incision. Extend the incision toward the tail of the pancreas. It is not necessary to extend through the entire tail, but one should ascertain that no high-grade strictures remain. Similarly, extend the incision toward the head of the pancreas. In contrast to the classic Puestow procedure, one need not extend fully into the duct as it dives deeper into the parenchyma of the head, because this will be excavated later (Figure 48-17).

Place a circumferential line of 2-0 Prolene sutures along the border between the medial aspects of the C-loop of the duodenum and the head of the pancreas. Tie each suture as you proceed, and leave the needles on the sutures. Be careful to avoid needlesticks. The line of sutures begins at the level of the neck of the pancreas on the superior border, typically close to the pylorus. The line of sutures terminates at the neck of the pancreas in the inferior border. This suture line will finally join the suture line in the longitudinal pancreaticojejunostomy (Figure 48-18). Identify the anterior superior and the anterior inferior pancreaticoduodenal arteries, divide, and ligate.