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

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

Incise the peritoneum, which envelops the hepatoduodenal ligament in a transverse direction, beginning in the distal third of this structure. Isolate and encircle, with vessel loops, the common bile duct and the proper hepatic artery and distract these vessels medially and laterally to reveal the portal vein (Figure 49-5).

Establish a plane, if possible, extending from the previously dissected inferior plane of dissection where the superior mesenteric vein courses beneath the head of the pancreas and current plane in the hepatoduodenal ligament where the portal vein has been identified. There is a dense layer of connective tissue overlying the portal vein, and this must be carefully incised to reach the proper plane. Carefully dissecting this plane from the superior aspect permits “meeting in the middle” with the inferior dissection. Pass a 1⁄2-inch Penrose drain along this newly established plane and place clamps separately on each end of the drain (Figure 49-6).

Follow the proper hepatic artery toward the celiac trunk. The proper hepatic artery travels in a generally transverse direction and takes a right-angle turn directed cephalad. At this right angle, the gastroduodenal artery continues along the same direction as the proper hepatic artery. Thus one must identify the common hepatic artery to avoid misidentifying the proper hepatic artery for the gastroduodenal artery. Dissect the gastroduodenal artery free and double loop it with a silk suture, but do not tie (Figure 49-7).

At this point, resectability is established and, if determined, then resection is undertaken. In spite of the fact that 1 or 2 hours of dissection may already have been completed, nothing has been done to this point in the operation that requires reconstruction.

Hepatic triad:

Common bile duct

Portal vein

Proper hepatic artery

Dissect hepatoduodenal ligament

Common hepatic artery

Gastroduodenal artery

Anterior pancreaticoduodenal artery

Superior mesenteric artery and vein

FIGURE 49–5

Portal vein

Penrose drain

Celiac trunk

Proper hepatic artery

Loop around common bile duct

Splenic artery and vein

Common hepatic artery

Gastroduodenal artery

Anterior pancreaticoduodenal artery

Superior mesenteric artery and vein

FIGURE 49–6

Superior mesenteric artery and vein

FIGURE 49–7

5 5 4 S E C T I O N V I I • PA N C R E A S

Dissect the gallbladder free of the gallbladder bed, and dissect the cystic duct/common duct confluence. 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, flat lymph nodes overlie the arterial structures (the celiac trunk, common hepatic artery, and splenic artery root). Include the lymph nodes with the specimen (see Figure 49-8). The head of the pancreas will finally be freely mobile for a transverse distance of 3 to 5 cm. The medial aspect of the portal vein is visualized. The anticipated dividing line for most resections approximates the line nearly vertical along the medial border of the superior mesenteric vein/portal vein confluence (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 reflect the stomach superiorly. This permits a broad, unobstructed view of the entire operative field including the entire pancreas (Figure 49-10).

Penrose drain

Proper hepatic artery

Portal vein

Gallbladder dissected

Gastroduodenal artery stump

FIGURE 49–8

Pyloric canal

FIGURE 49–10

5 5 6 S E C T I O N V I I • PA N C R E A S

Having established a horizontal plane along the superior and the inferior border of the pancreas, now place 2-0 Prolene sutures on the inferior and superior border of the body of pancreas 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.

Reflect the divided body and head of the pancreas toward the right, revealing the superior mesenteric vein/portal vein confluence. 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 final 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).

Intrapancreatic vessels

Duodenum divided

Sutures around anticipated line of resection of pancreas

Divide pancreas with scalpel

FIGURE 49–11

FIGURE 49–12

Portal vein

Superior mesenteric artery and vein

FIGURE 49–13