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

5 7 0 S E C T I O N V I I • PA N C R E A S

After a wider entry into the lesser sac is established, the tissues overlying the body and head of the pancreas are carefully dissected free.

The somewhat thickened fatty structure just inferior to the pylorus is the location of the right gastroepiploic artery and vein. It is at times necessary to divide these structures in performing the pancreaticojejunostomy. Very often there is an anterior branch between the right gastroepiploic artery and superior mesenteric vein or the superior mesenteric artery, which courses along the anterior surface of the body/head of the pancreas. It is advised and safe to divide this arterial connection between clamps as one clears the head of the pancreas

(see Figure 50-5).

In most cases, it is possible to palpate the dilated main pancreatic duct. This should be done with the fingertips and at times by using bimanual palpation by passing the left hand beneath the head of the pancreas. Typically the firm texture of a chronic pancreatitis pancreas is easily distinguished from what feels like a canyon through the course of the main pancreatic duct. Typically in chronic pancreatitis, the duct is displaced more anteriorly and therefore is easier to palpate (Figure 50-6).

After the location of the pancreatic duct is satisfactorily established, a 20-gauge angiocatheter is passed into the duct, and the clear pancreatic juice is identified (see Figure 50-6).

We will often perform manometry simply to take note of the presence of high pressures in the main pancreatic duct, which at times have served some predictive value in the success of relieving pain in this operation.

After the location of the duct with the catheter is established, electrocautery is used to open down along the angiocatheter tract into the pancreatic duct. Typically, the pancreatic duct has a reddish smooth surface, which distinguishes it from false passages within the parenchyma of the pancreas. Care should be taken not to enter through the lobulated texture of the pancreas into a false passage. After the duct is established, a tonsil clamp can be used to probe both toward the tail and toward the head of the pancreas, and the electrocautery follows the hemostat’s opened blades (Figure 50-7).

5 7 2 S E C T I O N V I I • PA N C R E A S

It is vital to continue the incision in the main pancreatic duct past the genu of the duct. This portion of the main pancreatic duct courses both inferiorly and posteriorly. Thus the depth of incision into pancreatic parenchyma is considerably greater in this portion of the dissection, and the risk of hemorrhage during this dissection is higher. One should be prepared to perform a suture ligature should one encounter any major bleeding during this dissection. Data confirm that an adequate incision in the main pancreatic duct must include a deep incision into the uncinate process in the head of the pancreas. Suture ligation of these parenchymal arteries is mandatory to prevent postoperative hemorrhage.

After this incision is completed, identify an area of proximal jejunum approximately 15 cm past the ligament of Treitz. The mesentery is divided between clamps in a vertical fashion down toward the spine. After acceptable mobility of the limb of jejunum, a GIA stapling device is placed across the jejunum, and the jejunum is divided (Figure 50-8).

The distal segment of the divided jejunum is passed through a rent in the transverse mesocolon and placed side-to-side against the body of the pancreas, with the divided end of jejunum directed toward the left (Figure 50-9).

5 7 4 S E C T I O N V I I • PA N C R E A S

A side-to-side pancreaticojejunostomy is performed in one layer using interrupted 3-0 silk stitch. The inferior suture line is placed before the jejunum is opened, and these sutures are tied. After the jejunum is opened, the superior row of sutures in the pancreaticojejunostomy is completed by placing a corner stitch to the left and right boundaries and by placing a stitch midway through the longitudinal incision in the body of the pancreas and midway through the incision in the jejunum (Figure 50-10). Immediately tying the sutures on the superior suture line prevents any mismatch in size between the jejunal incision and the pancreatic duct incision. It should be noted that typically the jejunum tends to open much larger than one can anticipate, so care should be taken to place the inferior sutures in the jejunum somewhat closer than they are placed in the inferior aspect of the incision in the wall of the pancreas. After the middle suture on the superior suture line is placed, sutures are placed that bisect the area to the left and right. Finally, individual sutures are placed as appropriate to complete the anastomosis (Figures 50-11 and 50-12).

Completed Roux-en-Y

FIGURE 50–10

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3. CLOSING

At completion of the pancreaticojejunostomy, the limb of jejunum is fixed in place as it traverses the transverse mesocolon with an interrupted 3-0 silk stitch. Finally, 40 cm distal to the pancreaticojejunostomy, a side-to-side jejunojejunostomy is performed in two layers, with 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 (see Figure 50-12).

We do not use drains. The fascia is reapproximated in the normal fashion, and the skin is closed using subcuticular suture.

STEP 4: POSTOPERATIVE CARE

Patients will have had a nasogastric tube placed. This is removed on the first postoperative day. The patient starts with a clear liquid diet, and if tolerated, this is advanced to a regular diet.

Care should be taken in the immediate postoperative period to monitor blood glucose, because these patients often have borderline insufficiency or frank diabetes, and for that reason the stress of surgery may result in significant hyperglycemia.

The only significant postoperative complication that can be anticipated in the first 24 to 48 hours is hemorrhage. For that reason, one should carefully monitor hemoglobin levels. Once these have proved to be stable, it is not necessary to continue to monitor these.

STEP 5: PEARLS AND PITFALLS

It can be challenging to find the pancreatic duct in some patients. Although the duct is easily palpable in most, it is not in some. On rare occasions, it may be necessary to perform a vertical incision in the mid-portion of the anterior surface of the body of the pancreas as a means of searching for the actual pancreatic duct. Care should be taken not to

extend this incision to either the superior or the inferior border of the pancreas. It is also often possible to express some of the pancreatic juice by massaging either the anterior surface of the tail of the pancreas or the anterior surface of the head of the pancreas. The pancreatic juice is crystal clear and should be easily recognized during this palpation.

As mentioned during the operative procedure, the mismatch between the opening in the jejunum and the opening in the pancreatic duct can be problematic. Care should be taken to limit the size of the opening in the jejunum until one can be certain that it is does not greatly exceed the length of the opening in the main pancreatic duct.

It is not uncommon to have associated bile duct stricture in patients undergoing Puestow procedure, and consideration should be given to the possible need for a hepaticojejunostomy at the same time as the pancreaticojejunostomy.

One may typically encounter stones either within the main pancreatic duct or easily palpable in some of the dilated side branches. We advocate removing these stones when possible. Instruments such as Fogarty catheters and some instruments typically used for biliary lithiasis may be helpful in this event.

SELECTED REFERENCES

1. Katz MH, Wang H, Fleming JB, 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 Pancreaticoduodenectomies. HPB (Oxford) 2008;10:464-471.

3. Katz MH, Fleming JB, Pisters PW, et al. Anatomy of the superior mesenteric vein with special reference to the surgical management of first-order branch involvement at pancreaticoduodenectomy. Ann Surg 2008;248:1098-1102.

C H A P T E R 51

PSEUDOCYSTS—CYSTOGASTROSTOMY, CYSTODUODENOSTOMY, AND

CYSTOJEJUNOSTOMY

William H. Nealon

STEP 1: SURGICAL ANATOMY

All pancreatic surgery requires an understanding of the anatomic relationships in the lesser sac (see Figure 47-1). After either an upper midline or a bilateral subcostal (chevron) incision, one enters the lesser sac by dissecting along the avascular plane at the points of attachment of the gastrocolic omentum to the transverse colon. The proper plane is between the anterior and posterior leaflets. This is my favored point of entry. The alternative entry is by transversely dividing and ligating the vascular structures embedded in the omentum while preserving the gastroepiploic vessels located along the greater curvature of the stomach.

Upon entering the lesser sac, one will encounter varying amounts of adhesions between the posterior wall of the stomach and the anterior surface of the pancreas. These fetal adhesions do not imply prior inflammatory events. Considerable dense adhesions may be encountered in pathologic states.

The pancreas is essentially encased in a sandwich of major blood vessels. The vena cava and aorta occupy the posterior surface in the midline. The splenic artery courses along the superior surface from the aorta toward the tail. The splenic vein occupies the posterior superior surface of the body and tail of the pancreas. It meets the superior mesenteric vein, which is oriented vertically in the groove created by the uncinate process in the posterior aspect of the head of the pancreas and the right lateral and anterior components of the head. The confluence of these two veins constitutes the portal vein, which traverses this uncinate groove and emerges to join the bile duct and the hepatic artery in the hepatoduodenal ligament.

The superior mesenteric artery is located in a plane posterior and slightly medial to the superior mesenteric vein. The common hepatic artery, another branch of the celiac trunk (along with the splenic artery and left gastric artery), courses along the superior border of the head of the pancreas to join the hepatoduodenal ligament. Its first branch is the typically miniscule right gastric artery. Just distal is the more substantial gastroduodenal artery, which emerges at a right angle to the hepatic artery from its inferior surface and courses beneath the pylorus, and after sending the right gastroepiploic artery in the plane between the inferior aspect of the pylorus and the superior surface of the head of the pancreas, the gastroduodenal artery pierces the head of the pancreas.

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