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

Stomach

Pancreas

Pseudocyst

FIGURE 51–9

Stomach

Pancreas

Pseudocyst

FIGURE 51–10

5 9 0 S E C T I O N V I I • PA N C R E A S

We then perform a Kocher maneuver by incising the peritoneum along the line outlining the lateral border of the C-loop of the duodenum and mobilizing the duodenum and the head of the pancreas toward the left, teasing the loose the areolar tissue in the retroperitoneum. This permits bimanual palpation of the head of the pancreas and permits the surgeon to ascertain the exact location of the cyst (Figure 51-11). Having ascertained the area of the duodenum most closely approximating the location of the cyst, the surgeon performs a duodenotomy. Stay sutures of 3-0 silk stitch are placed well away from the margin of the duodenum to the head of the pancreas, and after these have been placed, a longitudinal incision is made in the duodenum for the length of approximately 4 cm (Figure 51-12). With proper palpation, one can confirm the area of the posterior wall of the duodenum as it abuts the cyst. At this point, we place an angiocatheter into the cyst and confirm that cyst fluid aspirates (Figure 51-13). We then use electrocautery to carefully dissect through the posterior wall of the duodenum into the cyst. We excise a small portion of the wall of the cyst and send for frozen section analysis to exclude a neoplasm (Figure 51-14).

Duodenum

Kocherized

Palpation of pseudocyst

FIGURE 51–11

Duodenectomy

Pseudocyst

FIGURE 51–12

Angiocatheter

FIGURE 51–13

Dissection through wall of duodenum

FIGURE 51–14

5 9 2 S E C T I O N V I I • PA N C R E A S

We then open the cyst for a diameter of approximately 2 cm and place 3-0 Prolene sutures in a running fashion circumferentially around the duodenotomy into the cyst (Figure 51-15). In a cross-sectional view, one can see the orientation of the cystoduodenostomy to the pancreas and duodenum (Figure 51-16). Any solid material in the cyst is removed. We again obtain culture of the cyst fluid.

Running circumferential sutures

FIGURE 51–15

FIGURE 51–16

After this has been done, the longitudinal incision in the duodenum is closed in a transverse fashion similar to a technique of closure first described by Heineke and Mikulicz in their description of a pyloroplasty. This closure is performed in two layers with an outer layer of interrupted 3-0 silk stitch and an inner layer of a Connell type of stitch. Just as in the closure of the gastrotomy, the running absorbable suture line is again taken from each corner and tied in the middle. In this anastomosis, however, the superior and the inferior extent of the duodenotomy are sutured together at the midpoint of the transverse closure. To start, place a Lembert-type stitch with 3-0 silk at exactly the midpoint of the duodenotomy on both the lateral and the medial edges. These will be the new corners. Complete the Connell sutures and then place interrupted silk sutures to complete the closure (Figures 51-17 and 51-18). At completion, the closure should look to be at right angles to the course of the duodenum. This is performed to prevent any significant narrowing of the duodenum after the duodenotomy.

3-0 continuous sutures to close mucosa

FIGURE 51–17

Interrupted sutures to close seromuscularis

FIGURE 51–18

5 9 4 S E C T I O N V I I • PA N C R E A S

Cystojejunostomy

When the decision is made to proceed to a cystojejunostomy (our procedure of choice), a Roux-en-Y reconstruction is required. Although this reconstruction can be used for pseudocysts and any number of locations it really is the only option for pseudocyst in the mid-pancreas without any clear shared plane with the posterior wall of the stomach (Figure 51-19).

Once again, we typically perform this procedure by entering the lesser sac. This is achieved by dividing the attachments between the gastrocolic omentum and the transverse colon. We begin this dissection to the left of the spine and extend it over to the hepatic flexure

(Figure 51-20). If this access point is achievable, one may expose the anterior surface of the pancreas, and in most cases, the pseudocyst will be identified and palpable in this area. Care should be taken if extensive adhesions are encountered between the posterior wall of the stomach and the pseudocyst. However, it is not necessary to completely skeletonize the cyst (Figure 51-21). Once an acceptable exposure of the cyst has been performed in the lesser sac, one may then place an angiocatheter into the cyst to confirm the presence of cyst fluid. Finally, an incision for a length of approximately 3 cm is performed transversely, and a large amount of fluid typically is removed.

Any solid material in the cyst is removed and cultures are routinely obtained.

Stomach

Pseudocyst

Duodenum

Pancreas

FIGURE 51–19

Stomach

Pseudocyst

Pancreas

Gastrocolic attachments divided

FIGURE 51–20

Interrupted 3-0 sutures

Roux-en-Y limb

FIGURE 51–21

5 9 6 S E C T I O N V I I • PA N C R E A S

An area is chosen in the proximal jejunum approximately 15 cm distal to the ligament of Treitz. This is divided using a gastrointestinal anastomosis (GIA) stapling device, and mesentery is divided vertically toward the base of the mesentery to provide adequate length of jejunum to reach the pseudocyst. The distal end of the divided jejunum is brought up to the opening in the pseudocyst (see Figure 51-21). A single layer of 3-0 silk interrupted suture is used to first attach the jejunum to the inferior border of the open cyst before incising the jejunum (see Figure 51-21), and subsequently the anterior edge is similarly closed

(Figure 51-22).

After this has been completed, a jejunojejunostomy is performed approximately 40 cm distal to the cystojejunostomy in a side-to-side fashion in two layers, with an outer layer of interrupted 3-0 silk stitch and an inner layer of running locking 3-0 Vicryl stitch on the posterior wall. This is converted to a Connell type of stitch anteriorly. The rent in the mesentery, if one was used, is then reapproximated using 3-0 silk stitch, and any mesentery defect created by the jejunojejunostomy limb is reapproximated using 3-0 silk stitch (see Figure 51-22).

Completed cystojejunostomy

End-to-side

jejunostomy

FIGURE 51–22

In the event that one cannot easily access the lesser sac, we will occasionally resort to an incision through the transverse mesocolon into the cyst. We will at times use intraoperative ultrasound to facilitate this access point (Figure 51-23).

After adequately palpating through the transverse mesocolon, one will use an angiocatheter to confirm the access to the cyst and, by palpation, will determine that there are no significant mesenteric vessels in the line of dissection. In this case, some of the fat of the mesentery may be carefully divided, and after palpating the wall of the cyst, one may make an incision into the cyst following the path of the angiocatheter. A length of approximately 3 cm is achieved.

Transverse colon

Pseudocyst under

mesocolon

Mesocolon

Angiocatheter

FIGURE 51–23