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39
Pancreatic duct
Catheter
Anterior layer of sutures
40
42
Alternate method
Catheter
41a
41b
Pancreatic duct
Pancreas
First row
of sutures
Pancreas
43
Pancreas
Gastrojejunal
anastomosis
44
Second row of sutures
Preparation of
gastric stoma
Pancreas
Mesentery
closed
Catheters to be removed
293
Stomach
PLATE
138
INDICATIONS Total pancreatectomy may be indicated in the treatment of
neoplasms of the pancreas as well as for incapacitating, chronic, recurrent
pancreatitis. Excision of the entire gland ensures more complete removal
of neoplasms but adds little to the average long-term survival. Multicentric
tumor locations are excised and cellular implantations are obliterated
within the remaining ductal system, and intimately attached lymph nodes
are excised. Removal of the pancreas simpli es the reconstruction of the
upper gastrointestinal tract and minimizes the complications from pancreatic duct implantation, postoperative pancreatitis, hemorrhage, and sepsis.
e diabetes associated with total pancreatectomy is di cult to manage
because of hypoglycemia and requires careful and frequent evaluation of insulin requirements. e indications for this procedure are related not only to the
clinical history but also to the ndings at the time of the surgical exploration.
PREOPERATIVE PREPARATION ese patients are frequently poor surgi-
cal risks who have lost considerable weight and may be diabetic. e blood
volume should be restored and blood sugar levels monitored. Total parenteral nutrition may be indicated for several days before exploration. In
the presence of deep jaundice, the biliary tree is decompressed by percutaneous transhepatic intubation or stenting using at the time of endoscopic
retrograde cholangiopancreatography. e bile is cultured and the appropriate antibiotics are given, depending upon sensitivity studies. Vitamins
are given along with pancreatic replacement if oating stools are present.
Several units of blood should be available. Systemic antibiotics are given.
Constant gastric suction is instituted.
ANESTHESIA General anesthesia combined with endotracheal intubation
is satisfactory.
POSITION e patient is placed in a comfortable supine position.
OPERATIVE PREPARATION e skin of the lower thorax as well as of the
entire abdomen is prepared in a routine manner.
T P
INCISION AND EXPOSURE A liberal midline incision extending from
over the xiphoid process down to or below the le of the umbilicus is made
(figure 1). Some prefer an inverted U incision that parallels the costal
margins and crosses the midline near the top of the xiphoid process. All
bleeding points are carefully controlled. e rst decision involves establishing the diagnosis, ascertaining the presence or absence of metastases,
and nally, establishing the mobility of the pancreas with special reference to the portal vein. Any evidence of distant metastasis to the omentum, the base of the mesentery of the transverse colon, or to the liver or
adjacent lymph nodes makes any procedure palliative. In the absence
of metastasis, and in the presence of a freely movable pancreas, further
exploration is warranted. e removal of the entire pancreas does simplify
the reconstruction of the gastrointestinal tract by a variety of methods
(figures 2 and 3). Only the common duct and the remaining hemigastrectomy remain to be anastomosed to the jejunum.
DETAILS OF PROCEDURE e omentum is detached from the transverse
colon and the lesser sac inspected a er the right gastroepiploic vessels are
divided. A Kocher maneuver is carried out to mobilize the duodenum and
head of the pancreas (figure 4). Needle or knife biopsies of any suspicious
tumor mass are taken, and suspicious regional lymph nodes are sent for
frozen-section examination.
e duodenum and head of the pancreas can be mobilized as for the
Whipple procedure (Plates , , and ). When it has been decided to
remove the body and tail of the pancreas as well as the head, the peritoneum along the inferior border of the pancreas is incised in preparation
for mobilization by blunt nger dissection (figure 5). e splenic artery
is ligated near its point of origin. A er the peritoneum over the portal vein
has been incised, it is possible to insert the nger between the pancreas and
the portal vein (figure 6). ere should be no communicating veins anteriorly. e pancreas can be divided with electrocautery in this area, and the
two segments of the pancreas resected separately if preferred.
CONTINUES
294
1
Types of
incicions
3
2
Vagotomy
Right
gastroepiploic
vessels
4
Stomach
B
A
Methods of
reconstruction
Tumor
Colon
5
6
Left
gastric vessels
Ligated
splenic artery
Portal
vein
Line of
incision
Middle
colic vessels
Pancreas
Retroperitoneal
area
295
PLATE
139
DETAILS OF PROCEDURE Although antrectomy with gas-
trojejunostomy is the usual technique for reconstruction, some preserve
the entire stomach and pylorus plus several centimeters of duodenal bulb
for end-to-side anastomosis to the jejunal limb according to the method of
Longmire. In the usual reconstruction, however, better exposure is obtained
for the subsequent steps of the procedure if the stomach is divided at a level
that ensures complete removal of the antrum (figure 7). Truncal vagotomy
also is performed to decrease the incidence of late postoperative gastrojejunal stomal ulceration, unless lifetime treatment with proton pump inhibitors
or other acid suppressing medication is determined to be preferable.
T P
e spleen is freed up and all gastrosplenic vessels are divided and
ligated. e spleen and le half of the pancreas are re ected to the right,
providing good exposure for maximal ligation and division of the splenic
artery and vein at their origins (figure 8). Any arterial branches to the
superior mesenteric artery are carefully isolated and ligated (figure 9).
e most di cult part of the procedure may be the isolation and ligation of
the several short veins entering between the portal vein and the pancreas
(figure 10). e ligated right gastric artery and the pancreaticoduodenal
artery are shown in figure 10.
CONTINUES
296
297
PLATE
140
DETAILS OF PROCEDURE e gallbladder is removed in a
routine manner and the liver bed may be closed with interrupted sutures. A
noncrushing clamp is applied across the common duct and the duct is divided
(figure 11). e next step is to excise the rest of the duodenum down to and
slightly beyond the ligament of Treitz (Plate , figures 27 and 28).
A long arm of jejunum is prepared by dividing several vascular arcades
(figure 12). e mobilized jejunum is brought through an opening made
in the mesocolon of the transverse colon (figure 12). is opening is
made at either side of the middle colic vessels, depending upon how easily the jejunal loop can be brought up to the region of the common duct.
e jejunum is closed with a running absorbable suture or a stapler,
and this layer is inverted with a layer of silk mattress or interrupted
sutures. Following a gastrojejunal anastomosis, the jejunal loop is anastomosed without tension to the common duct (figure 2). Alternatively,
some prefer to anastomose the biliary duct to the jejunum, followed by
an anastomosis with the gastric pouch (figure 3). It is not necessary to
make the stoma the full width of the stomach. A stoma of to cm can
be made at the greater curvature end (figure 13). e jejunum should
T P
be anchored to the entire gastric outlet, regardless of how much has been
closed o by sutures. e jejunum between the stomach and the common
duct should be quite loose and free of tension (figure 14). All openings
in the mesocolon about the arm of the jejunum should be closed with
interrupted sutures to avoid angulation of the arm of jejunum or the possibility of an internal hernia. Closed-system suction catheters made of
Silastic are used.
CLOSURE e incision is closed in the routine manner. A subcuticular
close of the skin may be used, or the skin may be approximated with interrupted sutures or clips.
POSTOPERATIVE CARE Constant gastric suction is maintained until
bowel function returns within a few days. Blood sugar levels are determined
every to hours until stable control is attained. e amount of insulin
may not exceed to units daily in some patients. An insulin drip may
be necessary in the initial days a er surgery. Blood losses must be replaced.
Oral pancreatic replacement therapy is started as soon as tolerated. Frequent
nutritional evaluation is essential in postoperative care. ■
298
299
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MISCELLANEOUS
ABDOMINAL
PROCEDURES
PLATE
141 S
INDICATIONS e most common indications for splenectomy are irreparable
traumatic rupture and hematologic disorders. In splenic injury, nonoperative protocols result in a signi cant improvement in splenic salvage in both children and
adults. However, in severe splenic injury, particularly in severe multisystem trauma,
splenectomy is indicated. In some cases, splenic salvage is warranted. e most
common hematologic disorders requiring splenectomy include immune (idiopathic) thrombocytopenic purpura, thrombotic thrombocytopenic purpura, and
hereditary spherocytosis. Prior to splenectomy, clinical evaluation should be performed by an experienced hematologist and a bone marrow biopsy may be necessary to exclude unexpected bone marrow disorders not improved by splenectomy.
Whereas in the past emergency splenectomy may have been occasionally needed
in severe thrombocytopenia associated with hemorrhagic complications, today
this is almost never needed, as nearly all patients will have improvement in platelet
counts in response to steroids, intravenous immune globulin or Rho D immune
globulin (winrho). Splenectomy may be indicated in cysts and tumors. Symptomatic bene t may follow splenectomy in certain other conditions, such as secondary
hypersplenism, Felty’s syndrome, Banti’s syndrome, Boeck’s sarcoid, or Gaucher’s
disease. In these latter patients, the surgeon should work in consultation with an
experienced hematologist and medical specialists. In the past either total or partial
splenectomy was indicated as part of the procedure of “staging” to determine the
extent of Hodgkin’s disease
ally, those patients who are considered candidates for primary radiation therapy,
would undergo staging laparotomy (pathologic staging) to rule out de nitively the
presence of occult subdiaphragmatic disease. An appreciation of the risks of laparotomy and a recognition of the e ectiveness of salvage chemotherapy in patients who
fail primary radiation therapy have permitted the increased use of clinical staging as
the basis for treatment of these patients.
Laparoscopic splenectomy is clearly the procedure of choice when technically
feasible for elective splenectomy. It should be considered in all elective splenectomy
cases. Relative contraindications may be considered in certain cases of previous surgery or a large spleen. Coagulopathy is not a contraindication and may actually do
better with the laparoscopic approach.
PREOPERATIVE PREPARATION It is necessary to consider the nature of the
disease for which splenectomy is indicated in order to give the proper preoperative
treatment. In congenital hemolytic icterus, preoperative transfusion is contraindicated, even in the presence of the most severe anemia, because of the likelihood
of precipitating a hemolytic crisis. In cases of thrombocytopenic purpura, platelet
transfusions may be given the morning of operation if indicated. e patient with
primary splenic neutropenia, panhematopenia, or other types of hypersplenism
is transfused as indicated by his general condition and the information gained
from the clinical studies. Antibiotic therapy is given in the presence of neutropenia. Large amounts of blood should be available in cases of suspected traumatic
rupture of the spleen, and the patient should be operated on as soon as his condition permits. Prompt splenectomy may be a lifesaving procedure in some patients
with a blood dyscrasia, especially those with primary thrombocytopenic purpura.
Previous steroid therapy should be continued preoperatively and during the early
postoperative period.
ANESTHESIA General anesthesia is usually satisfactory and may be supple-
mented with muscle relaxants. Patients who have severe anemia should receive little
premedication, and ample oxygen should be administered with the anesthetic. In
the presence of a low platelet count, great care is taken to avoid trauma to the mouth
and upper respiratory passages, since hemorrhage may occur.
POSITION e patient is placed in a supine position. e spleen is made more
accessible by tilting the table to lower the feet.
OPERATIVE PREPARATION e skin is prepared in the routine manner. Gas-
tric intubation is avoided in portal hypertension or in the presence of a low platelet count, i.e., thrombocytopenic purpura, in order to avoid initiating hemorrhage.
However, in other indications it can be used to ensure a collapsed stomach and an
improved exposure.
INCISION AND EXPOSURE Two types of incision are commonly used: a liberal
incision midline from the xiphoid down to the level of the umbilicus (figure 1, a),
or a le oblique subcostal incision (figure 1, b). e vertical incision is usually
employed. In the presence of proven gallstones, the incision is placed in the midline
to facilitate removal of the diseased gallbladder, if the splenectomy has progressed
satisfactorily and was uneventful.
If a bleeding tendency exists in the presence of blood dyscrasias, it is necessary
to exercise rigid control of all bleeding points. In the very ill and anemic patient
the general oozing may be controlled by pressure with warm, moist gauze pads,
so that the abdomen may be opened and the splenic artery ligated as soon as possible. is will o en e ect a marked decrease in the bleeding tendency as soon as
the artery is clamped. In the absence of acute intra-abdominal hemorrhage or an
acute hemolytic blood crisis, the abdomen is explored. e gallbladder should be
carefully palpated if the splenectomy has been indicated for hemolytic jaundice,
since gallstones frequently occur in such patients. e pelvic organs in the female
are palpated carefully for evidence of other pathology that might be responsible for
. Historically stage I and II Hodgkin’s disease, tradition-
excessive blood loss from the reproductive system. Enlarged lymph nodes should be
biopsied and any accessory spleens removed.
e colon is packed downward out of the eld of operation by warm, moist
gauze, and the rst assistant maintains downward traction with a large S retractor.
A Babcock forceps is applied to the stomach, and a retractor is placed under the rib
margin on the le to facilitate the exposure of the spleen.
DETAILS OF PROCEDURE e exact procedure depends upon many factors:
the size and mobility of the spleen, the presence of extensive adhesions between the
spleen and the parietal peritoneum, the length of the splenic pedicle, the presence
of active bleeding from a ruptured spleen, or the patient’s poor general condition as
a result of blood dyscrasia. e approach to the immobilization and control of the
blood supply of the spleen must be individualized in each case. A thorough understanding of the attachments and blood supply of the spleen is essential (
When splenectomy is indicated for blood dyscrasias, a careful search should be
made for an accessory spleen both before and a er the spleen is removed and hemostasis is e ected (
region, A; the splenorenal ligament, B; the greater omentum, C; the retroperitoneal
region surrounding the tail of the pancreas, D; the splenocolic ligament, E; and the
mesentery of the large and small intestines, F (
found in two or more locations, one is usually in the hilus. In some cases of blood
dyscrasias the clinical course of the patient may suggest recurrence of the disease
because of a retained accessory spleen. In such instances not only should the sites
mentioned above be searched but the search should also be extended to the adnexa
in the pelvis. e spleen must not be lacerated, nor should remnants be le
the abdomen because of the danger of seeding, which may result in splenosis.
e diagram in
traction is exerted on the stomach medially, an avascular area in the gastrosplenic
ligament may be incised, giving direct entrance to the lesser sac. Several blood
vessels in the gastrosplenic ligament are divided and ligated to provide adequate
exposure of the splenic artery. Along the upper margin of the pancreas, the tortuous course of the splenic artery can be palpated. e peritoneum over the vessel is
incised carefully, and a long right-angle clamp is introduced beneath the artery to
isolate it and to facilitate its ligation. e splenic vein is immediately beneath the
artery. One or more silk sutures are drawn beneath the artery and carefully tied
(
figure 3). Preliminary ligation of the splenic artery has many advantages. It allows
blood to drain from the spleen, providing an autotransfusion. e spleen tends to
shrink, making its removal easier and with less blood loss. Finally, blood transfusions can be given immediately to the patient with hemolytic anemia. is preliminary step does not prolong the procedure and tends to ensure a safer splenectomy
with minimal blood loss.
A er the splenic artery has been secured, the remainder of the gastrosplenic ligament is divided between small curved clamps (
especially toward the upper margin of the spleen, to avoid injuring the gastric wall
during the application of clamps, for in this area the gastrosplenic ligament is sometimes extremely short. is is especially true when the spleen is very large or in the
presence of portal hypertension. Failure to secure the uppermost vein in the gastrosplenic ligament can result in serious blood loss. Because of the danger of postoperative bleeding following gastric dilatation, the vessels along the greater curvature
should be ligated with a trans xing suture that includes a bite of the gastric wall. In
addition, in this area several vessels commonly extend from the hilus of the spleen
over to the posterior wall near the greater curvature high on the fundus. At the inferior margin of the spleen, fairly sizable vessels, the le gastroepiploic artery and vein,
commonly will be encountered in the gastrosplenic ligament (
tents of the clamps are ligated on both the gastric and splenic sides, since the division
of the gastrosplenic ligament will leave a large opening directly into the lesser sac.
e preliminary ligation of the major splenic artery makes mobilization of the
spleen easier and safer. e surgeon passes the le hand over the spleen in an e ort
to deliver it into the wound (
the spleen and the peritoneum of the abdominal wall or the le diaphragm; however, the spleen can usually be mobilized a er a few avascular adhesions and the
gastrosplenic ligament have been divided.
As the spleen is mobilized, the surgeon passes the ngers over its margin to
expose the splenorenal ligament, which should be incised carefully (
peritoneal re ection in this area is usually rather avascular; however, it is necessary
to ligate many bleeding points in the presence of portal hypertension. Usually, the
index nger can be inserted into the peritoneal opening, and by blunt dissection
with the index nger of the le hand, which extends over the surface of the spleen,
the margin of the spleen can be freed easily (
tly since the capsule may be torn, resulting in troublesome bleeding or seeding of
splenic tissue.
A er the posterior margin of the spleen has been mobilized, the spleen may be
brought well outside the abdomen; however, if dense adhesions between the spleen
and the parietal peritoneum are encountered, it is easier to incise the overlying peritoneum and carry out a subperitoneal resection, which leaves a large, raw space.
is may be safer than attempting to free the spleen with sharp dissection. Warm,
moist packs may be introduced into the splenic bed to control oozing. Active bleeding points should be controlled with electrocautery.
figure 2). A routine search is made in the following order: the hilar
figure 2). If accessory spleens are
figure 2 illustrates the anatomic relationships of the spleen. As
figure 4). Great care is exercised,
figure 4). e con-
figure 5). Dense adhesions may be present between
figure 7). is must be done gen-
CONTINUES
figure 2).
within
figure 6). e
302
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