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13
Dilated
common duct
14
Right
gastric vessels
15
Pylorus
Right
gastric vessels
Tape
Right
gastroepiploic vessels
16
Antrum
Tumor
17
17a
Area cleared for
anastomosis
Pylorus
Common duct
Tail of pancreas
Stomach
283
PLATE
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133
P
(W P)
DETAILS OF PROCEDURE If there is oozing between the
staples, it is controlled by interrupted sutures of silk. e upper half
of the approximated gastric outlet is inverted by a layer of interrupted
silk mattress sutures (figure 18). A su cient length of the gastric outlet
near the greater curvature is retained to provide a stoma approximately two
to three ngers wide. is portion of the gastric wall should not be excised
until the nal steps of the anastomosis, although it may be necessary to
apply several sutures along the line of the clips to control oozing.
A very critical point now involves the identi cation of the common
hepatic artery and the gastroduodenal artery, which runs downward over
the pancreas behind the duodenum (figure 19a). e common hepatic
artery may be located by palpation just above the pancreas. e peritoneum
over it is carefully incised and this major artery clearly visualized in order
to avoid its injury. By blunt dissection, the surrounding tissue is separated
until the origin of the gastroduodenal artery is visualized. is vessel must
be identi ed clearly and doubly ligated (figure 19b). e lumen of the
common hepatic artery must not be encroached upon. e tissues about
the right gastric artery also must be freed gently and separated upward, as
shown by the dotted line (figure 19b). Following the ligation of these two
vessels, blunt dissection with a long right-angle clamp may be undertaken
to further free the region of the common duct and portal vein (figure 20).
Since these patients are o en rather emaciated, there is relatively little tissue
to be separated away from the portal vein. Great care should be taken gently to develop a cleavage plane over the portal vein, which will permit the
surgeon to introduce carefully a blunt-nosed clamp, such as a right-angle
clamp, behind the pancreas and to open and close the clamp as the tissues
are separated from the underlying portal vein. It may be safer and easier
for the surgeon to introduce the index nger directly behind the pancreas
and over the portal vein. Considerable time should be spent in manipulating the pancreas o the portal vein. is can be done since no vessels enter
from the anterior surface of the portal vein. e tissues about the inferior
surface of the pancreas may need to be incised so that the nger can be
introduced completely underneath the pancreas and come out inferiorly
near the region of the middle colic vein (figure 21).
Better exposure is gained if the body and tail of the pancreas have been
mobilized to serve as traction for the delicate dissection around the portal vein. Otherwise, the subsequent technical details of the procedure can
be enhanced if the pancreas is divided at this point. A blunt-nosed rightangle clamp is passed between the anterior surface of the portal vein and
the neck of the pancreas. e pancreas is divided with electrocautery
(figure 22). ere is usually one sizable bleeding point above the pancreatic duct (figure 23) and at least two other vessels below the pancreatic
duct. ese are controlled with suture ligatures of ne silk or electrocautery, making certain not to occlude the pancreatic duct. Although there
is debate about the value of obtaining a negative microscopic margin at
neck some surgeons continue to obtain a tissue sample for frozen section.
In this case a knife is used to take a -mm cross section of the divided
pancreas for frozen section to ensure negative margins. If the margin is
positive, additional pancreas should be removed. e duodenum and head
of the pancreas to be excised are grasped primarily with the surgeon’s le
hand as she proceeds gently to identify the friable vessels entering the head
of the pancreas from the right side of the portal vein.
CONTINUES
284
18
Exposure of common hepatic artery
19a
Area of anastomosis
Common hepatic artery
Right gastric artery
Gastroduodenal
artery
19b
Common
hepatic artery
Gastroduodenal
artery
20
22
Right
gastric artery
21
Common
hepatic artery
Pancreas
Middle
colic vein
Common duct
23
Portal vein
Line of incision
Pancreatic duct
285
PLATE
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134
P
(W P)
DETAILS OF PROCEDURE With the index nger of the
le hand above and the thumb below compressing the specimen to be
excised, the surgeon applies right-angle clamps in pairs to the strand of
tissue that extends from the portal vein into the pancreas (figure 24).
Within this strand of tissue, there are a number of small veins that must
be ligated very carefully lest troublesome bleeding occur. All areas should
be ligated to keep the specimen as free of clamps as possible while the
third portion of the duodenum is freed from the region of the ligament of
Treitz and the superior mesenteric vein and artery (figure 25). is can
be one of the most di cult steps in the procedure. An incision into the
peritoneum about the third portion of the duodenum produces an opening directly into the general peritoneal cavity, through which the upper
jejunum eventually will be pulled for the anastomosis (figure 25). e
blood supply in the mesentery to the third part of the duodenum and
adjacent jejunum is very short, and it is o en di cult to mobilize the area
about the ligament of Treitz with a minimal loss of blood. Small bits of
the mesentery near the duodenal wall are incorporated between pairs of
small curved clamps, and the contents are ligated as this area of the duodenum is further freed (figure 26). e attachment of the duodenum
that tends to x the duodenum beneath the inferior mesenteric vein may
be identi ed more easily and clamped if a portion of the upper jejunum
is pulled through the opening made in the transverse mesocolon in the
region of the ligament of Treitz (figure 27). e remaining short mesenteric attachments, including arterial branches going into the inferior
mesenteric artery, can then be clamped carefully with curved clamps if a
portion of the upper jejunum is pulled through the opening made in the
mesocolon (figure 28). Alternatively, the surgeon may choose to dissect
the ligament of Treitz and proximal jejunum from the le side of the mesentery. is approach is preferred in obese patients in whom exposure in
this area is di cult.
CONTINUES
286
24
Pancreatic veins
26
25
Portal vein
Middle
colic vein
Ligament of Treitz
Short mesentery
27
Superior
mesenteric
vein
Jejunum
28
Opening in mesocolon
Splenic vein
Short mesentery
287
PLATE
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135
P
(W P)
DETAILS OF PROCEDURE Since the gallbladder is o en quite
large and distended, it should be removed to provide additional room and
prevent late complication from gallstone formation (figure 29). Many surgeons prefer to remove the gallbladder prior to dissection of the porta hepatis
and identi cation of the common bile duct. Attention is now directed toward
further mobilization of the upper jejunum in the region of the ligament of
Treitz (figure 30). Usually, the peritoneum has been opened from above
the colon, just about where the dotted line is shown. e upper jejunum is
grasped with Babcock forceps and the bowel held up in order to enhance the
visualization of the arcades providing the rich blood supply to the jejunum.
Incisions are made through the avascular portion of these arcades, so that
two or three of the basic arcades can be divided and double ligated to enhance
the mobilization of the upper jejunum (figure 31). e nal result is shown
in figure 31; whereas figure 12, Plate provides additional guidance as
to the area of mesenteric division below the proximal jejunal vascular arcade.
e arcade to be divided must be identi ed very carefully, and no vessels
should be ligated in the mesentery near the mesenteric border of the bowel,
since the blood supply to that segment may be compromised. When a segment of the mesentery of the upper jejunum has been divided, the jejunum is
brought up through the opening in the mesocolon underneath the superior
(figure 31). A point to divide the bowel is selected where the mesenteric blood
supply is obviously good (figure 31). About cm of the mesenteric border is
freed of blood supply and the jejunum divided with a cutting linear stapler
(GIA). e specimen is removed and the jejunal arm is brought up through
the opening in the mesocolon must be long enough to reach well up into the
gallbladder fossa without undue tension or compromise of the blood supply.
If there appears to be considerable tension, the bowel should be returned back
below the colon and additional mesentery divided.
CONTINUES
288
Ligament of Treitz
29
Cystic artery
30
Portal
vein
Cystic duct stump
Division of mesentery
Mobilized
jejunum
31
Portal vein
Pancreas
Right kidney
289
PLATE
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136
P
(W P)
DETAILS OF PROCEDURE e diagrams in figures 32a and
32b outline two of the many variations of reconstruction a er removal of the
duodenum and head of the pancreas that have been developed. When total
pancreatectomy is performed, only the common duct and end of the stomach, or the rst portion of the duodenum if the entire stomach is preserved,
are anastomosed to the Roux-en-Y arm of the jejunum. e bile and pancreatic ducts are arranged to empty their alkaline juices into the jejunum before
the acid gastric juice as a measure of protection against peptic ulceration.
e mobilized jejunum can be used safely in a variety of ways for the several
anastomoses required. e end of the jejunum can be closed and anchored
up into the region of the gallbladder bed, followed by direct anastomosis
with the dilated common duct and pancreatic duct within a very short distance of the closed end of the jejunum. e jejunum is then anastomosed
to the partly closed end of the gastric pouch (figure 32a). Some prefer to
implant the open end of the pancreas directly into the open end of the jejunum (figure 32b). Unless the pancreatic duct is quite large, this is perhaps a
simpler procedure than that in figure 32a. Alternatively, a pancreaticogastrostomy may be performed. e common duct then is anastomosed to the
jejunum and at an easy point of approximation to the stomach. figures 33
and 34 demonstrate details of the technique shown in figure 32a. e end
of the jejunum then should be anchored to the tissues medial to the common duct or even up into the lower portion of the closed liver bed. Great
care should be taken, however, that sutures do not include the right hepatic
artery, which may curve upward into this area. e end of the common duct
is then anchored with interrupted sutures to the serosa of the jejunum.
Sutures of size are used to x either side of the end of the common duct
to maintain the wall under slight tension as a row of interrupted sutures is
placed to anchor it to the serosa of the jejunum. e xed angle sutures are
allowed to remain for traction (figure 33), while an incision is made into
the adjacent jejunal wall a little shorter than the diameter of the lumen of
the common duct (figure 33). A series of interrupted - or - absorbable sutures is used to accurately approximate the mucosa of the jejunum
to the common duct. Placement of the interrupted sutures in the closure of
the anterior layer is then performed (figure 34). e catheter also ensures
a sizable stoma. is is a single-layer anastomosis. e peritoneum, which
tends to be thickened over the region of the common duct, is anchored with
interrupted sutures to the serosa of the jejunum, starting beyond the angles
of the anastomosis and extending anteriorly parallel with the anastomosis
(figure 35), which holds the divided end of the pancreas (figure 36). e
posterior capsule of the pancreas is anchored with interrupted sutures
to the serosa of the jejunum (figure 37). ere should be no tension and
preferably some redundancy of the jejunum between the several sites of
anastomosis. e patency and size of the pancreatic duct are determined by
inserting a so rubber catheter. With the catheter in place to serve as a stent,
the margins of the duct are freed for a short distance to facilitate an accurate
anastomosis to the jejunal mucosa (figure 38).
CONTINUES
290
32a
Common duct
32b
33
Traction suture
Pancreas
Stomach
34
Jejunum
Common
duct
35
Fixation of jejunum
Peritoneal
support
Common duct
36
37
Posterior
layer
Jejunum
Pancreas
Catheter
38
Pancreas
Pancreas
Pancreatic duct
291
PLATE
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137
P
(W P)
DETAILS OF PROCEDURE A very small opening related to the
size of the pancreatic duct is made into the lumen of the jejunum, and interrupted or sutures are placed at both angles (figure 39). e
catheter is rotated to the le while the posterior layer of sutures is placed,
and it is then inserted into the lumen of the bowel as the anterior layer of
sutures nally is completed. e catheter serves as a stent and makes it easier
to place the sutures more accurately through the mucosa of the jejunum as
well as the pancreatic duct. When this anastomosis has been completed, the
capsule of the pancreas is anchored to the serosa to seal o the raw end of the
gland against the wall of the jejunum (figure 40).
Some prefer to insert the open end of the pancreas into the open
end of the jejunum, especially when the pancreatic duct is quite small
(figure 41a). e margins near the cut end of the pancreas should be
freed for several centimeters in preparation for telescoping the end of the
jejunum over it, and all bleeding points should be ligated carefully. e
end of the jejunum is usually large enough to admit the end of the pancreas. If not, it may be necessary to incise the full thickness of the jejunum along the antimesenteric border to make the opening large enough
to match easily the size of the end of the pancreas. A er all bleeding
is controlled, the mucosa of the jejunum is sewed to the capsule of the
pancreas in a manner similar to an end-to-end anastomosis. A small, so
rubber catheter can be inserted into the lumen of the pancreatic duct to
ensure its patency during the completion of the anastomosis. It is subsequently removed before closure of the gastrojejunostomy. An additional
one or two layers of interrupted nonabsorbable sutures are placed to pull
the jejunal wall up over the capsule of the pancreas for approximately
cm (figure 41b). e common duct and gastric anastomosis to the
jejunum are not altered.
e gastrojejunal anastomosis may be made over the entire length of the
gastric outlet, or the outlet may be partly closed and the stoma limited in
size. e full thickness of the gastric wall, including the staples, is excised to
provide a stoma three to four ngers wide (figure 42). Any retained gastric
contents are aspirated, and all bleeding points in the mucosa of the gastric
wall are controlled. e serosa of the jejunum near the mesenteric border
then is anchored to the posterior wall of the stomach from one curvature to
the other with silk (figure 43). e jejunum should be approximated
loosely so that there is some laxity between the anastomosis of the pancreas
and the gastric wall in the region of the lesser curvature. An opening about
two ngers wide is made in the jejunum, and the gastrojejunal mucosa is
approximated with interrupted absorbable sutures (figure 43). e
gastrojejunal anastomosis is then completed with a layer of interrupted
nonabsorbable sutures, with the knots buried on the inside. e second layer of the gastrojejunal anastomosis is then completed with a layer
of interrupted sutures from one curvature to the other (figure 44).
e opening in the mesocolon should be approximated to the jejunal wall
(figure 44) to prevent prolapse of small bowel up through this opening.
e opening about the region of the ligament of Treitz should be closed with
ooo silk. A gastrostomy tube and feeding jejunostomy may be indicated in
the malnourished patient. Closed-suction drains are placed adjacent to the
choledochojejunostomy and pancreaticojejunostomy.
CLOSURE e abdominal wall is closed in the routine manner. In the
presence of emaciation or in the older age group, it may be advisable to
close the fascia with gure-of-eight stitch or by the addition of numerous
retention sutures.
POSTOPERATIVE CARE It is of paramount importance, especially in
the jaundiced patient, to make certain that the blood volume is restored
at all times. Fluid balance is sustained by administration of Ringer’s
lactate solution. Blood sugar and amylase levels are obtained. e hourly
urine output should be watched carefully and should be maintained at
to mL/h. e administration of intravenous uids should be balanced
throughout the -hour period. Urinary output and the replacement of gastric drainage will determine the amount of uids required.
e patient’s weight must be watched carefully, and an adequate daily
caloric and vitamin intake assured. Blood sugar levels should be determined at regular intervals. If a feeding jejunostomy tube has been inserted,
tube feedings by continuous infusion may be started to hours a er
surgery. Initial infusion rate should be slow and gradually increased. e
output from the closed suction drains should be monitored and determination of amylase concentration performed a er starting oral intake, usually
to days a er surgery. e drains are removed if there is no bile in the drain
uid and if the amylase is less than that of serum. ■
292
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