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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_630_Библиотеки_им_академика_М_И_Перельмана
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6
Incision
Duodenum
Sphincterotomy
A
A
7
Papilla of Vater
Posterior row
of sutures
Lumen of cyst
B
B
9
10
Papilla of Vater
Catheter
11
8
Line of incision
Common
duct
Pancreatic
duct
Catheter
Duodenum
12
Anterior row
of sutures
Cyst wall
Duodenum
Stoma
Cyst
Closure
completed
Duodenum
253
PLATE
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118
D C P
P
DETAILS OF PROCEDURE Pseudocysts of the body and tail
of the pancreas usually are drained most easily by transgastric cystogastrostomy (figure 13). e lesser sac is explored carefully to determine
where the posterior stomach wall is adherent to the pancreas. is can
be done either above the lesser curvature or by separating the greater
omentum from the mid-transverse colon for a short distance. As shown
in figure 14, the eld is walled o with gauze pads, and guide sutures
are placed in the anterior wall of the stomach over the most prominent
portion of the palpated cyst and where the cyst is most adherent to the
stomach. An incision is made in the anterior gastric wall parallel to the
blood supply. e margins of the gastrotomy are grasped with noncrushing clamps for exposure as well as hemostasis.
e cyst is localized by partial aspiration through the posterior wall of
the stomach at the point where the cyst and stomach are intimately attached.
Aspiration con rms the diagnosis and provides a specimen of the cyst uid
for culture as well as amylase and electrolyte determination (figure 15).
At this point, operative cystography can be performed to determine the
size and extent of the cyst. e mucosa of the posterior wall of the stomach
is grasped gently with ne-toothed forceps by the surgeon and the assistant, and the full thickness of the posterior wall of the stomach and the full
thickness of the cyst wall are then incised (figure 16) as a wedge biopsy.
e contents of the cyst cavity are then aspirated with suction. e interior
of the cyst is explored with the index nger, and biopsy of the cyst wall
performed. All bleeding points are ligated with silk or absorbable
sutures. Firm attachment between the cyst wall and stomach is essential
rather than dependence upon suture approximation. All bleeding points
should be suture ligated. A one-layer anastomosis using interrupted or
running nonabsorbable sutures is performed (figure 17a). It is imperative that the full thickness of the stomach as well as the full thickness of the
cyst wall be included in each suture (figure 17b).
Upon completion of the cystogastrostomy anastomosis, the gastrotomy
is closed in two layers, using an inner layer of absorbable sutures and an
outer layer of interrupted horizontal mattress sutures (figure 18).
Cholecystectomy may be performed in good-risk patients with calculi, as
may operative cholangiography.
CLOSURE e abdomen is then closed in the usual manner.
POSTOPERATIVE CARE Nasogastric suction is maintained until gastro-
intestinal function resumes. Frequent blood amylase determinations are
made. e initial liquid diet is advanced as tolerated; however, frequent
small bland feedings without stimulants are recommended to place the
pancreas as rest. ■
254
13
15
14
Opening anterior
stomach wall
Drainage
site
Cyst
Stomach
17a
Anterior
stomach wall
Mucosa of posterior
stomach wall
Through-and-through sutures
Syringe
18
16
Suction
17b
Stomach
mucosa
Cyst wall
Closure
of anterior
stomach wall
255
PLATE
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119
P
(P-G P)
INDICATIONS Drainage of the pancreatic duct by anastomosis to the jeju-
num may be indicated in the treatment of symptomatic chronic recurrent
calci c pancreatitis. Before this procedure is carried out, all stones from
the biliary tract should be removed by cholecystectomy and choledochostomy. ere should be evidence of free drainage of bile through the papilla
of Vater into the duodenum. Decompression of the obstructed pancreatic
duct should be considered because of recurrent or persistent pain and evidence of progressive destruction of the pancreas.
PREOPERATIVE PREPARATION All too o en, these patients are addicted
to alcohol and/or narcotics because of persistent pain. Evidence of advanced
pancreatic disease may be diabetes, steatorrhea, and poor nutrition. e
entire gastrointestinal tract should be surveyed with barium studies or
endoscopy. e pancreatic and biliary systems are evaluated with ERCP
and with dye study of both duct systems. Stones in the gallbladder or the
common duct should be suspected, and ulceration of the duodenum is not
uncommon. Evidence for or against gastric hypersecretion should be determined by secretion studies. e stools should be examined to determine
the degree of pancreatic insu ciency, insofar as fats are concerned. Particular attention should be given to restoring the blood volume and controlling existing diabetes. Blood calcium and phosphorus levels should be
determined to rule out a parathyroid adenoma.
ANESTHESIA General anesthesia is used.
POSITION e patient is placed supine on the table that is positioned for a
cholangiogram or pancreatogram.
OPERATIVE PREPARATION e upper abdomen is prepared in the usual
manner.
INCISION AND EXPOSURE A curved incision following the costal mar-
gin on the le and extending across the midline around to the right or a
long midline incision, which may extend below the umbilicus on the le
side, may be used. An upper midline incision may be used.
DETAILS OF PROCEDURE e stomach and duodenum should be evalu-
ated thoroughly for evidence of an ulcer. Likewise, the gallbladder should
be palpated carefully for evidence of stones, and the size of the common
duct determined. In the presence of stones the gallbladder is removed and a
cholangiogram is taken through the cystic duct. A small amount of contrast
medium ( mL) is rst injected to avoid a dense shadow, which may hide
small calculi in the common duct. Su cient contrast medium should be
injected subsequently to determine the patency of the papilla of Vater by
visualization of the duodenum. It is advisable to carry out a Kocher maneuver to palpate the head of the pancreas, especially if there is radiographic
evidence of an enlarged C-loop. Under such circumstances, needle aspiration may be carried out to search for evidence of a pancreatic cyst. e
omentum, which is o en quite vascular, is freed in the usual fashion from
the transverse colon across to the region of the splenic exure. e lesser
sac may be obliterated, and sharp dissection may be required to separate
the adhesions between the stomach and the pancreas that may be due to
chronic pancreatitis. e stomach should be freed until the entire length of
the brotic and lobulated pancreas can be explored easily (figure 1). e
transverse colon is returned to the peritoneal cavity, while the stomach is
retracted upward with a large S retractor. e posterior wall of the antrum
should be freed from the pancreas so that the pancreatic duct can be palpated and opened as far to the right as possible to remove any calculi that
might be impacted in the duodenal end (figure 2). A er the lobulated
brotic pancreas has been exposed clearly, an e ort is made to identify the
location of the pancreatic duct by needle aspiration (figure 1). Occasionally, it is desirable to aspirate pancreatic juice from the dilated pancreatic
duct and then to inject a limited amount of contrast medium to ensure
x-ray visualization of the pancreatic duct. Evidence of calculi in the duct
is obtained as well as evidence to indicate whether the papilla of Vater is
blocked or patent.
If there is evidence of a large and obstructed pancreatic duct, decompression is performed by anastomosing it to the jejunum. e capsule of the
pancreas is incised directly over the needle (figure 3). is is done with
a small scalpel or with an electrocautery unit. Some prefer the electrocautery unit to control the bleeding; otherwise, the bleeding points need to be
grasped with ne forceps and ligated as the brotic pancreas overlying the
duct is divided.
CONTINUES
256
1
Stomach
Left gastric vessels
Pancreas
Aspiration syringe
Ligated
communicating vein
2
Splenic artery
Inferior
mesenteric vein
Middle colic vessels
Duct of Santorini
3
Pancreatic duct
Common
duct
Papilla of Vater
Electrocautery
Incision
Calculus
Line of incision
Duct of Wirsung
257
PLATE
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120
P
(P-G P)
DETAILS OF PROCEDURE A rather liberal incision is made in
the pancreatic duct and carried over toward the right side but not up against
the posterior wall of the duodenum, lest the pancreaticoduodenal vessels be
divided and massive hemorrhage occur. A dilated pancreatic duct is usually
encountered, and intermittent lakes or segmental dilatations may be found
(figure 4). As the pancreatic duct is divided, the brotic margins are grasped
by Allis forceps, and all bleeding points are controlled (figure 4). An e ort
can be made to establish the patency between the remaining segment of the
pancreatic duct in the head of the pancreas and the lumen of the duodenum through the papilla of Vater. Frequently one or more calculi may need
to be dislodged with a gallbladder type of scoop or small, fenestrated type of
forceps commonly used to remove ureteral calculi (figure 4). Considerable
time may be consumed in clearing the major pancreatic duct of calculi. A
French woven catheter can be directed into the pancreatic duct to determine
the patency of the papilla of Vater (figure 5). Patency can be proved by distention of the duodenum a er an injection of saline. In case of doubt, it may
be advisable to inject contrast medium followed by a roentgenogram to visualize the remaining short segment of the pancreatic duct.
Ordinarily, the pancreatic duct is opened for to cm, and a decision then must be made as to the type of anastomosis that will be carried
out: the Roux-en-Y arm as in a jejunal “fishmouth” lateral anastomosis,
full-width side-to-side anastomosis, or implantation of the mobilized
pancreas into the lumen of the jejunal segment. The jejunum is prepared for the Roux-en-Y anastomosis by dividing it to cm below
the ligament of Treitz (Plate ). The vessels in the mesentery of the
upper jejunum are visualized, and several vascular arcades are divided
some distance from the mesenteric border. This permits mobilization
of a sufficient length of jejunum to allow it to reach up into the region
of the pancreas. An opening is made in the mesocolon to the left of the
middle colic vessels in an avascular portion near the base of the mesentery. The arm of the jejunum is then tested for length and is turned
with the open end to the right as well as to the left to determine which
position of the mobilized jejunum produces the least interference with
the blood supply. Many procedures can be followed in accomplishing
the pancreaticojejunostomy.
FIRST TECHNIQUE: LATERAL FISHMOUTH ANASTOMOSIS e anti-
mesenteric border of the Roux limb may be opened with a cutting linear
stapler (GIA) stapling instrument. e distance required is longer than that
for the opening in the pancreatic duct (figure 6). is usually requires two
rings of the cutting linear stapler (GIA). Any active bleeding sites along the
stapled cut edge are secured with ne silk sutures (figure 7).
e pancreas is anchored to the opened jejunum with one layer of
interrupted silk or nonabsorbable sutures (figure 8). ese sutures
go through the entire wall of the jejunum but through only the capsule of
the pancreas. e full thickness of the brotic pancreatic wall down to the
opened pancreatic duct should not be sutured because there are numerous intramural smaller ducts that would be blocked and then would deliver
pancreatic secretions into the peripancreatic tissue instead of to the intestinal lumen.
CONTINUES
258
4
Pancreatic
calculus
6
Scoop
Papilla of Vater
Inferior
Dilated
pancreatic duct
Mobilized jejunum
mesenteric vein
5
Duodenum
7
Catheter
Middle colic vessels
Jejunum
Open pancreas
Splenic artery
8
Splenic vein
Pancreatic duct
Jejunal wall to
pancreatic capsule
259
PLATE
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121
P
(P-G P)
FIRST TECHNIQUE: LATERAL FISHMOUTH ANASTOMOSIS
e open end of the jejunal arm is anastomosed over the
opened pancreatic duct (figure 9). e jejunum is anchored to the cap-
sule of the tail of the brotic pancreas just beyond the end of the incision into the duct, and the full thickness of the jejunal wall is anchored to
the cut margins of the capsule of the pancreas throughout the full length
of the opened pancreatic duct. e open ( shmouth) end of the jejunum
may need to be tailored from time to time, as outlined by the dotted lines
(figure 9), to ensure a sealed anastomosis around the duct. Again, only
the capsule is included in these sutures, and the brotic wall of the pancreas is le free to promote drainage of the ne ducts, many of which
are lled with small calculi. e anterior layer is also made with interrupted sutures, and the free end of the jejunum is anchored to the capsule with three or four additional sutures toward the tail of the pancreas
(figure 10). When the pancreas is shortened and thickened, a splenec-
tomy may be necessary to adequately mobilize the pancreas and facilitate
this anastomosis.
SECOND TECHNIQUE: FULL-WIDTH SIDE-TO-SIDE ANASTOMOSIS Some
prefer to close the end of the Roux-en-Y arm of jejunum with two layers of
interrupted silk sutures (Plate ) and anastomose the jejunum to the pancreas
in a manner similar to a lateral anastomosis of small intestine (figures 11 and
12). Only one layer of sutures is used, but they must be placed accurately and
close enough together to prevent subsequent leakage.
When the Roux-en-Y principle is used, the jejunum near the ligament of
Treitz is anastomosed to the arm of the jejunum going to the pancreas by an
end-to-side anastomosis (figure 13). e free margin of the mesentery should
be secured by interrupted sutures (A) to the ascending jejunum to obliterate
any opening for the subsequent development of an internal hernia (figure 13).
e opening in the mesocolon is closed about the jejunal arm.
CONTINUES
260
Jejunal wall
to capsule
9
Pancreatic
capsule
Roux-en-Y lateral anastomosis
Dilated
pancreatic duct
Jejunal mucosa
10
Jejunal mesentery
12
Pancreatic duct
Jejunum
Fibrotic pancreas
11
13
Dilated
pancreatic duct
Lumen of
the jejunum
Duct
Middle colic vessels
A
Ligament of Treitz
End-to-side anastomosis
261
PLATE
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122
P
(P-G P)
THIRD TECHNIQUE—PANCREATIC IMPLANTATION WITHIN JEJUNUM
In addition to the previous procedures described, drainage of the
body and tail of the pancreas may be accomplished by implanting the le end of
the pancreas into the open end of the arm of jejunum that has been brought up
for a Roux-en-Y type of anastomosis.
When the pancreas is severely in amed, small, and contracted, it may
be advisable to mobilize as much of the tail and body as possible and to
remove the spleen in anticipation of implantation into the jejunum. Once
the presence or absence of a dilated duct is con rmed by needle aspiration
and palpation (figure 14), the peritoneum is incised superior and inferior to the body and tail of the pancreas, care being taken not to injure
the inferior mesenteric vein (figure 14). A er the peritoneum has been
incised, the surgeon inserts his index nger behind the pancreas and can
very easily, by a backward and forward motion, free the posterior wall
of the body and tail of the pancreas from adjacent tissues. e nger is
inserted completely around the pancreas, including the splenic artery and
vein, which run along the superior surface of the pancreas (figure 15).
A rubber drain is passed through this opening in order to provide gentle
traction on the pancreas for the dissection of the tail and exposure during the freeing of the remainder of the pancreas and the splenectomy
(figure 16). e gastrosplenic ligament is divided, and the blood supply
along the greater curvature of the stomach is trans xed to the gastric wall
with interrupted sutures. Alternatively, an ultrasonic dissector can be
used to coagulate and divide the short gastric vessels. Any attachments
between the superior pole of the spleen and the diaphragm are divided, and
the spleen is mobilized well into the wound. e pedicle of the attachments
between the inferior surface of the spleen and the colon is likewise divided,
as is the posterior splenorenal ligament (see Plate ). e blood supply to
the spleen is divided and ligated. e vessels then are doubly ligated with
nonabsorbable ligatures (figure 17). In the younger age-groups, it is
desirable to make every e ort to save the spleen because of the risk of subsequent sepsis. e mobilization of a chronically in amed tail and body of
the pancreas requires ligation of numerous small blood vessels entering the
major splenic blood supply.
CONTINUES
262
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