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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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14
Pancreas
Stomach
15
Left
gastric vessels
Penrose drain
Ligated
splenic artery
Middle
colic vessels
Liver
Stomach
Line of
incision
Pancreas
Inferior
mesenteric vein
17
16
Stomach
Spleen
Incision in
gastrosplenic
ligament
Splenic vessels
Spleen
Pancreas
Pancreas
263
PLATE
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123
P
(P-G P)
THIRD TECHNIQUE—PANCREATIC IMPLANTATION WITHIN JEJUNUM
e tail and body of the pancreas, now freely mobilized, are
rotated toward the midline so that the courses of the splenic artery and
vein are clearly visualized (figure 18). e splenic artery should be doubly
ligated and divided near its point of origin. It is advisable to remove the
artery from this point of ligature out to the tip of the pancreas. Likewise,
the splenic vein should be carefully dissected free of the adjacent pancreas
and doubly ligated very near its junction with the inferior mesenteric vein
(figure 18). A er the artery and vein have been removed from the distal
half of the pancreas, the tail of the pancreas is stabilized with a suture or
Allis forceps, and the end of the pancreas is transected carefully until the
pancreatic duct is identi ed (figure 19). e small amount of bleeding
that occurs can be controlled easily by compressing the pancreas between
the thumb and index nger, clamping the individual bleeding points, and
then ligating them with silk (figure 19). As soon as the pancreatic
duct is located, a probe is inserted into the duct (figure 20). e duct
is usually a little nearer to the superior than to the inferior margin of the
pancreas. e surgeon then grasps the pancreas with the thumb and index
nger and makes an incision directly down onto the probe, completely
exteriorizing the major pancreatic duct (figure 21). e incision should
be carried medially, and soon the pancreatic duct will greatly enlarge. With
intermittent strictures and dilatations, there is a tendency of the duct to
form a chain of individual lakes. Multiple calculi may be encountered and
small calci cations noted in many small ducts within the wall of the brosed pancreas. e incision is carried from the tail of the pancreas downward
as near as possible to the medial border of the duodenum (figure 22). is
is accomplished by stabilizing the pancreas with the le hand and inserting
scissors into the lumen of the duct and carrying the dissection medially
(figure 22). e nger is inserted into the enlarged proximal portion of
the dilated duct, and any calculi are removed. A small probe may be introduced into this area to determine whether or not there is free communication between the pancreatic duct and the duodenum through the ampulla,
but this is not absolutely necessary (figure 23). During the dissection the
brotic wall of the pancreas is grasped with multiple Allis forceps, usually
at the points of active bleeding. When these clamps are removed, the individual points are carefully ligated with interrupted absorbable sutures. No
e ort is made to approximate the wall of the duct and the brous capsule so
that free drainage from the smaller ducts will be possible.
CONTINUES
264
18
Stomach
Splenic
artery
19
Splenic vessels
20
Line of resection
Probe
Pancreas
21
Splenic vein
Pancreas
Inferior
mesenteric vein
Suction
Probe
Probe
23
22
Line of incision
Pancreas
Stomach
Open duct
Duodenum
Pancreas
Finger in pocket
Middle colic vessels
265
PLATE
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124
P
(P-G P)
THIRD TECHNIQUE—PANCREATIC IMPLANTATION WITHIN JEJUNUM
e jejunum is held up out of the wound. By transillumination the surgeon can study the vascular arcades and select more accurately
the blood vessels to be divided for mobilizing the arm of the jejunum to
be brought up to the pancreas (Plate ). e jejunum is divided at a point
to cm beyond the ligament of Treitz. A small opening is made in the
mesocolon to the le of the middle colic vessels, just over the ligament of
Treitz. e jejunum is pulled through this opening and measured along the
full length of the pancreas (figure 24). e length of the pancreas from
just beyond the end of the opened duct to the end of its tail is marked, point
X, on the jejunum, by Babcock forceps placed on its antimesenteric border
(figure 24). e tail of the pancreas will be drawn into the bowel lumen
and approximated to point X. Here the surgeon must be certain that there
is adequate jejunal length and that the mesenteric vascular pedicle will
reach easily without angulation. Traction sutures (A and B) of silk are
placed on the superior and inferior borders of the capsule of the pancreas
(figure 25) to aid in pulling the tail to point X. e Potts forceps are
removed from the open end of the jejunum and replaced by Babcock forceps at the antimesenteric border. e jejunum is gently stretched between
the two Babcock forceps as the needles, with attached traction sutures A
and B, are introduced into the lumen of the bowel. During insertion the
needles are held parallel to the long axis of the holder with points backward
to ensure that the bowel wall is not punctured (figure 26a). At point X,
the needle is sharply retracted to puncture the wall and carry the suture
externally (figure 26b). Gentle traction is maintained upon these sutures
to aid in pulling the pancreas up into the jejunum. When the pancreas is
completely encased inside the bowel, sutures A and B are tied together,
bringing the tail to point X (figure 27). e opened end of the jejunum is
then circumferentially tracked down to the capsule with interrupted nonabsorbable sutures. e posterior row is placed rst, beginning at the
mesenteric border and proceeding superiorly to the antimesenteric surface.
e anterior row is also begun at the mesenteric border of the jejunum.
If the jejunal circumference is too small, the bowel may be longitudinally
incised to accommodate the girth of the pancreas (figure 27).
e adequacy of the blood supply of the jejunum is repeatedly checked.
Intestinal continuity is established through a Roux-en-Y jejunojejunostomy, beyond the ligament of Treitz, using two layers of ne nonabsorbable sutures (figure 28). All free edges of the mesentery should be closed
with interrupted silk sutures, care being taken that the marginal
blood supply within the mesentery is not compromised. Before closure
the blood supply of the jejunum should be rechecked carefully. A few
sutures are taken to anchor the vascular margin of the mesentery to adjacent structures to prevent its rotation and the formation of an internal
hernia. e window in the mesocolon is also secured to the pancreatic
arm of the Roux-en-Y.
CLOSURE If biliary tract surgery has been performed simultaneously, a
closed-system suction catheter made of Silastic is inserted in the foramen
of Winslow. If T-tube drainage of the common duct has been instituted,
the tube is brought out through a separate stab wound on the right side.
Drainage is unnecessary for the pancreaticojejunostomy itself. e incision
is closed in a routine manner. In the presence of impaired nutrition, it may
be advisable to supplement the closure with retention sutures.
POSTOPERATIVE CARE Although varying degrees of pancreatitis can be
anticipated following this procedure, the postoperative course is surprisingly
mild. Blood amylase and sugar levels are determined and attention given
to the narcotic requirements. ese patients tend to be addicted to narcotics and may be di cult to sedate because of chronic alcoholism. Pancreatic
enzyme therapy should be instituted, the diabetic tendency should be regulated, and any previous addiction should be corrected, if possible, before the
patient is discharged from the hospital. An ulcer type of dietary program
should be followed, with a gradual return to a more liberal diet. ■
266
24
Pancreas
Duct
A
Traction suture
25
B
Suture line
27
Encased pancreas
A and B tied together
Jejunum
Traction
suture
26a
26b
A
Jejunum
Incision
Middle
colic vein
Marginal artery
of Drummond
Encased pancreas
Jejunum
28
Jejunum
Colon
267
Roux-en-Y anastomosis
PLATE
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125
INDICATIONS e more common indications for resecting the body and
tail of the pancreas include localized adenocarcinoma in this area, islet cell
adenomas, cysts, and chronic calci c pancreatitis. is procedure may be the
initial approach for total pancreatectomy for carcinoma of the pancreas.
PREOPERATIVE PREPARATION e preparation is related to the pre-
operative diagnosis. If splenectomy is contemplated then vaccines for
pneumococcus, haemophilus in uenza, and meningococcus should be
administered prior to the surgery.
e patient with an insulinoma, suggested by repeated fasting blood
sugars of below mg/dL, requires supplementary glucose by mouth or
intravenously at regular intervals for hours preceding surgery and intravenously during surgery.
When an ulcerogenic tumor is suspected, the uid and electrolyte balance
should be corrected, particularly if there have been large losses of gastric secretion or losses from enteritis. Serum gastrin levels may establish the diagnosis,
and the patient may require a total gastrectomy in the future. Every e ort
should be made to localize one or more endocrine tumors by CT, MRI, somatostatin scintigraphy, or selective arteriography and selective arterial stimulation with either secretin (for gastrinoma) or calcium (for insulinoma).
ANESTHESIA General anesthesia with endotracheal intubation is used.
POSITION Supine position with the feet lower than the head.
OPERATIVE PREPARATION e skin is shaved from the level of the nip-
ples well out over the chest wall and down over the abdomen, including the
anks. e skin is prepared in the routine manner.
INCISION AND EXPOSURE Either a long vertical midline or an extensive
curved incision parallel to the costal margins, as described for pancreaticoduodenectomy (Plate ).
DETAILS OF PROCEDURE When the procedure is carried out for an
in ammatory lesion of the body and tail of the pancreas, a direct exploration of this region is performed. When the procedure is carried out for
tumor, a thorough exploration of the abdomen, with particular reference to
the liver and the gastrohepatic ligament in the region of the celiac plexus,
should be made for evidence of metastasis. A possible microscopic diagnosis of adenocarcinoma is sought by biopsy before proceeding with a total
pancreatectomy from the le -side approach. Since the adenomas can be
distributed throughout the pancreas, the head of the pancreas must be
thoroughly explored by visualization and palpation preliminary to a de nitive type of procedure on the le half of the pancreas. Evidence of gastric
hypersecretion, as indicated by increased vascularity and thickening of the
gastric wall, along with a hyperemic and hypertrophic duodenum and an
ulcer in the duodenum or beyond the ligament of Treitz, adds support to
the potential diagnosis of gastrinoma tumor of the pancreas. Likewise, the
inner wall of the duodenum should be carefully palpated in the search for
small adenomas extending into the lumen of the duodenum from the pancreatic side. Finally, a sterile ultrasound probe for intraoperative scanning
of nonpalpable lesions is advocated by most surgeons.
R T P
A er the abdomen has been explored and the region of the head of
the pancreas evaluated, the greater omentum is re ected upward, and
downward traction is maintained on the transverse colon as the omentum is separated by sharp dissection and the lesser sac entered (figure 1).
Usually, the stomach is easily separated from the pancreas, but sharp dissection may be required to separate it from the capsule of the pancreas,
especially if there have been repeated bouts of acute in ammation. Sharp
as well as blunt dissection is used to sweep the posterior gastric wall away
from the pancreas, particularly in the region of the antrum, to make certain
the middle colic vessels have not been angulated upward and attached to
the posterior gastric wall. A clear view must be ensured of the entire pancreas and the rst part of the duodenum all the way over to the hilus of the
spleen (figure 1). To avoid troublesome bleeding, it is usually desirable to
divide the communicating vein between the right gastroepiploic vessels and
the middle colic vein inferior to the pylorus. is permits better mobilization in the region of the antrum. Large S retractors can be used to retract
the stomach upward as the transverse colon is either pulled downward outside the wound or returned to the abdomen and packed away. e pancreas
should be inspected thoroughly and palpated to verify the pathology. It is
safer and far easier to mobilize and remove the spleen rather than attempt
to separate the pancreas from the splenic artery and vein running along the
superior surface of the body and tail of this organ.
In carcinoma the tumor’s mobility and the presence or absence of
regional metastasis must be determined before a radical resection is
planned. It is less uncommon to nd a resectable carcinoma involving the
tail or body of the pancreas. In insulinomas it is more common to nd only
one tumor; this may be enucleated without removing a large segment of
the pancreas, depending on the adenoma’s location and relationship to the
major pancreatic duct and vessels. Finding a solitary gastrinoma of considerable size may tempt the surgeon to do a local excision only, followed by
vagotomy, pyloroplasty, and proton pump inhibitor therapy postoperatively.
Any enlarged lymph nodes around the pancreas are excised for frozen section examination searching for evidence of metastases. For gastrinoma, the
duodenum must be opened and explored to search and remove a possible
duodenal primary lesion.
When the lesion cannot be seen or palpated by digital examination of
the anterior surface of the gland, the body and tail must be mobilized for
direct palpation with the thumb and index nger and for visualization of
the under-side of the pancreas. is is accomplished by incising the peritoneum along the inferior surface of the pancreas (figure 2). Only a few
small blood vessels are encountered. e inferior mesenteric vein should be
identi ed, and the incision should avoid it as well as the middle colic vessels. A er the inferior surface of the peritoneum has been incised, a nger
can be introduced rather easily underneath the pancreas, and the substance
of the gland can be palpated quite easily between the thumb and index nger (figure 3). As a matter of fact, the nger can be inserted completely
around the pancreas following the incision in the peritoneum just above the
splenic artery and vein. Finally, a hand-held ultrasound unit is very useful
in nding nonpalpable lesions within the pancreas.
CONTINUES
268
Communicating vein
1
Tumor
Middle colic vein
2
Opening above
pancreas
3
Tumor
Tumor
Inferior
mesenteric vein
269
PLATE
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126
DETAILS OF PROCEDURE In the presence of a tumor that
necessitates removal of the le half or all of the pancreas, steps should be
taken to mobilize and remove the spleen. e splenic artery is doubly ligated
with silk near its point of origin. is tends to decrease the blood loss
following manipulation of the spleen and permits blood to drain from
this organ into the systemic circulation during the subsequent steps of its
removal. e le gastroepiploic vessel is doubly clamped and ligated, and
the short gastric vessels are then divided all the way up to the diaphragm.
e blood supply on the greater curvature should be ligated by trans xing
sutures that incorporate a bite of the gastric wall to prevent hemorrhage
if gastric distention should occur and the ligature slip o the gastric side
(figure 4). Alternatively, the ultrasonic dissector can be used to coagulate
and divide the short gastric vessels. e splenorenal ligament is divided as
the surgeon pulls the spleen medially with his le hand (figure 5). Blunt
and sharp dissection may be carried out to free the tail of the pancreas, but
this is rather easily done by nger dissection as the organ is re ected medially
R T P
(figure 6). e le adrenal and kidney are clearly visualized as well as a
segment of the le renal vein. e inferior mesenteric vein is ligated and
divided (figure 6). at the inferior border of the pancreas. e splenic artery
is divided near its point of origin and ligated and then trans xed distally with
double ties of silk. e splenic vein is cleared and separated from the posterior surface of the pancreas and is followed over to the point where it joins
the superior mesenteric vein to form the portal vein (figure 7). e splenic
vein is gently freed from the pancreas, using blunt-nosed right-angle clamps
(figure 7). e vessel is ligated and is trans xed proximally to this tie to
avoid any possible late hemorrhage. e spleen and body of the pancreas can
then be mobilized su ciently to be brought outside the peritoneal cavity.
is approach is useful in performing a total pancreatectomy since
it ensures a good exposure for the identi cation of veins coming o the
medial aspect of the portal vein. e superior surface of the portal vein is
free of venous tributaries. However, the resection may be restricted due to
involvement of the portal vein by adenocarcinoma.
CONTINUES
270
4
5
Gastrosplenic ligament
6
Colon
Spleen
Spleen
Splenocolic ligament
Splenorenal
ligament
Splenic vein
Spleen
Splenic artery
Stomach
Splenic artery
7
Splenic vein
Inferior
mesenteric vein
Kidney
Renal vein
271
PLATE
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127
DETAILS OF PROCEDURE A er the spleen and the tail of the
pancreas have been mobilized outside the peritoneal cavity, the entire pancreas
is palpated once again for evidence of tumor involvement. e pancreas can
be divided with electrocautery to the le of the portal vein or, if need be, even
to the right side of the portal vein, provided that a nger has been introduced
between the vein and the pancreas to free its anterior margin (figure 8).
e surgeon usually nds it advisable to make multiple serial sections
of the pancreas in searching for additional adenomas and in determining
whether his line of incision is free of tumor. Frozen section consultations
may be obtained, although pancreatic tissue is di cult to evaluate under
these circumstances, and the nal diagnosis may have to be delayed until
the permanent sections have been made.
e cut end of the pancreas is examined and the pancreatic duct is
identi ed. e pancreatic duct is closed with a nonabsorbable mono lament suture (figure 9a). e end of the pancreas is closed with interrupted overlapping silk sutures of the mattress type (figure 9b).
Additional sutures are taken, particularly where there is persistent bleeding
(figure 10). Alternatively, the pancreas may be divided and secured with
staples using a linear stapler.
CLOSURE A closed-system suction catheter made of Silastic is used to
drain the stump of the pancreas. e drain is brought out either directly
R T P
through a stab wound in the midportion of the abdomen or to either side
through a separate stab wound incision. e incision is closed in the routine manner.
POSTOPERATIVE CARE e postoperative care is routine except for
repeated laboratory checks on the blood sugar and amylase levels. A mild
degree of pancreatitis may occur, and colloids and other solutions should
be given in adequate amount. A transient diabetic tendency may occur; on
the other hand, it is di cult to determine in the immediate postoperative
period what e ect the surgical procedure will have on total pancreatic function. Oral replacement of pancreatic enzymes may be indicated. Determination of amylase in the drain output is necessary prior to drain removal.
An amylase concentration less than serum is generally required for the
closed-suction drain to be removed.
When total pancreatectomy is planned, the pancreas is not divided
but used for traction as the head of the pancreas and the duodenum are
excised in the Whipple operation. Systemic symptoms associated with the
gastrinoma, a hormone-producing islet cell tumor, may be controlled partially, but rarely completely, for years by resection of a solitary tumor. ose
associated with other apudomas (vipoma, glucagonoma, insulinoma, and
so forth) may respond to local excision in the absence of malignancy and
metastases. ■
272
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