Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_663_Библиотеки_им_академика_М_И_Перельмана

When a handsewn closure is used, the surgeon tries to identify the very small main pancreatic duct. This identica­tion, although difcult, is possible in most cases. If used cor­rectly modern electrocautery devises do not cause as much tissue damage and discoloration and so they can be used to divide the pancreas without making identication of the duct more difcult. The pancreatic duct when identied is closed using a nonabsorbable 5/0 suture using a gure-of-eight stitch. Although the different techniques of closure of the pancreatic stump aim at controlling the bleeding as well as a leak from the pancreatic duct by compressing them within the pancreatic tissue, applying the gure-of-eight stitch at the pancreatic duct separately can diminish the risk of stula formation.

The pancreatic stump should be closed by inserting over­lapping interrupted mattress sutures of polypropylene or silk. Which is the best way for inserting these mattress sutures? There is a tendency for the surgeon to move the needle holder, while inserting sutures, from away toward his/her body (in the right-handed surgeon, from the right to the left). So in the case of the pancreas, the mattress stitch will be inserted from the posterior pancreatic surface to the anterior and then from the anterior to the posterior. Consequently, the stitch will be knotted on the posterior surface of the pan­creas. As the normal pancreatic tissue is very soft, it is impor­tant, when the surgeon puts tension on the knot, to do it in such a way that it compresses the occluded pancreatic tissue but does not cut through it. This can be better achieved when the knot is in front, so that more controlled tension is applied with the two index ngers. Therefore, the mattress stitch is inserted “backhanded” (remember the surgeon is standing on the patient’s right side) starting from the anterior surface to the posterior and back from the posterior to the anterior. The rst knot—the one that counts—should be straight and dou­ble, so that appropriate tension can be applied and it does not give way while “relaxing” it on throwing the second knot.

If the pancreas is very swollen, as happens frequently in patients with blunt transection of the body of the pancreas especially when there is a delayed presentation—a stapler should not be used. The clips are too small to include the whole width of the transected pancreas. In this case, a thick stitch is used (usually stitches with high tensile strength like 0, 1, and 2, which are also thicker). This helps the surgeon in two ways: rst, the needle is longer, so that the surgeon includes in his/her bite the whole cut surface of the pancreas,

and, second, as the stitch is thicker, there is less chance of cutting through the parenchyma—“like a hot wire through Swiss cheese.”

The remaining issue is the timing of the reconstruction. In experienced hands and with a stable patient without the need for damage control, an immediate reconstruction can be per­formed. However, this is the exception. We advocate that the reconstruction is performed at a second procedure, delayed for 48–72h to address the patient’s general condition as per damage control guidelines. Again, it is the pancreatic recon-

struction that is difcult due to the normal pancreas and small duct. We make no recommendation as to the type of pancreatic reconstruction that should be employed. Our own practice is to perform a posterior pancreaticogastrostomy. Then a proximal gastrojejunostomy is fashioned followed about 10 cm distally with a side-to-side hepaticojejunos­tomy. There is some suggestion that the gallbladder can be used as a conduit for biliary reconstruction. We think this is unnecessary and unwise and recommend routine cholecys­tectomy. In addition, the bile duct is also usually not dilated, and care and experience should be employed to prevent post­operative strictures of the bile duct anastomosis. Should the bile duct be small, mobilize the common bile duct proxi­mally and identify the left hepatic duct. Open the anterior wall of the common hepatic duct onto the left hepatic duct for at least 2cm. During this dissection, a small branch of the hepatic artery crosses the left hepatic duct and is often divided at this point. This vessel is hard to identify before you cut it and can be controlled with a small suture or dia­thermy. A note of caution at this point is important, and pres­ervation of the blood supply to the biliary tree is very important. Excessive mobilization can devascularize the bile ducts resulting in late ischemic strictures. A side-to-side hepaticojejunostomy using a 4/0 or 5/0 monolament absorbable, as originally described by Hepp and Couinaud, is then performed. The bowel loop is brought antecolic based on the evidence that this reduces the incidence of delayed gastric emptying it is worth mentioning that if a narrow com­mon bile duct is ligated during the initial operation, it will be dilated at the time of the reconstruction, making the Hepp and Couinaud anastomosis, technically easier.

In the situation where there is a signicant injury to the duodenum with a borderline injury to the pancreas with an intact ampulla, we believe that a well-placed purse-string suture, occluding the pylorus and placing it from inside the

erature, there are numerous classications and consensus statements. The ISGPF guidelines are used to dene postop­erative pancreatic stula. A leak of amylase-rich uid per­sisting for several days and having clinical implications should be dened as a stula. The role of the volume of uid in the denition is unclear. We consider a daily output of between 50 and 100mL to be signicant. In such a patient, the rst step is to exclude a peripancreatic collection that is not adequately addressed by the drain. CECT scan is the investigation of choice. If there is a collection, percutane­ously placed pigtail drains are inserted. Control of the stula is the main objective in this situation. Can we avoid the development of stulae? The role of octreotide in the postop­erative period is not well dened. Some work from Heidelberg in Germany suggests a real benet in reducing the postoperative stula rate. This has not been shown in the trauma situation. We do not use it routinely, but if there is real concern regarding the risk of a stula in an individual patient, we would use it. In well-established postoperative stulae, we would routinely use octreotide in addition to TPN or semi-elemental enteral feeds. In a low-output stula, we would start with enteral semi-elemental oral feeds. If the stula output does not increase, we continue with this regi­men. However, if the output is very high or increases with enteral feeding, we convert to TPN as our primary nutritional support. ERCP and MPD stenting does have a role in manag­ing these ductal leaks. The main issue is, however, timing. If the leak is controlled, then there is no rush and the patient’s general condition will determine the timing. In addition, many low-output stulae will close spontaneously within a few days and do not require endoscopic interventions. It is difcult to move an unstable patient to the ERCP suite, and, therefore, when the patient is stable, and the stula persists longer than 5–7days, we perform ERCP, and if a duct dis­ruption is dened, a small pancreatic duct sphincterotomy is performed and a 7fr plastic stent inserted. Removal of the stent should be as soon as possible to prevent damage to the duct. We recommend removal within 4–6weeks of the stu­lae clinically closing.

Pancreatic pseudocysts usually present as a delayed pre­sentation. This can be when a minor pancreatic injury was missed or after the removal of the surgically placed drains when the extent of the ductal injury was underestimated. The management of pancreatic pseudocysts is beyond the scope of this chapter. Our primary approach is always endoscopic, and today this is usually endoscopic ultrasound guided. However, other endoscopic approaches including ERCP and transpapillary stenting have been shown to work and can be employed. Surgical cystenterostomy should be avoided as minimally invasive approaches are usually successful.

subsequent to admission, these drains can be placed laparoscopically.

manage complex liver injuries. These methods usually require existing experience and rapid access to extracorpo­real circulation technology and expertise. These techniques are difcult to improvise or implement without planning ahead of time.

If bleeding is indeed uncontrollable with packing, and a transplant program is available, a last effort at salvage may include hepatectomy with hope for an emergency transplant. This option is obviously limited to a small number of centers and even then, unlikely to succeed.

If bile leakage and sepsis are controlled, biliary enteric con­tinuity can be re-established weeks or even months later when other problems have been settled.

• If the Pringle maneuver does not control life-threatening bleeding look to the vena cava.