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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_670_Библиотеки_им_академика_М_И_Перельмана
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202 Atlas of Gastrointestinal Surgery: The Duodenum
Either an end-to-end duodenojejunostomy
or an end-to-side duodenojejunostomy can
be performed; I prefer the latter. The end
of the jejunum is inverted with a series of
interrupted 3-0 silk Lembert sutures (7).
An end-to-side duodenojejunostomy is per-
formed. The outer layer of the posterior row
consists of interrupted 3-0 silk Lembert sutures.
Second
portion of
duodenum
Proximal
jejunum
Transverse colon
Staple
line
inverted
7
Duodenum
Outer
layer of
posterior
row
A jejunotomy is then performed, and the distal duodenal
staple line is resected, both with the electrocautery (8).
Jejunum
8
Resection of the Third and Fourth Portions of the Duodenum with Duodenojejunostomy 203
The inner layer of the posterior row is placed in a continuous locking
fashion with 3-0 synthetic absorbable material (9) and is brought
around anteriorly using the Connell stitch (10). The outer layer of the
anterior row consists of interrupted 3-0 silk Lembert sutures (11).
Generally, it is thought preferable to bring the proximal jejunum up
into the right upper quadrant through a rent in the transverse mesocolon
in the region of the bare area. When the end-to-side duodenojejunos-
Balloon at
ampulla
9
Inner layer of
posterior row
tomy is performed, one has to be careful to not to impinge on the
ampulla with either the outer or inner layers of the posterior row.
However, because the end of the duodenum is open during the anas-
tomosis, and because there is a catheter through the ampulla, this is
easily accomplished.
Inner layer of
anterior row
Outer layer of
antterior row
10
11
204 Atlas of Gastrointestinal Surgery: The Duodenum
Cystic duct
12
Duodenum
Stomach
Jejunum
Transverse
mesocolon
The jejunum is tacked to the rent in the trans-
verse mesocolon with interrupted 3-0 silk (12).
An alternative to performing an end-to-side
duodenojejunostomy is to perform an end-
to-end duodenojejunostomy (13). The
jejunum is brought up through a rent in
the transverse mesocolon; the anasto-
mosis is performed in two layers,
with an inner continuous layer of 3-
0 synthetic absorbable material and
an outer layer of interrupted 3-0
Alternative reconstruction
End-to-end duodenojejunostomy
silk. The end-to-end is a somewhat
Colon
more difficult anstomosis to perform
than an end-to-side, because of the
lack of mobility of the fixed duode-
num. Nevertheless, it is preferred
by some. On completion of the
anastomosis, the biliary Fogarty is
removed, the cystic duct doubly lig-
ated, and the gallbladder removed
from the operative field. In addition, the
defect in the retroperitoneum previously
occupied by the third portion of the duo-
denum is closed with a continuous synthetic
4-0 nonabsorbable suture.
13
Common bile duct
Duodenum
Jejunum
The criticism of this operation for a malignant tumor of the
third portion of the duodenum is that it does not include a
lymph node dissection. However, to perform a complete lym-
phadenectomy for a lesion in this location would probably
require a total pancreatectomy. Therefore, this local resection
is generally the treatment of choice with the addition of adju-
vant therapy, including both radiotherapy and chemotherapy.
Duodenojejunostomy for Superior
Mesenteric Artery Syndrome
Operative Indications
The superior mesenteric artery syndrome occurs when the
superior mesenteric artery compresses the third portion of
Liver
the duodenum against the aorta (1). This results in partial
obstruction of the third portion of the duodenum, produc-
ing nausea, vomiting, and dilation of the first and second
Pancreas
portions of the duodenum (2). It is a rare disorder and
usually follows the loss of an inordinate amount of body
weight or a fairly dramatic change in body habits, such as
wearing a body spica for a long period. When it occurs,
the diagnosis can be made by an upper gastrointestinal
study with barium and/or by upper endoscopy. Frequently
the syndrome can be ameliorated without surgery by
instructing the patient on postural changes, particularly after
eating. Occasionally, however, surgery is indicated.
Transverse
colon
Stomach
Aorta
SMA
Duodenum
1
206 Atlas of Gastrointestinal Surgery: The Duodenum
Operative Technique
The patient is explored through an upper midline incision. The entity can be
confirmed by identifying dilated first and second portions of the duodenum to
the right of the mesenteric vessels, with normal-sized third and fourth portions
to the left of the mesenteric vessels (2, 3).
Aorta
Dilated duodenum
Stomach
Normal
duodenum
Superior
mesenteric artery
compressing duodenum
Distended
duodenum
3
Aorta
Jejunum
2
Duodenojejunostomy for Superior Mesenteric Artery Syndrome 207
The transverse colon and transverse mesocolon are retracted in a cephalad direction. The dilated junction of the sec-
ond and third portions of the duodenum is usually visible in the bare area at the root of the transverse mesocolon (4).
This portion of the duodenum is mobilized. The proximal jejunum is then brought adjacent to the duodenum, and a long
side-to-side anastomosis performed.
Transverse colon
Mesocolon
Jejunum
4
Dilated second and
third portions
of duodenum
(bare area)
208 Atlas of Gastrointestinal Surgery: The Duodenum
Duodenum
Jejunum
This is carried out with an inner continuous layer of 3-0 synthetic absorbable
material and an outer layer of interrupted 3-0 silk (5). This simple
operative procedure is very effective in alleviating
symptoms by bypassing the area of partial
Side-to-side
duodenojejunostomy
obstruction (6).
5
Superior
mesenteric
vessels
Stomach
Dilated
duodenum
Jejunum
6
Surgical Management of Annular Pancreas
Operative Indications
Annular pancreas is a congenital anomaly that results from failure of normal rotation of the ventral and dorsal buds of the
pancreas. The result is a complete ring of pancreatic tissue around the second portion of the duodenum (1, 2). This ring
is often not immediately recognizable as pancreatic tissue at the time of laparotomy. Instead it may appear to be fibrous
tissue or scar, resulting from an inflammatory process. This ring invariably contains a pancreatic duct. The entity may pres-
ent with symptoms in infancy, usually duodenal obstruction. In many instances the entity is not symptomatic until adult-
hood. In the adult, the lesion may present as partial duodenal obstruction, usually following episodes of pancreatitis. An
inflammatory mass is often present in the head of the pancreas and may result in obstructive jaundice. In the asymptomatic
patient, an annular pancreas may be encountered as an incidental finding. When symptomatic, the treatment is surgical.
When the presentation is duodenal obstruction, the diagnosis may be suggested preoperatively from an upper GI series or
upper endoscopy showing partial obstruction of the second portion of the duodenum, or by computerized tomography.
However, the diagnosis is usually made at surgery.
210 Atlas of Gastrointestinal Surgery: The Duodenum
Biliary tree
Pancreas
Esophagus
Stomach
Annular
pancreas
Second portion
of duodenum
Omentum
Transverse colon
1
Pancreatic duct
in annular portion
Duodenum
2
Surgical Management of Annular Pancreas 211
Operative Technique
The patient is explored through an upper midline incision. On examining the second
portion of the duodenum, a band of what appears to be fibrous connective tissue
passes anterior to the middle second portion of the duodenum, blending with the pan-
creas (1). It often does not look like normal pancreatic tissue. When a patient pres-
ents with obstructive jaundice, a mass in the head of the pancreas, and is suspected
of having a pancreatic tumor, the diagnosis may only be made after a pancreaticoduo-
denectomy is performed.
A variety of techniques may be used in treating an annular pancreas.
Duodenum
Outer layer of
posterior row
3
Jejunum
Rent in
transverse
mesocolon
Because the pancreatic tissue that surrounds the duodenum contains a
sizable duct, it is generally thought best not to attempt to divide the
pancreatic tissue, but to bypass the partially obstructed duode-
num. Perhaps the most frequently used procedure is to bring a
proximal loop of jejunum up through a rent in the transverse
mesocolon and perform a side-to-side duodenojejunostomy.
The proximal jejunum is brought up into the right upper
quadrant through the transverse mesocolon (bare area),
generally directly on top of the second portion of the duo-
denum. The anastomosis is performed in two layers. The
outer layer of the posterior row consists of interrupted 3-0
silk Lembert sutures (2).
After a duodenotomy and jejunotomy are
performed with the electrocautery, the inner
layer of the posterior row is placed using a con-
tinuous locking stitch of 3-0 synthetic
absorbable material (4).
Inner layer of
posterior row
4
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