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X
- •Disclaimer
- •Contents
- •Contributors
- •Embryology
- •Lymphatics
- •Nerves
- •Clinically Relevant Anatomic Variations
- •Duodenum Inversum
- •Pancreas Divisum
- •Annular Pancreas
- •Ectopic Pancreas
- •Ansa Pancreatica
- •Pancreaticobiliary Maljunction
- •Duplication Anomalies
- •Physiology
- •Duodenal Physiology
- •Mechanical Function
- •Endocrine Function
- •Pancreatic Physiology
- •Exocrine Physiology
- •Normal Anatomy
- •Duodenal Anatomy
- •Pancreatic Anatomy
- •Ductal Anatomy
- •Vasculature
- •Endocrine Physiology
- •References
- •Etiology
- •Pathophysiology
- •Diagnosis
- •Clinical Presentation
- •Laboratory Tests
- •Imaging
- •Medical Management
- •Fluid Resuscitation
- •Analgesics
- •Prophylactic Antibiotics
- •Nutrition
- •Complications
- •Long-Term Sequelae of Acute Pancreatitis
- •References
- •Introduction
- •Initial Treatment
- •Reducing Severity of Acute Pancreatitis
- •Fluid Resuscitation
- •Pain Management
- •Nutrition
- •Preventing Infectious Complications
- •References
- •Introduction
- •Sterile Pancreatic Necrosis
- •Antibiotic Therapy
- •Catheter Drainage
- •Video-Assisted Retroperitoneal Drainage (VARD) Procedure
- •Sinus Tract Necrosectomy
- •Open Necrosectomy
- •Open Trans-Gastric Cystogastrostomy
- •Disconnected Distal Pancreatic Duct Syndrome
- •Introduction
- •References
- •Introduction
- •Venous Thrombosis
- •Intra-Abdominal Hypertension
- •Thoracic Complications
- •Gastrointestinal Complications
- •References
- •Pain
- •Endocrine Dysfunction
- •Exocrine Dysfunction
- •Conclusion
- •References
- •Background
- •Postoperative Care
- •References
- •Background
- •Head-Dominant Disease
- •Tail-Dominant Disease
- •Perioperative Management
- •Procedure Steps
- •Open Whipple
- •MIS Whipple
- •Open Distal Pancreatectomy
- •MIS Distal Pancreatectomy
- •Pearls
- •References
- •Introduction
- •Procedures
- •Indications
- •Contraindications
- •Preoperative Workup
- •Pediatrics
- •Patient Selection
- •Contraindications
- •Key Steps
- •Common Steps
- •Pitfalls/Tricks
- •Local Complications
- •Systemic Complications
- •References
- •History/Introduction
- •Indications
- •Adults
- •Procedural Aspects
- •Preoperative Care
- •Total Pancreatectomy
- •Islet Infusion
- •Minimally Invasive Surgery (MIS)
- •Postoperative Care
- •Outcomes
- •Perioperative Data
- •Perioperative Complications
- •Endocrine Function
- •References
- •Introduction
- •Duodenal Adenomas
- •Duodenal Adenocarcinomas
- •Duodenal Neuroendocrine Tumors (D-NETs)
- •Other Non-neoplastic Epithelial Lesions
- •Duodenal Gastrointestinal Stromal Tumors (DGISTs)
- •Leiomyoma
- •Lipoma
- •Choledochal Cysts
- •Duodenal Lymphoma
- •Conclusion
- •References
- •Introduction
- •Pre-procedural Considerations
- •Indications
- •Resection Techniques
- •Sporadic Non-ampullary Adenomas: Cold Snare Polypectomy
- •Sporadic Non-ampullary Adenomas: EMR
- •Sporadic Non-ampullary Adenomas: ESD
- •Sporadic Non-ampullary Adenomas: Full-Thickness Resection Device
- •Ampullary Adenomas: Endoscopic Papillectomy
- •Sporadic Non-ampullary Adenomas: Cold Snare Polypectomy
- •Sporadic Non-ampullary Adenomas: EMR
- •Endoscopic Papillectomy
- •Surveillance
- •References
- •Introduction
- •Benign Tumors
- •Genetic Syndromes
- •Pre-Malignant Tumors
- •Low-Grade Malignancies
- •Alternatives
- •Inclusion Criteria
- •Preoperative Planning
- •Open Transduodenal Ampullectomy
- •Minimally Invasive (Robotic-Assisted) Transduodenal Ampullectomy
- •Outcomes
- •Conclusions
- •References
- •Introduction
- •Anatomy
- •Laparoscopic Segmental Duodenectomy
- •Robotic Segmental Duodenectomy
- •Technique
- •Open Segmental Duodenectomy
- •Patient Positioning
- •Technique
- •Conclusion
- •References
- •Overview
- •Intraductal Papillary Mucinous Neoplasm (IPMN)
- •General Concepts
- •Novel Biomarkers
- •DNA-Based Biomarkers
- •MiRNA
- •Protein-Based Biomarkers
- •IPMNs
- •MCNs
- •SCNs
- •SPTs
- •Guidelines
- •Surveillance Discontinuation
- •Follow-Up Strategy
- •The Verona Policy
- •Conclusions
- •References
- •Introduction
- •Pathophysiology
- •Work-Up
- •Tissue Diagnosis
- •Serum Tumor Markers
- •Multidisciplinary Decision-Making
- •Adjuvant Trials
- •Systemic Chemotherapy
- •Chemoradiation
- •Neoadjuvant Trials
- •Chemotherapy
- •Chemoradiation
- •Pancreatectomy
- •Summary
- •References
- •Introduction
- •Diagnosis
- •Imaging
- •Functionality
- •Insulinoma
- •Gastrinoma
- •VIPoma
- •Glucagonoma
- •Staging/Surgical Decision-Making
- •Nonmetastatic Disease
- •Metastatic Disease
- •Multidisciplinary Decision-Making
- •Surgical Resection
- •Systemic Treatments
- •Open Trials
- •Surveillance
- •References
- •Renal Cell Carcinoma
- •Introduction/Epidemiology
- •Diagnosis/Radiology/Pathology
- •Treatment/Outcome
- •Colorectal Carcinoma
- •Introduction/Epidemiology
- •Diagnosis/Radiology/Pathology
- •Treatment/Prognosis
- •Melanoma
- •Introduction/Epidemiology
- •Diagnosis/Radiology/Pathology
- •Treatment/Prognosis
- •Sarcoma
- •Introduction/Epidemiology
- •Diagnosis/Radiology/Pathology
- •Treatment/Prognosis
- •Conclusion
- •References
- •Preoperative Considerations
- •Key Steps
- •Staging Laparoscopy
- •Specimen Removal
- •Vascular Resection
- •Reconstruction
- •Pancreaticojejunostomy
- •Hepaticojejunostomy
- •Gastro- or Duodeno-Jejunostomy
- •Final Steps
- •References
- •Randomized Controlled Trials
- •Surgical Technique
- •Resection Phase
- •Reconstruction Phase
- •Postoperative Course
- •Conclusions
- •References
- •Introduction
- •Preoperative Workup
- •Preoperative Planning
- •Surgical Management
- •Patient Preparation
- •Surgical Steps
- •Step 1: Kocher Maneuver
- •Step 4: Pancreatic Transection
- •Reconstruction
- •Hepaticojejunostomy
- •Pancreaticojejunostomy
- •Duodenojejunostomy
- •References
- •Introduction
- •Preoperative Planning
- •Diagnostic Laparoscopy
- •Radical Antegrade Modular Pancreatosplenectomy (RAMPS)
- •Splenic Vein Stump Length
- •Ligamentum Teres/Falciform Pedicle Flap
- •References
- •History
- •Early Exploration
- •Trends Over Time
- •Morbidity
- •Safety
- •Oncologic Safety
- •Preoperative Planning
- •Clinical Considerations
- •Anatomical Considerations
- •Surgical Technique
- •Conclusion
- •References
- •Introduction
- •Indications
- •Preoperative Testing
- •Operative Approach
- •Peritoneal Access
- •Specimen Extraction
- •Closure
- •Clinical Outcomes
- •Conclusions
- •References
- •Introduction
- •Preoperative Preparation
- •Key Shared Operative Steps
- •Trocar Placement
- •Splenic Flexure Mobilization
- •Pancreas Mobilization
- •Identify Pancreatic Pathology
- •Pancreatic Transection
- •Splenic Vein Dissection
- •Splenic Artery Dissection
- •Conclusion
- •References
- •Introduction
- •Historical Evolution
- •Perioperative Outcomes
- •Oncologic Outcomes
- •Neoadjuvant Therapy
- •Preoperative Adjuncts
- •Preoperative Coiling
- •Aortic Stenting
- •Robotic DP-CAR Surgical Technique
- •Positioning
- •Port Placement
- •Surgical Steps
- •Perioperative Care
- •Conclusion
- •References
- •Introduction
- •Preoperative Considerations
- •Laparoscopic Enucleation
- •Patient Positioning
- •Procedure
- •Robotic Enucleation
- •Patient Positioning
- •Procedure
- •Open Enucleation
- •Postoperative Management
- •Postoperative Outcomes
- •References
- •Introduction
- •Indications
- •Preoperative Assessment
- •Serologic Testing
- •Surgical Management
- •Patient Preparation
- •Diagnostic Laparoscopy
- •Surgical Steps
- •Step 1: Gastric Mobilization
- •Step 2: Pancreatic Resection
- •Step 3: Reconstruction
- •Jejunojejunostomy
- •Pancreaticojejunostomy
- •Discussion
- •References
- •Introduction
- •Biliary Obstruction
- •Endoscopic Interventions
- •Plastic Versus Metal Stents
- •Covered Versus Uncovered Metal Stents
- •Stent Obstruction
- •Surgical Options
- •Endoscopic Versus Surgical Intervention
- •Duodenal Obstruction
- •Duodenal Stents
- •Venting Percutaneous Gastrostomy Tubes (PEG)
- •Surgical Gastrojejunostomy (Duodenal Bypass)
- •Endoscopic Versus Surgical Intervention
- •Abdominal Pain
- •Celiac Plexus Neurolysis
- •Surgical Celiac Plexus Block
- •Summary
- •References

xii
Contents
38 How to Measure Postoperative Outcomes . . . . . . . . . . . . . . . . . . . . . . 645
Elizabeth L. Barbera, Alexandra M. Adams,
and Timothy J. Vreeland
39 SAGES University Master’s Program: Pancreas Pathway . . . . . . . . . 657
Hemasat Alkhatib, Voranaddha Vacharathit, and Kevin M. El-Hayek
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673

Contributors
MartinaAbati Division of Pancreatic Surgery, Pancreas Translational and Clinical
Research Center, San Raffaele Scientic Institute, Milan, Italy
Nutrition Service, San Raffaele Scientic Institute, Milan, Italy
Gerard J. Abood Department of Surgery, Loyola University Medical Center,
Maywood, IL, USA
AlexandraM.Adams Brooke Army Medical Center, Fort Sam Houston, TX, USA
Hemasat Alkhatib Division of General Surgery, MetroHealth System,
Cleveland, OH, USA
Adnan Alseidi Department of Surgery, University of California, San Francisco,
San Francisco, CA, USA
OsaidAlser Texas Tech University Health Sciences Center, Lubbock, TX, USA
DomenechAsbun Division of Hepatobiliary and Pancreas Surgery, Miami Cancer
Institute, Miami, FL, USA
HoracioJ.Asbun
Institute, Miami, FL, USA
Subhashini Ayloo Department of Surgery, Warren Alpert Medical School of
Brown University, Providence, RI, USA
ElizabethL.Barbera Brooke Army Medical Center, Fort Sam Houston, TX, USA
JacksonA.Baril Department of Surgery, Indiana University School of Medicine,
Indianapolis, IN, USA
JodieAdamBarkin Pancreas Center, Division of Gastroenterology, University of
Miami Miller School of Medicine, Miami, FL, USA
RicardoJ.Bello Division of Surgical Oncology, Medical College of Wisconsin,
Milwaukee, WI, USA
Division of Hepatobiliary and Pancreas Surgery, Miami Cancer
xiii

xiv
Contributors
MarcG.Besselink Department of Surgery, Amsterdam UMC, Location University
of Amsterdam, Amsterdam, The Netherlands
Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The
Netherlands
StefanA. W.Bouwense Department of Surgery, Maastricht University Medical
Centre+, Maastricht, The Netherlands
VincentButano Digestive Health Institute at AdventHealth, Tampa, FL, USA
Nicholas Caminiti
Department of Surgery, University of Louisville,
Louisville, KY, USA
Mei Zhen Cao Department of General Surgery, The Brooklyn Hospital Center,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
Chelsea F. Cardell Department of Surgery, Loyola University Medical Center,
Maywood, IL, USA
FabioCasciani University of Verona, Verona, Italy
University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
EugeneP.Ceppa Department of Surgery, Indiana University School of Medicine,
Indianapolis, IN, USA
Jenny Chang Department of General Surgery, Digestive Disease Institute,
Cleveland Clinic, Cleveland, OH, USA
ZaimChaudhary University of California, Berkeley, Berkeley, CA, USA
ArianaChirban Department of Surgery, St. Elizabeth’s Medical Center, Boston
University School of Medicine, Boston, MA, USA
University of California, San Diego, School of Medicine, La Jolla, CA, USA
Edward Cho Department of Surgery, University of Oklahoma at Tulsa,
Tulsa, OK, USA
Department of Surgery, University of Illinois Peoria, Peoria, IL, USA
CallisiaN.Clarke Division of Surgical Oncology, Medical College of Wisconsin,
Milwaukee, WI, USA
ClaudiusConrad Department of Surgery, St. Elizabeth’s Medical Center, Boston
University School of Medicine, Boston, MA, USA
Carle Cancer Institute, Carle Illinois College of Medicine, Urbana, IL, USA
G.Corvino Department of General and Pancreatic Surgery, The Pancreas Institute
Verona, University of Verona Hospital Trust, Verona, Italy
KanakDas Texas Tech University Health Sciences Center, Lubbock, TX, USA
Jonathan C. DeLong Division of Surgical Oncology, University of Tennessee
Medical Center Knoxville, Knoxville, TN, USA

Contributors
xv
Nicolas Demartines Department of Visceral Surgery, Lausanne University
Hospital CHUV, University of Lausanne, Lausanne, Switzerland
Kevin M. El-Hayek Division of General Surgery, MetroHealth System,
Cleveland, OH, USA
Case Western Reserve University School of Medicine, Cleveland, OH, USA
Northeast Ohio Medical University, Rootstown, OH, USA
Imad Elkhatib Advanced/Therapeutic Endoscopy, Advocate Christ Medical
Center, Oak Lawn, IL, USA
Amir H. Fathi
University of California San Francisco, Fresno MEP,
Fresno, CA, USA
Ashley Faulx Division of Gastroenterology, University Hospitals of Cleveland,
Case Western Reserve University School of Medicine, Cleveland, OH, USA
Alexandra Gangi Department of Surgical Oncology, Cedars-Sinai Medical
Center, Los Angeles, CA, USA
RomuloGenato Department of General Surgery, The Brooklyn Hospital Center,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
CamillaGomes Department of Surgery, University of California, San Francisco,
San Francisco, CA, USA
AndrewGumbs Department of General Surgery, The Brooklyn Hospital Center,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
Jessica Heard Department of Surgery, University of Oklahoma at Tulsa,
Tulsa, OK, USA
EmilyHensler Department of Surgery, Warren Alpert Medical School of Brown
University, Providence, RI, USA
Matthew Hernandez Department of Surgery, City of Hope National Medical
Center, Duarte, CA, USA
PamelaJ.Hodul Moftt Cancer Center, Tampa, FL, USA
MelissaE.Hogg NorthShore University HealthSystem, Evanston, IL, USA
Carlos Theodore Huerta DeWitt Daughtry Family Department of Surgery,
University of Miami Miller School of Medicine, Miami, FL, USA
MalynnAnneIlanga Department of Surgery, University of Oklahoma at Tulsa,
Tulsa, OK, USA
HarelJacoby Advent Health Tampa| Digestive Health Institute, Tampa, FL, USA
Sheba Medical Center, Tel-Aviv, Israel
Dhiresh Rohan Jeyarajah Department of Surgery, Methodist Health System,
Dallas, TX, USA
Department of Surgery, TCU Burnett School of Medicine, Fort Worth, USA

xvi
Contributors
RachelC.Kim Department of Surgery, Indiana University School of Medicine,
Indianapolis, IN, USA
JörgKleeff Department of Visceral, Vascular and Endocrine Surgery, University
Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle
(Saale), Germany
Johannes Klose Department of Visceral, Vascular and Endocrine Surgery,
University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg,
Halle (Saale), Germany
Joshua P. Kronenfeld
DeWitt Daughtry Department of Surgery, University of
Miami Miller School of Medicine, Miami, FL, USA
Onur C. Kutlu DeWitt Daughtry Department of Surgery, University of Miami
Miller School of Medicine, Miami, FL, USA
JaewonLee Department of Surgical Oncology, Cedars-Sinai Medical Center, Los
Angeles, CA, USA
ChiaraLimongi Vita-Salute San Raffaele University, Milan, Italy
Núria Lluís Division of Hepatobiliary and Pancreas Surgery, Miami Cancer
Institute, Miami, FL, USA
Szu-Aun Long Department of Surgery, University of Cincinnati College of
Medicine, Cincinnati, OH, USA
G.Marchegiani Hepatopancreatobiliary and Liver Transplant Surgery, Department
of Surgery, Oncology and Gastroenterology (DiSCOG), University of Padua,
Padua, Italy
David Martin Department of Visceral Surgery, Lausanne University Hospital
CHUV, University of Lausanne, Lausanne, Switzerland
Robert Martin Department of Surgery, University of Louisville,
Louisville, KY, USA
HeatherE.Matheny Vascular Surgery, University of Washington, Seattle, WA, USA
LalehMelstrom Department of Surgery, City of Hope National Medical Center,
Duarte, CA, USA
Marc Mesleh Department of Surgery, University of Illinois Chicago (UIC),
Chicago, IL, USA
Advocate Christ Medical Center, Oak Lawn, IL, USA
LucaMilone Division of Robotic Surgery, Department of General Surgery, The
Brooklyn Hospital Center, Icahn School of Medicine at Mount Sinai, New
York, NY, USA

Contributors
xvii
DavidCabaMolina Loma Linda University, Loma Linda, CA, USA
Riverside University Health System/University of California-Riverside, Loma
Linda, CA, USA
RossMudgway Loma Linda University, Loma Linda, CA, USA
Gilbert Murimwa Department of Surgery, University of Texas Southwestern
Medical Center, Dallas, TX, USA
AnneNagelhout
Department of Surgery, Radboudumc, Nijmegen, The Netherlands
Department of Research and Development, St. Antonius Hospital, Nieuwegein, The
Netherlands
Trang K. Nguyen Division of Surgical Oncology, Washington University in St.
Louis, St. Louis, MO, USA
DanielJ.Oliveira Loma Linda University, Loma Linda, CA, USA
EdwinOnkendi Texas Tech University Health Sciences Center, Lubbock, TX, USA
Houssam G. Osman Department of Surgery, Methodist Health System,
Dallas, TX, USA
ElenaPanettieri Department of Surgery, St. Elizabeth’s Medical Center, Boston
University School of Medicine, Boston, MA, USA
Hepatobiliary Surgery, Fondazione “Policlinico Universitario A.Gemelli”, IRCCS,
Università Cattolica del Sacro Cuore, Rome, Italy
NicolòPecorelli Vita-Salute San Raffaele University, Milan, Italy
Division of Pancreatic Surgery, Pancreas Translational and Clinical Research
Center, San Raffaele Scientic Institute, Milan, Italy
Pancreas Translational & Clinical Research Center, San Raffaele Scientic Institute,
Vita-Salute San Raffaele University, Milan, Italy
G. Perri Hepatopancreatobiliary and Liver Transplant Surgery, Department of
Surgery, Oncology and Gastroenterology (DiSCOG), University of Padua,
Padua, Italy
Patricio M. Polanco Division of Surgical Oncology, Department of Surgery,
University of Texas Southwestern Medical Center, Dallas, TX, USA
AnnPolcari University of Chicago, Chicago, IL, USA
Motaz Qadan Division of Surgical Oncology, Department of Surgery,
Massachusetts General Hospital, Boston, MA, USA
AllenA.Razavi Department of Surgical Oncology, Cedars-Sinai Medical Center,
Los Angeles, CA, USA
AramRojas NorthShore University HealthSystem, Evanston, IL, USA

xviii
Contributors
UlrichRonellentsch Department of Visceral, Vascular and Endocrine Surgery,
University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg,
Halle (Saale), Germany
Alexander Rosemurgy Department of Surgery, University of Central Florida,
Orlando, FL, USA
Advent Health Tampa| Digestive Health Institute, Tampa, FL, USA
Department of Surgery, Nova Southeastern University, Fort Lauderdale, FL, USA
Sharona Ross
Department of Surgery, University of Central Florida,
Orlando, FL, USA
Advent Health Tampa| Digestive Health Institute, Tampa, FL, USA
Department of Surgery, Nova Southeastern University, Fort Lauderdale, FL, USA
Didier Roulin Department of Visceral Surgery, Lausanne University Hospital
CHUV, University of Lausanne, Lausanne, Switzerland
R.Salvia Department of General and Pancreatic Surgery, The Pancreas Institute
Verona, University of Verona Hospital Trust, Verona, Italy
Maximiliano Servin-Rojas Department of Surgery, Massachusetts General
Hospital, Boston, MA, USA
Robert Simon Department of General Surgery, Digestive Disease Institute,
Cleveland Clinic, Cleveland, OH, USA
AndrewJ.Sinnamon Moftt Cancer Center, Tampa, FL, USA
RebeccaA. Snyder Department of Surgical Oncology, The University of Texas
MD Anderson Cancer Center, Houston, TX, USA
JohnStauffer Department of Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
Martijn W. J. Stommel Department of Surgery, Radboudumc, Nijmegen, The
Netherlands
Iswanto Sucandy Department of Surgery, University of Central Florida,
Orlando, FL, USA
Advent Health Tampa| Digestive Health Institute, Tampa, FL, USA
Cameron Syblis University of South Florida Morsani College of Medicine,
Tampa, FL, USA
Advent Health Tampa| Digestive Health Institute, Tampa, FL, USA
MaxwellT.Trudeau University of Pennsylvania Perelman School of Medicine,
Philadelphia, PA, USA
University of Connecticut School of Medicine, Farmington, CT, USA
Voranaddha Vacharathit Faculty of Medicine, Department of Surgery,
Chulalongkorn University, Bangkok, Thailand

Contributors
xix
King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok,
Thailand
AlessiaVallorani Vita-Salute San Raffaele University, Milan, Italy
EduardoA.Vega Department of Surgery, St. Elizabeth’s Medical Center, Boston
University School of Medicine, Boston, MA, USA
Brendan C. Visser Division of Hepatobiliary and Pancreas Surgery, Stanford
University, Stanford, CA, USA
Charles M. Vollmer University of Pennsylvania Perelman School of Medicine,
Philadelphia, PA, USA
CatherineVozzo Division of Gastroenterology, University Hospitals of Cleveland,
Case Western Reserve University School of Medicine, Cleveland, OH, USA
TimothyJ.Vreeland Brooke Army Medical Center, Fort Sam Houston, TX, USA
R.MatthewWalsh Department of General Surgery, Digestive Disease Institute,
Cleveland Clinic, Cleveland, OH, USA
JaneWang Department of Surgery, University of California, San Francisco, San
Francisco, CA, USA
Paul Wong Department of Surgery, City of Hope National Medical Center,
Duarte, CA, USA

Part I
Anatomy and Physiology

Chapter 1
Anatomy andPhysiology
JessicaHeard, MalynnAnneIlanga, andEdwardCho
Embryology
Rapid cell division of the blastula and subsequent gastrulation is completed by the
end of the third embryonal week, giving the embryo the necessary endoderm, mesoderm, and ectoderm required for further development. Initially, these germ layers
exist in a trilaminar disc which undergo craniocaudal and lateral folding as organogenesis begins in the fourth embryonal week. Ultimately, the endodermal cells will
form the mucosal lining of the gastrointestinal tract in addition to the liver, pancreas, and gallbladder. The mesenteries and the muscular walls of the gastrointestinal organs develop from the splanchnic mesoderm. Finally, nerves, including the
vagus nerve and the bowel wall plexuses, will develop from neural crest cell (ectoderm) origins.
Craniocaudal folding initiates the formation of the cranial and caudal portions of
the primitive gut. In conjunction with craniocaudal folding, lateral folding completes the process of the primitive gut tube formation whereby the dorsal aspect of
the yolk sac (endoderm) is slowly pinched off by the developing ventrolateral body
walls (somatic mesoderm) in the formation of the midgut. During this process,
splanchnic mesoderm is rolled with the endodermal cells resulting in an enveloping
layer of mesoderm about the primitive gut tube. Migration of neural crest cells
begins and will eventually provide innervation to the primitive gut [1].
J. Heard · M. A. Ilanga
Department of Surgery, University of Oklahoma at Tulsa, Tulsa, OK, USA
e-mail: MalynnAnne-Ilanga@ouhsc.edu
E. Cho (*)
Department of Surgery, University of Oklahoma at Tulsa, Tulsa, OK, USA
Department of Surgery, University of Illinois Peoria, Peoria, IL, USA
e-mail: echo0818@uic.edu
Switzerland AG 2025
E. P. Ceppa et al. (eds.), The SAGES Manual of Evolving Techniques in
Pancreatic Surgery, https://doi.org/10.1007/978-3-031-78409-5_1
3© The Author(s), under exclusive license to Springer Nature
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