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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_734_Библиотеки_им_академика_М_И_Перельмана.pdf
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A. Polcari et al.
10. Prior to resection of mucosal or submucosal lesions, saline or epinephrine can
be injected in the submucosal space to lift the lesion from the exterior layers of
the duodenal wall.
11. A gure of eight suture can be placed through the lesion itself once visible to
assist in retraction and visualization of the ducts [12]. TIP: A 5 Fr pediatric
feeding tube or small catheter can be placed into the CBD to ensure safe dissection of lesions near the ampulla [11].
12. Wide local excision is performed using electrocautery, generally 5mm to 1cm
margin in a clockwise manner circumferentially around the lesion. Tumors that
are mucosal or submucosal in origin and periampullary or peri-pancreatic can
be lifted off the duodenal wall via dissection in the subcutaneous space. Lesions
with deeper origin and far from the ampulla (>2 cm) should undergo fullthickness wedge resection, removing the duodenal wall circumferentially
around the lesion. TIP: Abe etal. describe using indigocarmine dye solution to
assist in visualizing tumor margins [13]. In this series, the solution is mixed
with epinephrine and injected into the submucosa to help lift the tumor.
13. Close the submucosal defect with interrupted, absorbable suture (e.g., 3-0
Vicryl™). Close the duodenotomy transversely in two layers—we use an inner
absorbable suture and a permanent silk suture to Lembert the outer layer. TIP:
If the resection defect is too large to be closed primarily (e.g., 50% of the duodenal wall), one should consider proximal GI reconstruction [13]. Other alternatives such as a duodenal sleeve or pancreas preserving duodenectomy are
options described in a later chapter.
Minimally Invasive (Robotic-Assisted) Transduodenal Submucosal
andWedge Resection
1. The patient should be positioned supine on the operating table with both arms
out at 90 degrees. The authors also choose to split the patient’s legs (Fig.13.7).
2. After intubation and initiation of general anesthesia, a nasogastric tube and uri-
nary catheter should be placed in addition to pneumatic compression devices
for DVT prophylaxis. The patient should be prepped according to hospital
protocol.
3. After entry into the abdomen, set pneumoperitoneum to 10–15mmHg.
4. Perform diagnostic laparoscopy of the liver and peritoneum to rule out meta-
static lesions.
5. Robotic ports for the Xi (Intuitive Surgical, Sunnyvale California) should be
placed as follows: 8mm port in the left upper quadrant, 8mm port above the
umbilicus, 8mm port in the left mid-clavicular line, and an 8mm port in the left
mid-axillary line.
6. At least one laparoscopic 12 mm assistant port is required for passing: ultra-
sound probe, sutures, and mini-lap pads. An additional 5mm assistant trocar
can be placed as well if needed for suction or retraction of the colon, which may
be more critical in patients with central obesity.
13 Surgical: Transduodenal Resection (Open vs Minimally Invasive)
Fig. 13.7 Patient
positioned with split legs
213
Fig. 13.8 Complete Kocher maneuver
7. Dock the robot. This can be done a variety of ways, but the authors prefer to
dock from the patient’s left, in the upper abdomen conguration of the Xi robot.
8. Mobilize the hepatic exure of the colon.
9. Perform an extensive Kocher maneuver to expose the entirety of D2—lysing
the duodenum’s retroperitoneal attachments from the foramen of Winslow to
the Ligament of Treitz and posteromedial to the root of the SMA (Fig.13.8).
The posterior wall of the duodenum should be visible after completion of this
maneuver and duodenum should be mobilized away from hepatoduodenal
ligament.
10. Since the lesion cannot be reliably palpated, the lesion is identied and its rela-
tionship to the ampulla assessed using intra-operative ultrasound. Given
advancements in robotic-assisted technology, one can also use indocyanine
green (ICG) to locate the CBD (Fig.13.9) [14]. While the bile duct is patient
dependent, it can sometimes be visualized through the intra-pancreatic portion
of the bile duct.
214
Fig. 13.9 ICG
A. Polcari et al.
Fig. 13.10 Stay sutures
11. Stay sutures may be placed through the lateral walls of the duodenum near the
lesion (Fig.13.10). These can assist in closure and can be retracted by the third
robot arm to give more exposure. Laparotomy sponges can also be used to
bump up the duodenum, bringing the mass to the forefront.
12. Wide local excision is performed using electrocautery, generally a 5 mm to
1cm margin in a clockwise manner circumferentially around the lesion starting
at 3 o’clock (Fig.13.11). Tumors that are mucosal or submucosal in origin and
periampullary or peri-pancreatic can be lifted off the duodenal wall via dissection in the submucosal space. Lesions with deeper origin and enough distance
from the ampulla should undergo full-thickness wedge resection, removing the
duodenal wall circumferentially around the lesion (Fig.13.12).
13. Place the specimen in bag for removal through the umbilical port.
13 Surgical: Transduodenal Resection (Open vs Minimally Invasive)
Fig.
13.11 Circumferential
demarcation around the
lesion
215
Fig. 13.12 Full-thickness resection removing the duodenal wall
14. Close any submucosal defects with interrupted, absorbable suture (e.g., 3-0
Vicryl™).
15. Close the duodenotomy in two layers—we use an inner absorbable barbed
suture (Fig. 13.13) and a permanent silk suture to Lembert the outer layer
(Fig.13.14).
Open Transduodenal Ampullectomy
1. Patient should be positioned supine on the operating table with both arms out at
90 degrees.
2. After intubation and initiation of general anesthesia, a nasogastric tube and uri-
nary catheter should be placed in addition to pneumatic compression devices
for DVT prophylaxis. Patient should be prepped according to hospital protocol.
3. Both a midline incision and an extended right subcostal incision are acceptable.
A midline incision is recommended for patients who may require adhesiolysis
216
Fig. 13.13 Duodenum closure: rst layer with barbed suture
A. Polcari et al.
Fig. 13.14 Duodenum closure: second layer with silk
due to prior surgical history. Some authors will also make a reversed “L” incision [15].
4. Palpate the liver and inspect the rest of the peritoneum to rule out evidence of
metastatic disease.
5. After the surgeon’s preferred self-retaining retractor is placed, mobilize the
hepatic exure of the colon.
6. Perform an extensive Kocher maneuver to expose the entirety of D2—lysing
the duodenum’s retroperitoneal attachments from the foramen of Winslow to
the Ligament of Treitz and posteromedial to the root of the SMA.The posterior
wall of the duodenum should be visible after completion of this maneuver.
7. Physically palpate the duodenal wall in a bimanual fashion to identify the target
lesion and the ampulla. TIP: Several authors also describe creating a cystic
ductotomy and passing a catheter into the duodenum to assist in identifying the
ampulla, especially if the bile duct is small [15–17]. A cholecystectomy must
then be performed.
13 Surgical: Transduodenal Resection (Open vs Minimally Invasive)
217
8. At this time, stay sutures may be placed through the duodenal wall lateral to the
lesion and planned site of duodenotomy to maintain adequate exposure throughout the operation. TIP: A laparotomy sponge can be placed behind the duode-
num to facilitate positioning prior to making the duodenotomy.
9. Using cautery, make a 2–4cm longitudinal duodenotomy on the antimesenteric
border of D2, opposite the ampulla.
10. Resect the ampulla. Use electrocautery to incise the mucosa 5 mm to 1 cm
reaching the submucosal plane. Dissect in the submucosal plane starting at the
11 o’clock position and moving clockwise until reaching the CBD.Mark the
duct with a suture on its superior edge. Continue dissecting clockwise until
reaching the pancreatic duct, typically at the 4–6 o’clock position. Complete
the dissection circumferentially until margins are grossly clear. TIP: Jung etal.
prefer to use the needle point electrocautery device on cutting (monopolar)
mode to avoid distorting the margins for pathology [18].
11. Reconstruct the ampulla; this is the most challenging step. Using 5-0 absorb-
able monolament suture (i.e., 5-0 PDS), sew the ducts back to the duodenal
wall using interrupted sutures. Start with the CBD and work toward the pancreatic duct. It is important to suture the septum between the two ducts together, as
well. NOTE: Some authors also describe reconstructing the ampulla in con-
junction with dissection of the lesion (i.e., combining Steps 10 and 11 above, or
“suturing as you go”). Papalampros etal. place serial sutures from the duodenal wall to the CBD and pancreatic duct as dissection of the mass progresses,
leaving only re-approximation of the two ducts to be completed after the mass
in completely removed [12, 17].
12. Stent the bile duct. Sometimes this is done prior to resection, for reconstruction,
or at the end. Occasionally, suturing the stent with lesion can allow manipulation of the lesion without touching it. For the end, 4–7 French stents that are
designed to pass are used. Some surgeons suture these in place with absorbable suture.
13. Mathiel etal. note that there is typically an extra fold of duodenal tissue due to
a larger duodenal defect than duct area; this defect can be closed with simple
interrupted sutures [17].
14. Close the duodenotomy transversely in two layers—the authors use an inner
absorbable suture and a permanent silk suture to Lembert the outer layer.
Minimally Invasive (Robotic-Assisted) Transduodenal Ampullectomy
1. Patient should be positioned supine on the operating table with both arms out.
The authors also choose to split the patient’s legs.
2. After intubation and initiation of general anesthesia, a nasogastric tube and uri-
nary catheter should be placed in addition to pneumatic compression devices
for DVT prophylaxis. Patient should be prepped according to hospital protocol.
218
A. Polcari et al.
3. After entry into the abdomen, typically via Veress needle at the umbilicus or at
Palmer’s point followed by an optical separator entry, set pneumoperitoneum to
10–15mmHg.
4. Perform diagnostic laparoscopy of the liver and peritoneum to rule out meta-
static lesions.
5. Robotic ports for the Xi (Intuitive Surgical, Sunnyvale California) should be
placed as follows: 8mm port in the left upper quadrant, 8mm port above the
umbilicus, 8mm port in the left mid-clavicular line, and an 8mm port in the left
mid-axillary line (Fig.13.15).
6. At least one laparoscopic 12 mm assistant port is required for passing: ultra-
sound probe, sutures, and mini-lap pads. An additional 5mm assistant trocar
can be placed as well if needed for suction or retraction of colon which may be
more critical in patients with central obesity.
7. Dock the robot. This can be done a variety of ways, but the authors dock from
the patient’s left, in the upper abdomen conguration of the Xi robot
(Fig.13.16a, b).
8. Mobilize the hepatic exure of the colon.
9. Perform an extensive Kocher maneuver to expose the entirety of D2—lysing
the duodenum’s retroperitoneal attachments from the foramen of Winslow to
the Ligament of Treitz and posteromedial to the root of the SMA to mobilize the
entire duodenum. The posterior wall of the duodenum and pancreas should be
visible after completion of this maneuver.
10. Interrogate the duodenal wall for the target lesion and the ampulla. This may
not be possible in minimally invasive fashion given lack of haptic feedback;
adjuncts include ICG, ultrasound, and catheters via the cystic duct (Figs.13.17
and 13.18; see Tips and Tricks below).
11. Stay sutures may be placed through the lateral walls of the duodenum near the
pancreas at the level of the ampulla on either side of where the duodenotomy is
planned to maintain exposure and later close the duodenum (Fig.13.19).
Fig. 13.15 Robotic ports
placement
ab
13 Surgical: Transduodenal Resection (Open vs Minimally Invasive)
Fig. 13.16 Docking
219
Fig. 13.17 (a) Fluorescence, (b) Ultrasound
Fig. 13.18 Fogarty Catheter via the cystic duct
220
ab
Fig. 13.19 Stays sutures placed on both sides of the duodenal wall
A. Polcari et al.
Fig. 13.20 (a) stent placed in the pancreatic duct. (b) Stent placed in the CBD
12. Using cautery, make a 2–4cm longitudinal duodenotomy on the antimesenteric
border of D2, opposite the ampulla. TIP: A few mini-laparotomy sponges can
be placed behind the duodenum to facilitate positioning prior to making the
duodenotomy.
13. Resect the ampulla. Use electrocautery to incise the mucosa 5 mm to 1 cm
reaching the submucosal plane. Dissect in the submucosal plane starting at the
6 o’clock position and moving clockwise until reaching the CBD ~12 o’clock.
Mark the duct with a suture on its superior edge. Continue dissecting clockwise
until reaching the pancreatic duct, typically at the 4–6 o’clock position.
Complete the dissection circumferentially until margins are grossly clear. TIP:
Using stents within the bile and pancreatic duct are helpful to the dissection
and reconstruction (Fig.13.20). Sometimes suturing the stent to the bile duct
can create a handle to manipulate the ampulla without touching the adenoma.
A four French stent is left unsutured in the PD to pass soon after the case. Its
primary purpose helps avoid back-walling the duct during suturing.
ab
13 Surgical: Transduodenal Resection (Open vs Minimally Invasive)
221
c d
Fig. 13.21 Reconstruction of the ampulla: (a, b) First stitch 12 o’clock. (c, d) Second stich
between bile duct and pancreatic duct
14. Place specimen in bag for removal through the 12mm port.
15. Reconstruct the ampulla; this is the most challenging step. 5-0 absorbable
monolament (i.e., PDS) cut to 5 inches allows for use 2–3 times. The rst
stitch placed is 12 o’clock at the top of the bile duct (Fig.13.21a, b). Then, the
third robotic arm can retract this anteriorly. Place the second stitch inferior on
the bile duct and superior on the pancreas duct for a septoplasty to unite the
ducts (Fig.13.21c, d). Next sew the ducts full thickness to the mucosa of the
duodenal wall using interrupted sutures.
16. Stent the CBD and pancreatic duct—as describe previously if not already done.
17. Close the duodenotomy transversely in two layers—we use an inner absorbable
barbed suture and a permanent silk suture to Lembert the outer layer
(Fig.13.22a–c).