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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_734_Библиотеки_им_академика_М_И_Перельмана.pdf
356
N. Lluís et al.
hepatic artery). Other hepatic artery anatomical variations, such as a replaced/
accessory right hepatic artery, may run in close proximity to the CBD, usually
posterolateral. A thorough inspection of preoperative imaging is key to identify
the presence of these variants, especially during this part of the pancreatoduodenectomy. Preoperative biliary stents should be placed low within the
CBD.Plastic or fully covered biliary stents are preferred since they are easier to
remove intraoperatively, as opposed to uncovered stents where tissue ingrowth
makes its removal much more difcult.
Prior to CBD transection, a gauze is placed posteriorly, and a bulldog clamp
is passed proximally around the CBD to prevent bile spillage and minimize
peritoneal contamination. This is especially important if the patient has a biliary
stent in place. The curved bulldog is inserted with a bulldog applier to facilitate
manipulation. A silk suture is tied to the back of the bulldog clamp to facilitate
removing it from the abdominal cavity. The CBD is transected sharply with
scissors, as low as possible, as long as a clear biliary margin is achieved. A
lower level of transection will facilitate the angle of the bilioenteric anastomosis, even if it is transected below the junction with the cystic duct. Another useful strategy to facilitate reconstruction is to leave the posterior wall of the bile
duct 3–4mm longer than the anterior wall. Peri-choledochal vessels are coagulated in small bursts using ultrasonic shears. Bile cultures are taken if a stent
was present, and the margin is sent for frozen examination to ensure it is not
involved by tumor. The distal CBD is closed with a running silk suture to prevent further spillage during the rest of the procedure. If a stent was present,
attempts are made to leave it in the specimen. Otherwise, it is removed through
the choledochotomy and can be extracted from the abdomen in a retrieval bag.
Once the CBD is clamped, a continuous infusion of indocyanine green (ICG)
at a rate of 0.4 mg/min may be started. This allows pancreatic parenchymal
impregnation with ICG without signicant background uptake by the liver and
other organs. Further ICG boluses of 1.25mg may be given, which help delineate arterial (rst) and venous (later) anatomy. Although not always, ICG may
be a very useful aid during the resection phase of the pancreatoduodenectomy
especially when dissecting the uncinate process of the mesenteric vessels.
13. Retropancreatic window formation
Attention is now paid to the inferior edge of the pancreas. Gentle traction and
observation of countermovement of tissues in this area help identify the plane
between the pancreas and the adipose tissue of the retroperitoneum/transverse
mesocolon. A wide window is created along the inferior edge of the pancreas
using ultrasonic shears or a bipolar device. This wide exposure of the area is
important to avoid the poor visualization and vascular control, which can happen when “working in a hole.” Several tricks may be used to locate the SMV:
(1) follow venous tributaries that drain into the SMV, especially the tributaries
that form the trunk of Henle; (2) locate the extrahepatic main portal vein above
the pancreas and estimate its position caudally; (3) review preoperative imaging
20 Laparoscopic Pancreatoduodenectomy
to assess, in coronal views, the angle between the main portal vein and the SMV
at its conuence; and (4) use of intraoperative ultrasound, including Doppler.
A retropancreatic tunnel is created in a caudad-cephalad fashion, along the
avascular plane between the anterior aspect of the SMV and the posterior aspect
of the pancreatic neck (Fig.20.8). Meticulous blunt dissection in small strokes,
as well as ultrasonic shears to ligate small veins, is used to create the window.
The neck of the pancreas is completely encircled with the aid of a nger-type
retractor, and a Penrose drain, or similar, is passed. The tip of the Penrose drain
is cut into a long, thin point so that it can be easily introduced through the
opening in the nger-type retractor (Fig. 20.9). If necessary, the common
hepatic artery is further separated from the superior edge of the pancreas to
avoid encircling it with the Penrose drain.
14. Mesenteric-uncinate groove exposure
Venous branches draining from the uncinate process and proximal jejunum into
the SMV can be identied by anteriorly retracting the pancreatic neck with the
Penrose. Identifying and ligating these veins at their insertion to the SMV can
facilitate later separation of the uncinate process from mesentery as they are
usually easier to identify here (Fig.20.10). In case it is not clear whether these
vessels drain the uncinate process or the jejunal/colonic mesentery, a Kocher
maneuver that swipes the whole mesentery can be useful to identify and divide
only those vessels that drain the uncinate process, or those early jejunal branches
if they must be sacriced.
15. Pancreatic neck transection
Preoperative imaging assessment is helpful to identify the location of the main
pancreatic duct (MPD) within the pancreas, as well as its size. In sagittal series,
the distance from the edge of the pancreas to the MPD, as well as the superiorinferior location, gives an estimate of where the MPD is to be expected during
pancreatic transection (Fig.20.11).
The pancreatic neck is transected in a caudad-cephalad fashion, as follows:
the inferior edge of the pancreas is divided by applying a generous bite with
ultrasonic shears, and using a gradual compression technique that will divide
the inferior pancreatic arcade. Then, the parenchyma is divided using a backand- forth movement of the active blade of the ultrasonic shears in order to rec-
357
Fig. 20.8 Retropancreatic
tunnel. Meticulous blunt
dissection is used to create
the window between the
superior mesenteric vein
and the neck of the
pancreas (Figure
reproduced with
permission of Horacio J
Asbun)
358
Fig. 20.9 Pancreatic neck
is encircled with a
nger-type retractor and a
Penrose drain. The tip of
the drain is cut in a thin
long diagonal to facilitate
its insertion through an
opening in the nger
retractor (Figure
reproduced with
permission of Horacio J
Asbun)
Fig. 20.10 Mesentericuncinate groove exposure
dissection (Figure
reproduced with
permission of Horacio J
Asbun)
N. Lluís et al.
ognize the MPD without thermal injury before its transection (Fig.20.12). The
MPD is divided sharply with scissors, leaving a 2–3mm protruding stump in
preparation for the duct-to-mucosa anastomosis (Fig.20.13). The distal end of
the duct may be stented with a 3.5 or 5 Fr pediatric feeding tube for later identication and manipulation during pancreatic reconstruction. Finally, the
remaining parenchyma and the superior pancreatic arcade are transected with
ultrasonic shears using gradual compression.
16. Kocher maneuver
A reverse Trendelenburg position with a left-side down tilt of the operative
table is encouraged. The 45-degree laparoscope and camera are moved from
port 4 to port 3. The retraction made by the rst assistant is crucial to adequately
mobilize the duodenum beyond the inferior vena cava (IVC) and to open the
ligament of Treitz from the right side. For this, the assistant performs a swiping
maneuver toward the midline of the previously mobilized colon with a closed
large bowel clamp inserted through port 6. Simultaneously, the divided distal
20 Laparoscopic Pancreatoduodenectomy
Fig. 20.11 Preoperative
sagittal MRI series
determine the cephalocaudal and antero-posterior
location of the main
pancreatic duct which is
useful to plan for the
pancreatic neck transection
(Figure reproduced with
permission of Horacio J
Asbun)
Fig. 20.12 Pancreatic
neck division. The
parenchyma is divided
using a back-and-forth
movement of the active
blade of the ultrasonic
shears in order to
recognize the MPD
without thermal injury
before its transection
(Figure reproduced with
permission of Horacio J
Asbun)
359
duodenal stump is pulled obliquely toward the left upper quadrant with a grasping forceps through port 5. The IVC and insertion of the left renal vein are
exposed. The duodenum, head of the pancreas, and uncinate process are now
completely mobilized from the retroperitoneum and reected medially. This
dissection brings the retropancreatic lymph nodes into the specimen.
17. Ligament of Treitz opening and proximal jejunum division
The ligament of Treitz is accessed and released from the right side of the patient.
The rst jejunal loop is pulled behind the superior mesenteric vessels, transected with a laparoscopic 60 mm stapler (blue load), and delivered to the
supramesocolic compartment. The jejunal mesentery is carefully ligated with a
vessel sealer to avoid any potential source of post-pancreatectomy hemorrhage.
Minimizing the amount of jejunum and mesentery that is transected is encour-
360
Fig. 20.13 Main
pancreatic duct division
with scissors. A 2–3mm
protruding stump is left in
preparation for the
duct-to-mucosa
anastomosis (Figure
reproduced with
permission of Horacio J
Asbun)
N. Lluís et al.
Fig. 20.14 Uncinate process dissection. A partially-opened large bowel grasper retracts the specimen laterally. A 5mm endo-Kittner retracts the superior mesenteric vein left and cephalad. The
parenchyma is dissected with a bipolar vessel sealing device using small bites (Figure reproduced
with permission of Horacio J Asbun)
aged, as this decreases the amount of cut mesentery that can bleed
postoperatively.
18. Uncinate process dissection
The uncinate process and head of the pancreas are lifted cephalad to the right in
the crotch of a partially opened large grasper, such as a bowel clamp. The rst
assistant is of crucial importance to achieve adequate retraction and exposure,
as well as to perform precise hemostasis, if needed. A 5mm endo-Kittner is
used to retract the SMV to the left and cephalad (Fig.20.14).
Adequate retraction using the above-mentioned method helps identify the
plane of dissection between the uncinate process and the superior mesenteric
vessels. ICG infusion as mentioned above may aid in achieving complete visualization and resection of the pancreatic parenchyma in this challenging area.
The parenchyma is dissected with a bipolar vessel sealing device using small
bites. The jaws of the vessel sealer can be continuously opened and closed
while active to improve hemostasis. Inferior pancreatoduodenal vessels may be
encountered and are ligated and divided. Lymphadenectomy, including tissue
lateral to the SMA, is performed en bloc. Extreme caution in this area is needed
20 Laparoscopic Pancreatoduodenectomy
in case a replaced right hepatic artery off the superior mesenteric artery (SMA)
exists (Fig.20.15). Preoperative imaging review helps assess the origin and trajectory of this anatomic variant. Identication, isolation, and ligation of the
inferior pancreatoduodenal artery (IPDA) and other SMA branches to the pancreas are important during this step.
In case of hemorrhage from the SMV or tributaries, the lateral portion of the
distal end of the suction shaft is used to apply gentle pressure and achieve
temporary control of bleeding; using the tip should be avoided as it may enlarge
the hole in the vein. Very short bursts of suction, pressing the suction button
only partially allow for clearance of blood and identication of the bleeding site
when it occurs. Monolament sutures are used to control bleeding. Once the
stitch is ready to be thrown, the suction shaft is slowly rolled sideways to expose
the injured vein and allow the stitch to be placed in the vessel. Advanced laparoscopic skills, such as mounting and passing the needle with one hand, are
important, especially in this phase of the procedure. A similar technique can be
used to control arterial bleeding, which is less common.
If vascular involvement by the lesion is suspected, the portal conuence
should be completely exposed and vessels dissected circumferentially, including the splenic vein. Vessel loops are used to gain proximal and distal vascular
control. Depending on anatomic variants, the left gastric vein may also need to
be surrounded and looped individually. Heparin is administered prior to clamping the vein, which is resected en bloc with the PD specimen when vascular
involvement is present.
19. Specimen removal
The specimen is placed in a laparoscopic 15-mm retrieval bag. Orientation of
the specimen with the cut jejunal end at the edge of the bag is important to
decrease the need to enlarge trocar sites in excess. The jejunum is grasped and
pulled outside the abdominal cavity, along with the rest of the specimen, through
port 5, which is enlarged only to about 4cm when the specimen is oriented
361
Fig. 20.15 Replaced right hepatic artery off the superior mesenteric artery might be encountered
during the uncinate process dissection. Thorough preoperative imaging review is warranted to
assess for the presence of vascular variants (Figure reproduced with permission of Horacio
J Asbun)
362
N. Lluís et al.
appropriately. A small Pfannenstiel incision may be used instead if the specimen is very large or bulky. Frozen section evaluation of the margins, including
the pancreatic neck, uncinate process/SMA margin, and CBD, is performed.
Fascia is reapproximated with a monolament absorbable suture, and pneumoperitoneum is reestablished in preparation for reconstruction. While the resection margins are being evaluated, the cholecystectomy is completed.
Reconstruction Phase
The authors’ preference is to use a 3D camera during the reconstruction phase in
order to obtain better visualization for stitch placement during the anastomoses.
20. Hepaticojejunostomy
Once the cholecystectomy is completed, the liver retractor is now placed from
the left side. The jejunum is pulled through where the ligament of Treitz was
opened. It is positioned in an inverted “J” shape (candy cane) in the right supramesocolic area, where the biliary and pancreatic anastomosis will be performed.
Bowel loop kinking or mesenteric torsion should be avoided. The surgeon now
moves to the right side of the patient to perform the end-to-side hepaticojejunostomy. This angle facilitates mounting the needle and suturing in a more
ergonomic fashion. The camera is placed in port 2 and triangulated with the
working ports 1 and 3. A gauze is placed posteriorly to avoid any bile spillage
and potential contamination of the abdominal cavity, especially in patients with
a previous biliary stent. If possible, the bulldog is left in place until completion
of the anastomosis. The rst assistant holds suction to avoid bile spillage after
enterotomy and holds the jejunum in place using a grasper through port 5. An
enterotomy slightly smaller than the size of the cut common bile/hepatic duct is
preferred. The posterior wall is sutured with a 4-0 or 5-0 barbed spiral suture
mounted on a TF or RB-1 needle, in a running method from patient left to right.
The previously cut longer posterior wall of the bile duct provides space that
facilitates adequate placement of stitches in this area (Fig.20.16). The anterior
wall is then sutured similarly. A 15 Fr Blake drain is inserted through port 1 and
will serve to drain the posterior aspect of both the biliary and pancreatic anastomosis. Placing the drain before the pancreaticojejunostomy avoids the need to
place traction on that anastomosis once completed. The jejunal loop is xed to
the Gerota’s fascia with a silk to avoid its kinking, prevent the drain from being
in direct contact with the bilioenteric anastomoses, and decrease tension on the
anastomosis.
21. Pancreaticojejunostomy
The surgeon now stands between the legs of the patient. The camera is placed
in port 4 and triangulated with the working ports 3 and 5. Precise stitching and
maneuvering of the needle during this part of the procedure are facilitated by
20 Laparoscopic Pancreatoduodenectomy
Fig. 20.16 Hepaticojejunostomy. The previously cut longer posterior wall of the bile duct
(3–4 mm longer than the anterior wall) provides space that facilitates adequate placement of
stitches in this area (Figure reproduced with permission of Horacio J Asbun)
363
3D visualization, as well as instruments (needle driver, grasper) with a 3mm tip
mounted on a 5mm shaft.
The anastomosis is constructed in four layers in a duct-to-mucosa fashion. A
rst posterior outer layer will propel the duct stump anteriorly. For this, a running 4-0 absorbable barbed spiral suture mounted on an RB1 needle is performed between the posterior surface of the pancreas and the posterior
seromuscular layer of the jejunum, near the mesenteric border and well into the
posterior aspect of the pancreas. This suture is started cranially and left untied
caudally. Each stitch is placed at the same level and spaced equally in the bowel
wall. This creates a ledge of seromuscular layer behind the pancreas creating a
patch of bowel wall behind the future duct-to-mucosa layer.
An enterotomy is created using ultrasonic shears. The enterotomy is tailored
to be a little larger than the size of the MPD opening. A pediatric feeding tube
may be placed in the MPD during reconstruction to facilitate manipulation,
retraction, and stitch placement, and removed prior to nishing the anastomosis. If the MPD is very small, a very small anterior slit can be used to gently
dilate its opening. The pediatric feeding tube or the tip of a 3mm Maryland
retractor may also be used for this purpose. However, one should not risk damaging the duct opening. A duct-to-mucosa anastomosis is performed. A rst
suture in the posterior layer, including both the duct and jejunum, is placed at 6
o’clock (most posterior aspect) and left untied. A 5-0 or 6-0 polyglactin suture
mounted on a TF needle is used. This suture, as well as the MPD stent, is
manipulated in different directions exposing the edge of the duct to be stitched.
The next interrupted suture is placed cranially, and then one caudally. These are
tied and cut immediately after being placed, and the 6 o’clock suture is generally tied at the end of the posterior wall. The number of stitches to be placed
will depend on the size of the MPD but the minimum used is usually three
posterior stitches even for a 1mm duct.
364
N. Lluís et al.
The anterior layer is constructed. A rst stay suture at 12 o’clock is passed
only in the MPD opening and left untied (Fig.20.17). This will open the duct
and allow for continuous visualization of the duct lumen. The rest of the interrupted stitches are passed from cephalad to caudad and left untied until all
stitches are passed (Fig.20.18). When placing each stitch, care is taken not to
cross the sutures. After all anterior sutures are placed, the initial 12 o’clock
stitch is completed by passing it through the jejunum, and all are tied. Caution
to ensure the suture tails are also not crossed when tying. At least four anterior
stitches are usually placed even for the very small ducts. Since the size of the
enterotomy is a little larger than the MPD opening, the stitches are placed in a
radial fashion on the side of the enterotomy, taking a good purchase of the
bowel, almost with the intent of inserting the MPD opening well inside the
bowel opening.
An anterior outer layer is created in a running fashion between the anterior
aspect of the pancreas and the anterior seromuscular layer of the jejunum
(Fig.20.19). The same 4-0 absorbable barbed suture on an RB1 needle is used.
Caution is advised when placing these sutures on a soft pancreas. In order to
avoid tearing of the pancreas and increasing the risk of a postoperative pancreatic stula, the knot should be tied by pushing on the jejunal side of the knot. A
falciform ap may be wrapped around the anastomosis if desired and if it
reaches easily.
22. Duodenojejunostomy
The gastrointestinal reconstruction is done using the same jejunal loop as for
the other two anastomoses, but using a segment distally, approximately
20–30cm distal to the ligament of Treitz. The area of the ligament of Treitz is
identied by retracting the transverse colon mesentery superiorly and looking
in the area between the two pedicles of omentum that were created at the initial
part of the operation. The anastomoses will end up sitting between these two
Fig. 20.17 Pancreatojejunostomy. A rst stay suture at 12 o’clock is passed only in the main pancreatic duct and left untied. This allows for continuous visualization of the duct lumen while placing the remaining stitches of the anterior layer of the duct-to-mucosa anastomosis (Figure
reproduced with permission of Horacio J Asbun)
20 Laparoscopic Pancreatoduodenectomy
Fig. 20.18 The stitches of the posterior layer of the duct-to-mucosa anastomosis are already tied.
The suture at 12 o’clock in the anterior layer is manipulated in different directions exposing the
edge of the duct to be stitched. The rest of the interrupted stitches are passed superiorly and inferiorly (Figure reproduced with permission of Horacio J Asbun)
Fig. 20.19 An anterior
outer layer is created in a
running fashion between
the anterior aspect of the
pancreas and the anterior
seromuscular layer of the
jejunum. A 4-0 or 5-0
absorbable barbed suture
on a RB1 needle is used
(Figure reproduced with
permission of Horacio J
Asbun)
365
omental pedicles. An end-to-side duodenojejunostomy is constructed in four
layers, with barbed sutures, and in an antecolic fashion (Fig.20.20). The rst
seromuscular posterior layer is created in a running fashion. The rst stitch is
placed approximating the right aspect of the jejunum to the greater curvature
end of the divided post-pyloric duodenum. A 3-0 polydioxanone absorbable
barbed suture is used for all layers. The duodenum and jejunum are opened
after the outer posterior layer is run. The duodenal staple line is kept when
opening the bowel parallel to it. This facilitates the anastomoses. The inner
posterior and anterior layers are done. Since the duodenal staple line potentially
may have decreased blood supply, the authors encourage its inclusion in the
inner posterior layer of the anastomosis. The anastomosis ends with an outer
anterior seromuscular layer. If needed, a second 15 Fr Blake drain is inserted
through port 6 and will serve to drain the anterior aspect of the pancreatojeju-