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292 Atlas of Gastrointestinal Surgery: Pancreas
Vein of Belcher
The superior mesenteric and portal veins are then dissected off the uncinate
process. Again, this is generally done with very little need to ligate and divide sub-
stantial vessels. The superior pancreaticoduodenal vein draining into the portal vein,
also known as the vein of Belcher, is a fairly constant landmark and needs to be
Superior
mesenteric a.
First jejunal
branch divided
(first time)
Superior
mesenteric
v.
14
Hepatic a.
identified, doubly ligated and divided. In addition, more distally on the superior
mesenteric vein, near the inferior border of the uncinate process, the first jejunal
branch is a constant landmark, arising from the right lateral border of the supe-
rior mesenteric vein, and coursing around and posterior to the superior
mesenteric artery to the proximal jejunum, to the left of the mesenteric ves-
sels. This generally has to be ligated and divided (14).
A good deal of the dissection of the superior mesenteric and por-
tal veins off the uncinate process, however, can be done gently,
but bluntly. The uncinate process of the pancreas ends flush
against the right lateral border of the superior mesenteric
artery. In most instances, the dissection and division of
the uncinate process should be flush with the superi-
Neck of
pancreas
or mesenteric artery, cleaning approximately 180
degrees of the artery’s circumference (15).
15
Superior
mesenteric a.
Superior
Superior
mesenteric v.
mesenteric v.
Uncinate
process
divided
There are several sizable arterial branches that
have to be identified, ligated and divided.
Finally, the first jejunal venous branch, as it
courses underneath the superior mesenteric
artery to pass to the proximal jejunum, often
has to be doubly ligated and divided for a
second time (16).
Vein of Belcher
Superior
mesenteric v.
Superior
mesenteric a.
16
First jejunal
branch divided
(second time)
One then retracts cephalad the transverse
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 293
colon and identifies the ligament of Treitz
and the proximal jejunum. The proximal
jejunum at a convenient point distal to the
ligament of Treitz, in the middle of a large
arcade, is divided with a GIA stapler
(17). The mesentery to the proximal
jejunum and fourth and third portions of the
duodenum are then doubly clamped,
divided and ligated with 2-0 silk.
Since the third portion of the duodenum has been extensively kocherized
and mobilized during the earlier
part of the dissection, and since
the uncinate process has been
17
Jejunum
divided
Transverse
colon
completely divided during the earlier dissection, this dissection
below the transverse mesocolon to
completely mobilize the specimen
proceeds easily and quickly. Once
the jejunum is divided and the
mesentery is clamped, divided
and ligated down to the ligament
of Treitz, the proximal jejunum is
passed underneath the superior
mesenteric vessels over to the right
side of the abdomen, and the
specimen is removed from the
operative field (18).
Common
hepatic duct
Common hepatic a.
Mesentery
divided
First portion of
duodenum
18
Duodenum
Transverse colon
Jejunum
Pancreatic
head
Uncinate
process
294 Atlas of Gastrointestinal Surgery: Pancreas
Gall bladder
Distal
biliary
tree
19
Head and neck of pancreas
Duodenum
Uncincate
process
Resection specimen
Proximal
jejunum
The specimen consists of the distal
portion of the first part of the duodenum, all of the second, third and
fourth portions of the duodenum, and
approximately 10 cm of proximal
jejunum. In addition, the neck, head
and all of the uncinate process of the
pancreas are included, as are the gall
bladder and distal biliary tree (19).
There are a variety of ways to
perform the pancreaticojejunostomy.
Many have been used very effec-
tively, with a reasonably low incidence of pancreatic leakage and with low morbidity and mortality. We prefer to invaginate the end of the pancreas into
the side of the jejunum. Other pancreatic surgeons prefer to perform a duct to mucosa pancreaticojejunostomy, also in an
end-to-side fashion. Whether or not to stent the anastomosis with a small polyethylene tube is still under debate. We will
demonstrate the invagination technique with an end-to-side pancreaticojejunostomy (20), which also includes a duct-tojejunal mucosal anastomosis; we will also demonstrate a duct-to-mucosa anastomosis; finally, we will demonstrate the invagination technique.
The end-to-side invagination anastomosis is carried out in two layers: an outer interrupted layer of 3-0 silk and an inner
continuous layer of 3-0 synthetic absorbable material. The jejunum is brought up into the lesser sac through a rent in the
transverse mesocolon, generally through the bare area of transverse mesocolon that resided over the junction of the second
and third portions of the duodenum. The outer row of the posterior layer is placed first. The 3-0 silks are placed through
the posterior surface of the pancreas, and then through the jejunum (21).
Outer layer of
posterior row
20
Pancreaticojejunostomy
Jejunum
Pancreas
21
22
Inner layer of
posterior row
Pancreatic duct
included in inner layer
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 295
23
Inner layer of
anterior row
When all sutures have been placed, they are secured. A
jejunotomy is then performed. The inner posterior layer of
the anastomosis consists of a continuous 3-0 synthetic
absorbable suture placed in a locking fashion (22). The
pancreatic duct is included in this inner layer. If it is a normal-sized duct, only two or three throws are placed
through the duct. If the duct is dilated, however, several
throws are placed through and through the dilated pancreatic duct. Thus, this technique combines both the
invagination technique as well as a duct-to-mucosa anastomosis. The inner layer of the anterior row of the anastomosis is
performed next. This consists of an over-and-over suture passing
from above to below, through the capsule of the pancreas and out
through the divided parenchyma, and then from inside out on the
24
Outer layer of
anterior row
jejunum. Again, the pancreatic duct is incorporated in several throws
of this inner layer of the anterior row (23). When this has been completed, the outer interrupted layer of 3-0 silk sutures is placed such
that some of the jejunum is drawn over to cover the anastomosis (24).
296 Atlas of Gastrointestinal Surgery: Pancreas
This is performed by passing the
25
Jejunum
Invaginated
pancreas
silk sutures through the capsule of
the pancreas about 1 cm from the
anastomosis, then out at the anastomosis, and then through and
through the jejunum about a cen-
timeter away from the anastomosis.
This anastomosis results in invagina-
tion of the end of the pancreas into
the side of the jejunum, utilizing two lay-
ers, and also incorporates the pancreatic duct
(25). This anastomosis can also be performed
in an end-to-end fashion, when the pancreatic remnant has a relatively small diameter, and
the jejunal diameter is of sufficient size. The
Jejunotomy
(small)
26
anastomosis is performed in an identical fashion as the end-to-side anastomosis.
For the duct-to-mucosa anastomosis, the
outer layer is placed exactly as it is for the
invagination technique. The next step creates
a jejunotomy the same size and exactly adjacent to the pancreatic duct (26). The ductto-mucosa anastomosis is performed with
interrupted 5-0 synthetic absorbable suture
material. The posterior row is placed first, the
sutures passing from inside out on the duct
side and outside in on the mucosal side.
Once all posterior row sutures have been
27
placed, they are secured (27).
Posterior
duct-to-mucosa
row
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 297
Stent placed in
pancreatic duct
and secured
29
28
Anterior
duct-to-mucosa
row
30
Next, one can choose to place a stent or
not. We demonstrate a stent created from a
No. 8 French pediatric feeding tube, 8 cm in
length, being secured with one of the 5-0
sutures previously placed in the posterior row
(28, 29). The anterior row of the duct-tomucosa anastomosis is completed by placing a
row of interrupted 5-0 synthetic absorbable
sutures from outside in on the duct, and inside
out on the jejunal mucosa (30). The outer
anterior layer is completed with an interrupted
row of 3-0 silk sutures placed in a Lembert
31
Completed anastmosis
Stent
fashion (31).
298 Atlas of Gastrointestinal Surgery: Pancreas
Finally, in the unusual
situation of a very thin, soft gland
in which the pancreatic duct can not be
identified, we resort to placing the end of
the pancreas into the end of the jejunum for a 5-
cm distance and then tacking the jejunum circumfer-
When these are secured, the pancreas
32
entially to the body of the gland. This is accom-
plished by mobilizing the end of the pancreas for a
5-cm distance and then placing stay sutures 2.5 cm
from the cut end on the superior and inferior bor-
ders. These stay sutures are tied, then passed into
the end of the jejunum and out the side, 2.5 cm
from its end (32).
is inserted into the jejunum for a 5cm distance. The end of the
jejunum is then sutured to the
body of the pancreas circumferentially with a series of interrupted 3-0 silk sutures (33).
33
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 299
Two to five centimeters distal to the pancreaticojejunostomy, the
hepaticojejunostomy is performed (34). This is carried out with a single
layer of interrupted 4-0 synthetic absorbable suture material. An appropriately sized enterotomy is performed, and the posterior row is placed
with through-and-through sutures passing from inside out on the jejunum
and outside in on the hepatic duct (35). When all sutures are placed,
they are secured. The anterior layer is then carried out, again first placing
all sutures before securing them. They pass from outside in on the jejunum,
and inside out on the hepatic duct (36).
Posterior row
Hepatic
duct
Anterior row
34
Hepaticojejunostomy
35
36
300 Atlas of Gastrointestinal Surgery: Pancreas
37
The final anastomosis is an end-to-side duodenojejunostomy
(37). If one leaves only a 2-cm cuff of duodenum on the pylorus, it
is not necessary to preserve the right gastric artery, although this is
always preferable. The right gastric artery is often small, arises from the
hepatic artery, and actually joins the first portion of the duodenum. In
most instances, the right gastric artery can be identified and preserved.
The duodenojejunostomy is performed with an outer interrupted layer
of 3-0 silk and an inner continuous layer of 3-0 synthetic absorbable
Hepaticojejunostomy
Duodenojejunostomy
Jejunum
Outer layer of
posterior row
suture (38). Once the outer layer of the back row of the
First portion of
duodenum
anastomosis has been placed, these sutures are
secured and an enterotomy is made on the
side of the jejunum (39).
Stomach
38
Enterotomy
39
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 301
The staple line on the first portion of the duodenum is then
excised. The inner layer on the posterior row is a continuous
locking suture of 3-0 synthetic absorbable material (40).
This is continued onto the anterior row and placed in a
Connell fashion (41). The duodenojejunostomy is completed with an outer layer of interrupted 3-0 silk sutures (42).
Inner layer of
anterior row
Inner layer of
posterior row
40
41
Outer layer of
anterior row
42