Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_738_Библиотеки_им_академика_М_И_Перельмана.pdf
312 Atlas of Gastrointestinal Surgery: Pancreas
The removal of the omentum from the transverse colon proceeds up along the splenic flexure of the colon, and the splenic flexure of the colon is mobilized and retracted inferiorly. At
this point, the omentum is divided anterior to the hilum of the spleen between Kelly clamps,
and ligated with 2-0 silks. The vasa brevia are then divided between Reinhoff clamps, and
ligated with 2-0 silks (3).
Omentum
Vasa brevia
divided
Stomach
Tumor
3
Next, the spleen is
mobilized out of retroperitoneum by dividing the
Distal Pancreatectomy for Tumor 313
serosal attachments
between the lateral and
posterior aspects of the
spleen, and the retroperitoneum. This generally proceeds relatively bloodlessly.
During the dissection and mobilization of the tail of the gland, one
has to be certain that the left adrenal
gland, which is adjacent to the tail of
the pancreas, is not injured (4).
Bleeding from the left adrenal gland
can be troublesome to control.
If the splenic vein is involved
Spleen
4
Adrenal
gland
Kidney
with tumor and is thrombosed,
and splenomegaly is present, or if
the tumor is particularly large,
before mobilization of the spleen and
tail of the pancreas, one might want to
identify the splenic artery after its takeoff
from the celiac axis and ligate it immediately (5). One needs to be absolutely
certain not to confuse the hepatic
artery with the splenic artery. The
splenic artery can be difficult to
identify, as it often passes posterior to the pancreas immediately after arising from the celiac
Celiac axis
Superior
mesenteric
v.
Splenic a.
looped
Inverior mesenteric v.
5
axis, and the only prominent
artery above the superior border of the pancreas is the
hepatic artery.
314 Atlas of Gastrointestinal Surgery: Pancreas
Splenic a.
6
divided
The spleen and the tail and body of the pancreas are fur-
ther mobilized. If one identifies the inferior mesenteric vein
7
coursing through the tumor to meet the splenic
vein, it can be doubly clamped, divid-
Splenic v.
divided
ed, and ligated with 2-0 silk (4). If
the inferior mesenteric vein can be
easily preserved, it should be; one
can, however, divide the inferior
mesenteric vein with impunity, if nec-
essary. Once the tail and body of the
pancreas have been mobilized up to the
neck, if the splenic artery has not been lig-
ated and divided, it should be done now (6).
Again, clear identification of the hepatic artery aris-
ing from the celiac axis should be accomplished before one
triply ligates and divides the splenic artery.
Distal Pancreatectomy for Tumor 315
Spleen
8
Neck of pancreas
divided
Head
Tail
Tumor
Once the splenic artery
has been divided the splenic
vein can be identified under the
neck of the pancreas, clamped,
divided, and triply ligated (7).
The neck of the pancreas is then
divided with the electrocautery (8).
A full cross-section of the neck of the
9
pancreas should be send for frozen section to
be certain there is a clear margin (9).
The pancreatic duct should be identified in the prox-
imal remnant. The incidence of pancreatic cutaneous fistulas is
actually higher for distal pancreatectomies than it is following a
Whipple resection. The incidence can be kept to a minimum if the
pancreatic duct is identified and suture ligated.
316 Atlas of Gastrointestinal Surgery: Pancreas
Portal v.
Head of
pancreas
10
Ligated
splenic v.
Inferior
pancreaticoduodenal
v. and a.
The end of the pancreatic remnant is closed with two layers of interrupted
3-0 synthetic absorbable suture; the first is an overlapping horizontal mattress
suture, and the second is a figure-of-eight suture (10). Two closed suction
Silastic drains are left to drain the pancreatic remnant. A specific lym-
phadenectomy is not performed as a rule during distal pancreatectomy. But
Uncinate
process
wide soft-tissue margins are included, particularly in the retroperitoneum,
to be sure that the posterior margin of the tumor is negative.
Rarely, even in the face of celiac axis involvement by tumor, the
Superior
mesenteric
v. and a.
tumor may be resectable via distal pancreatectomy. If good hepatic
artery flow is provided by the gastroduodenal artery via its collaterals
with the superior mesenteric artery, as demonstrated either preoperatively
by angiogram or, at the time of surgery, by clamping the celiac axis and
observing a pulse in the hepatic artery distal to the gastroduodenal artery, a
resection can be performed that includes a distal pancreatectomy and splenecto-
Hepatic aa.
Gastroduodenal a.
my, and resection of the celiac axis and proximal hepatic artery (11).
Celiac axis
Tumor
11
Superior
mesenteric a.
Superior
mesenteric v.
Central Pancreatectomy with
Pancreaticogastrostomy
Operative Indications:
There are instances when small benign, or low-grade malignant, tumors arise in the neck or proximal body of the pancreas,
leaving one undecided as to whether to perform a pancreaticoduodenectomy or a distal pancreatectomy. If one performs
a pancreaticoduodenectomy, one is doing a very extensive operative procedure for a small lesion that probably does not
require it. If one were to do a distal pancreatectomy, 85% of the gland would be removed, again for a small benign or
low-grade malignant lesion. In these instances, a central resection seems appropriate. Small benign serous or mucinous cystadenomas, small islet cell tumors that cannot be shelled out, or an occasional intraductal papillary mucinous neoplasm, are
examples of tumors in the neck and proximal body that might be amenable to a central pancreatectomy. In addition, instead
of constructing a Roux-en-Y loop in which to drain the distal pancreatic remnant, we feel it is preferable—and quicker—
to perform a pancreaticogastrostomy. The back wall of the stomach rests on the anterior surface of the body and tail of the
pancreas, and this adjacency makes a pancreaticogastrostomy between the distal pancreatic remnant and the back wall of
the stomach very feasible.
Operative Technique:
The patient can be explored either through a midline incision or a transverse bilateral subcostal incision. Once the abdomen is entered, a thorough exploration is carried out to
be certain there is no pathology elsewhere. The lesser sac is entered by removing the
omentum from the transverse colon. The pathology is easily identified in the neck and/or
proximal body of the pancreas. The rest of the pancreas should be thoroughly explored
through the lesser sac, by mobilizing the neck, body and tail of the pancreas along the
inferior border. The duodenum should also be kocherized and the head, neck and unci-
318 Atlas of Gastrointestinal Surgery: Pancreas
nate process palpated from the right side. When one is satisfied that one is dealing with a small benign or low-grade malignant tumor, such as an islet cell tumor, one can proceed with a central pancreatectomy.
The inferior border of the neck and proximal body of the pancreas is mobilized after incising the serosal attachment onto
the inferior border of the pancreas. The superior mesenteric vein is easily identified. The anterior surface is carefully dissected from the posterior aspect of the neck of the pancreas. The superior border of the pancreas along its neck is next mobilized by incising the serosal reflection. The portal vein is identified and dissected from the posterior aspect of the neck of the
pancreas and connected to the superior mesenteric vein dissection. The neck of the pancreas is looped with a small Penrose
drain (1). The central portion of the pancreas is then reflected anteriorly, and the splenic vein identified. The splenic vein
has to be carefully dissected from the undersurface of the neck and proximal body of the pancreas. There are a few small
venous branches that have to be carefully dissected free, doubly ligated, and then divided. The splenic artery is often separate from the neck and proximal body of the pancreas, and
does not have to be dissected. But if it does arise and
join the superior border of the neck and proximal
body, it also needs to be dissected free. There
may be several small arterial branches that have
Omentum
to be doubly ligated and divided.
Once the central portion of the pancreas has been mobilized, it can be divided
with the electrocautery proximally at the
Stomach
junction of the neck and head of the pancreas, and distally such that there is at
least a 2 cm margin on either side of
the tumor (1). The specimen
should be sent for frozen section,
and both margins checked.
Resection of
central pancreas
1
Central Pancreatectomy with Pancreaticogastrostomy 319
The proximal pancreatic remnant
should be oversewn with two layers of
3-0 synthetic absorbable suture. The
first layer is placed in an overlapping horizontal mattress fashion, and the second
layer is placed in a figure-of-eight fashion. An attempt should be made to identify the pancreatic duct in the proximal
pancreatic remnant, as its ligature with a
mattress suture (2) will decrease the likelihood of a pancreatic cutaneous fistula.
2
Pancreatic
duct closed
An end-to-side pancreaticogastrostomy is performed between the distal pancreatic remnant and
the posterior wall of the stomach. It is performed in
two layers: an outer interrupted layer of 3-0 silk
and an inner continuous layer of 3-0 synthetic
absorbable suture material. The pancreatic
duct may or may not be dilated. In either
case, it is incorporated in the inner continuous layer of 3-0 synthetic absorbable
suture. If the duct is of normal caliber,
often two (or at the most three)
throws can incorporate the duct,
both inferiorly and superiorly. If it
is dilated, several throws of the
3
End-to-side
pancreaticogastrostomy
Posterior row
inner layer can incorporate the
dilated pancreatic duct (3).
320 Atlas of Gastrointestinal Surgery: Pancreas
The outer interrupted layer of the left lateral anastomotic site is placed first. A gastrotomy is then fashioned of the
appropriate length. The inner continuous layer of 3-0 absorbable suture is then placed running down the left lateral side
of the anastomosis first in a locking fashion (3), and then passing along the right lateral inner layer in an over-and-over
suture. The anastomosis is completed when one places the outer interrupted layer of 3-0 silk sutures along the right lateral anastomotic border (4).
These patients are particularly prone to developing pancreatic cutaneous fistulas out through the drains, since often both
the proximal and distal pancreatic remnants are normal soft tissue. We generally use three Silastic closed suction drains for
a central resection. One drain each is placed on either side of the pancreaticogastrostomy and a third drain at the proximal pancreatic remnant. This central resection maximally preserves pancreatic parenchyma in patients in whom one is not
concerned about doing a radical resection or including a large amount of surrounding soft tissue or lymph nodes.
End-to-side
pancreaticogastrostomy
Specimen
Proximal
pancreatic
remnant
Splenic v.
4
Laparotomy for Insulinoma
Operative Indications:
Once the diagnosis of an insulinoma has been confirmed on the basis of serum glucose and insulin levels, there are a variety of options in attempting to localize the tumor. In the past, angiography was used routinely. It is rarely performed today.
Three-dimensional, thin-section CT scans often will be able to identify the location of the insulinoma. The use of magnetic resonance imaging has shown promise; however, the most accurate means of tumor identification pre-operatively is with
endoscopic ultrasound. Even with these more accurate means of identifying the location of an insulinoma, in some instances
the patient will be explored with the diagnosis of insulinoma, but without knowing its exact location.
Operative Technique:
Either a bilateral subcostal or midline incision can be used. Once the abdomen has been
entered, a thorough exploration is carried out for evidence of other pathology. Because
most insulin-secreting neuroendocrine tumors are benign, however, only rarely would one
find evidence of metastatic disease.