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322 Atlas of Gastrointestinal Surgery: Pancreas
Kocherized
duodenum
Stomach
Head of
pancreas
1
Duodenum
2
Body of
pancreas
The duodenum is extensively
kocherized and the head, uncinate
process, and neck of the pancreas
carefully palpated for evidence of
tumor (1, 2). The head is the
Head of
pancreas
Uncinate
process
Superior
mesenteric v.
Superior
mesenteric a.
thickest portion of the pancreas,
and a small tumor may be particularly difficult to palpate in this location. The lesser sac is then entered
by removing the greater omentum
from the transverse colon. The peritoneal reflection along the inferior
border of the pancreas is incised,
and the neck, body and tail of the
Body of
pancreas
Laparotomy for Insulinoma 323
Stomach
Divided greater
omentum
Spleen
3
gland are mobilized out of the retroperitoneum (3).
This can generally be done rapidly, bluntly, and
bloodlessly. It is particularly important when explor-
Inferior border
of pancreas
Transverse
colon
Splenic a.
Palpation
of body
and tail of
pancreas
ing a patient for an insulinoma that one be able to
visualize and palpate the entire pancreas. Once the
body and tail have been mobilized, one can easily
palpate both anteriorly and posteriorly for evidence
of a mass (4). If, after careful visualization and palpation of the entire pancreas, the lesion cannot be
identified, intraoperative ultrasound should be used.
Of all the pre- and intraoperative imaging devices
that are available, this is the most accurate. Most
insulinomas will be identifiable.
4
324 Atlas of Gastrointestinal Surgery: Pancreas
When the insulinoma is identified, it often can be
shelled out without performing a formal pancreatic
resection. Some insulinomas, however, are malignant;
5
Body of
pancreas
Islet cell
tumor
and if such a lesion is encountered, a formal pancreatic resection will be necessary. In addition, even with
some benign lesions, the adherence of the lesion to
surrounding pancreatic tissue and/or its size may make
a formal resection necessary. If the lesion is in the
head, this might require a pancreaticoduodenectomy. If
the lesion is in the body or tail and cannot be shelled
out, a distal pancreatectomy will be necessary. If it is
in the neck of the gland, or in the proximal body, a
central resection might be possible.
Because of the relatively thin nature of the pancreas, and because insulinomas are soft and spherical, usually a part of the neoplasm will be evident
underneath the capsule of the pancreas. It will usually appear to have a darkish coloration although,
occasionally, lesions are flesh-colored. Such lesions
will usually shell out with a combination of blunt and
sharp dissection (5). A variety of techniques can be
used (6).
6
Placing small ligaclips on the pancreas side and cauterization toward the insulinoma side will provide for a
rapid bloodless mobilization of the lesion (7). Once
the lesion is removed (8), one should examine the bed
of the tumor carefully to be certain there is no evidence
of a major pancreatic duct injury that occurred during
the dissection. If not, the remaining portion of the
Cauterize
vessels
on tumor
Laparotomy for Insulinoma 325
Clip vessels
on pancreas
gland should be carefully examined again to be certain
that a second lesion is not present. Closed-suction
Silastic drains are left in the area of the insulinoma
removal, and brought out through stab wounds in the
left upper quadrant.
In the past after thorough examination, if an islet
cell tumor could not be identified, many surgeons felt
that performing a distal 85% pancreatectomy was
appropriate. Other surgeons, however, actually felt
one should perform a pancreaticoduodenectomy
because the head of the gland is the thickest portion of
the gland and is more likely to hide an insulinoma and
make it undetectable. Today, however, very few surgeons feel that a blind pancreatectomy of any sort
Shelling out of Islet Cell Tumor
7
Pancreatic
bed of islet
cell tumor
should be performed. If an insulinoma cannot be identified after thorough examination and the extensive use
of intraoperative ultrasound, the patient should be
closed and other means of insulinoma identification
subsequently carried out.
8
Débridement and Drainage of
Pancreatic Abscess
Operative Indications:
The development of a pancreatic abscess is the major cause of morbidity and mortality following an episode of severe acute
pancreatitis. Early diagnosis is essential if pancreatic débridement and drainage are to be performed early enough to prevent life-threatening complications. With three-dimensional CT scanning to identify peripancreatic fluid collections and areas
of necrotic pancreas with or without air bubbles, and with the ability of fine-needle aspiration of fluid collections to look
for bacteria, the diagnosis of a pancreatic abscess can now be made relatively early in the development. When the diagnosis is made, the patient should be stabilized and taken to the operating room as soon as possible. There are instances in
which there are large collections of fluid in association with an infected pancreatic necrosis that can be drained percutaneously. In some instances, percutaneous drainage will allow the patient to be stabilized, and subsequently undergo pancreatic débridement under more favorable conditions. There perhaps are unusual instances in which the pancreatic necrosis
and abscess can be managed entirely percutaneously, but these instances are rare, and most patients with infected pancre-
atic necrosis require surgical intervention.
Operative Techniques:
Either a long midline or a bilateral subcostal incision can be used. Adequate exposure is particularly important because it is essential that the entire abdomen be
explored for extension of the abscess away from the pancreas, down either pericolic
gutter, into the transverse mesocolon, or into the left and right upper quadrants. With
the superb imaging with thin-section, three-dimensional CT scans today, when patients
with pancreatic necrosis and abscess are explored, generally the extent of the disease
has been clearly identified. Once the abdomen is entered, the omentum is taken off
Débridement and Drainage of Pancreatic Abscess 327
the transverse colon if possible and reflected cephalad. Sometimes the omentum is so adherent that this is not possible,
and it is then divided below the level of the greater curvature of the stomach, and reflected cephalad. The entire lesser sac
needs to be exposed (1). Rather than large collections of pus, the most frequent finding is of a grumous, necrotic material filling the lesser sac and surrounding the pancreas. This often is thought to be necrotic pancreas. More often, it is
necrotic soft tissue and fat necrosis surrounding the inflamed pancreas. With the excellent preoperative imaging of threedimensional CT scans, the areas of abscess extension out of the lesser sac are generally known.
Duodenum
Omentum
Spleen
Stomach
Pancreatic
abscess
Transverse
colon
1
328 Atlas of Gastrointestinal Surgery: Pancreas
It is always important, however, that the transverse
colon be reflected cephalad to look for
extension of the abscess inferiorly in the
retroperitoneum and into the root
of the transverse mesocolon
(2). This is a frequent
route of extension.
Transverse mesocolon
Transverse colon
Middle collic a.
Proximal
jejunum
2
Retroperitoneal
extension of
abscess
Fourth portion
of duodenum
If extension of the abscess involves
the root of the transverse mesocolon, this area needs to be
extensively débrided (3).
Débridement and Drainage of Pancreatic Abscess 329
Root of
transverse
mesocolon
Transverse
colon
R. paracolic
gutter
Mobilized
r. colon
Proximal
jejunum
If extension down the right pericolic gutter
is suspected from pre-operative imaging, it is
important to take down the hepatic flexure and
mobilize the right colon out of the retroperi-
toneum so that this abscess extension down the
right gutter can be débrided (4). Generally,
this is also a good time to kocherize the duode-
num to be certain that there are no extensions of
necrotic tissue from the head of the pancreas in a
3
cephalad direction.
4
330 Atlas of Gastrointestinal Surgery: Pancreas
If there is extension down the left peri-
colic gutter, the left colon should also be
mobilized (5). This brings into view
any extension of the necrotic tissue
Extension of
abscess into l.
paracolic gutter
and abscess down the left gutter,
so that débridement can be carried
out. Débridement of the grumous,
infected necrotic tissue in the less-
er sac, and throughout any exten-
sions, can be carried out sharply
using scissors, but generally blunt
débridement using one’s fingers (or
instruments such as sponge forceps)
is preferred (6). Again, what often
appears to be necrotic pancreas is
5
L. colon
usually fat necrosis and inflammatory
debris that is actually on top of, and sur-
rounding, still viable pancreas. During this
Stomach
Pancreatic
debridement
phase of the débridement, it is essen-
tial to follow the abscess out to
the tip of the tail of the pan-
creas to be certain that one
does not miss extension
of the abscess into the
left upper quadrant
under the left
hemidiaphragm.
Transverse
colon
6
Stomach
Débridement and Drainage of Pancreatic Abscess 331
Irrigation of lesser sac
7
Transverse
colon
Once the débridement has progressed to the point where further débridement results in bleeding, extensive irrigation should
be carried out (7). We prefer a dilute antibiotic-containing, saline solution. Overly aggressive, sharp débridement can lead
to bleeding that is difficult to control.