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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Section II • Esophagus, Stomach, and Duodenum
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Step2
Vertical transection of stomach and placement of band
Beginning in this circular defect, the proximal stomach is divided with a 60-mm Endo GIA stapler
(blue cartridge) up to the angle of His, staying close to the le side of the 32-Fr calibration tube. A
7 × 1.5-cm strip of polypropylene or ePTFE is introduced and wrapped around the outow (stoma)
of the proximal gastric pouch along the lesser curvature (. Fig. 35.19a).
A circular “band” is created by sewing together the ends of the strip with three or four interrupted, non-absorbable sutures with a 32-Fr. calibration tube in place; the circumference should
be 5 cm (.
ring of Silastic tubing instead of a band.
Fig. 35.19b
). A very similar procedure, called a vertical ring gastroplasty, uses a circular
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. Fig.35.19
Robotic Bariatric Surgery
In some specialized centers, surgeons prefer robotic-assisted bariatric surgery, although its percentage comparing to the overall bariatric procedures is quite low. e advantages of robotic
surgery over conventional laparoscopic surgery include 3D visualization of the operative eld,
increased degrees of freedom of movement of the tips of the instruments, ergonomic positioning,
and elimination of any surgeon tremor. As robotic surgery gains popularity in bariatric surgery
and becomes less expensive, robotic-assisted laparoscopic RYGB may become more common.
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Chapter • Operations for Morbid Obesity
Step1
Positioning of the patient and access
e patient and trocars are placed as described for the laparoscopic RYGB. e robotic cart is
placed above the patient on the patient’s le side in a 30°angle. e surgeon’s console stands distant
from the patient (. Fig. 35.20).
Step2
. Fig.35.20
Creation of Roux-en-Y limb
Similar to the conventional laparoscopic RYGB, the ligament of Treitz is identied. e jejunum
is transected 50 cm distally with 60-mm Endo GIA.
Aerwards, the mesentery is transected perpendicular to the bowel wall with Ultracision
shears. e Roux-en-Y limb is measured (150 cm).
As with the laparoscopic RYGB, the jejunojejunostomy is created with a 60-mm Endo GIA
stapler using a white cartridge or hand sewn. e site of stapler insertion is closed with a running
4-0polydioxanone suture. e mesenteric defect should be closed with interrupted stitches of
non-reabsorbable suture. e alimentary Roux-en-Y limb is brought antecolic to the proximal
gastric pouch. e omentum should be transected vertically to allow a path for the Roux limb to
be brought antecolic.
Section II • Esophagus, Stomach, and Duodenum
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Step3
Construction of the Gastric Pouch and Gastrojejunostomy
e gastric pouch is created with three linear stapler rings, similar to conventional laparoscopic
gastric bypass surgery. Parallel openings are made in the small intestinal limb and the gastric
pouch. e anastomosis is sewn back and forth with a running suture (. Fig. 35.21). It is here
where the robot has its greatest advantage.
. Fig.35.21
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Standard Postoperative Investigations
Postoperative surveillance in an intermediate care unit if the patient has sleep apnea or a
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history of severe cardiac disease.
Oral liquid diet aer routine Gastrogran swallow radiography on the rst or second post-
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operative day; this radiograph becomes less oen obtained with increasing experience of the
surgeon.
Clinical and metabolic follow-up at 2 and 6weeks and at 3, 6, 9, and 12months and once
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yearly thereaer are absolutely mandatory to ensure outcome.
Multivitamin administration routinely, parenteral vitamin B12 aer RYGB, BPD/DS, and
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BPD, and iron supplementation according to the blood tests.
Postoperative Complications
General
Intra-abdominal bleeding
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Wound infection
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Port site hernia
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Deep vein thrombosis/pulmonary embolism
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Adhesive small bowel obstruction
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Protein/calorie malnutrition (depending on the procedure)
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Chapter • Operations for Morbid Obesity
Procedure-specific
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z RYGB, BPD/DS, BPD
Anastomotic leakage from gastrojejunostomy or duodenoileostomy (BPD/DS), remnant
gastric pouch, or enteroenterostomy
Internal hernia
Stenosis at gastrojejunostomy
Stomal ulcer/stomal bleeding
Aerent (pancreatobiliary) limb obstruction
z SG
Staple line leakage
Gastroesophageal reux
Stenosis within the sleeve (usually at the incisura of the lesser curvature)
z LAGB
Pouch dilation or band slippage
Reservoir infection
Band erosion into the stomach (late)
Band leakage (late)
Reservoir/band (balloon) dysfunction
z VBG
Stricture at the stoma
Gastroesophageal reux
Staple line rupture causing gastrogastric stula
Band erosion into stoma
Maladaptive eating disorder
Tricks of the Senior Surgeon
The Opti-View trocar (FIOS; Ethicon) allows the easiest and fastest access to the abdominal
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cavity. The incision should be placed just below (< 1 cm) the left costal margin.
Generally a high placement of trocars is recommended, especially the upper two 10/12-mm
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trocars below the xiphoid and left costal arch.
The circular EEA staplers for the laparoscopic approach are wrapped with a plastic cover
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to protect the abdominal wall incision from contact with the contaminated outside of the
cartridge of the stapler after intraluminal insertion and ring.
Conservative weight reduction with dietary measures of 5–10 kg before surgery is believed
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by some to facilitate technical performance by “shrinking liver size,” especially in super-obese
(male) patients.
Placement of the Brolin “anti-obstruction” stitch between the eerent limb of the common
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channel and the biliopancreatic limb can prevent obstruction at the jejunojejunostomy
(RYGB) or jejunoileostomy (BPD, BPD/DS).
Pancreas-Sparing Duodenectomy
Maximilian Bockhorn, Michael G. Sarr
Pancreas-sparing duodenectomy (PSD) is reserved for premalignant lesions of the duodenal mucosa and the papilla of Vater, when local excision is not appropriate owing to the size or multiplicity of the lesions. PSD involves complete or near-complete resection of the duodenum with
preservation of the entire pancreas. Although the duodenum and the pancreas share the same
blood supply, the duodenum may be resected without compromising viability of the pancreas, but
reinsertion of the bile and pancreatic duct into a “neoduodenum” is necessary.
Indications and Contraindications
Indications
Contraindications
Step1
Multiple premalignant lesions of the duodenal mucosa (e. g., familial adenomatous polypo-
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sis syndrome) and of the papilla of Vater (villous and tubulovillous adenomas)
Localized benign or premalignant neoplasms of the duodenum
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Malignant disease
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Previous surgical procedures of the duodenum, the stomach, or the pancreatic head
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Preoperative Investigations/Preparation for the Procedure
Gastroduodenoscopy with biopsy
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Endoscopic ultrasonography to determine depth of wall involvement
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Endoscopic retrograde cholangiopancreatography (ERCP) (alternatively magnetic reso-
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nance cholangiopancreatography [MRCP]) for duct anatomy and morphology
Procedure
Exposure of the duodenum
e abdomen is explored via a transverse or midline upper celiotomy. e gallbladder is resected
to allow later passage of a probe or biliary Fogarty catheter to localize the ampulla. e hepatic
exure of the colon is mobilized inferiorly and the lesser sac is opened widely. An extensive Kocher maneuver well to the le of the midline is performed to expose the rst through the third
portions of the duodenum.
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_36, © Springer-Verlag Berlin Heidelberg 2016
Section II • Esophagus, Stomach, and Duodenum
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Step2
Preparation and resection of the duodenum
e ligament of Treitz is transected. e proximal jejunum is then transected with a GIA stapler,
aer which the mesenteries to the proximal jejunum and fourth portion of the duodenum are
transected and ligated close to the bowel wall. e now-freed proximal jejunum is transposed
either in the bed of the duodenum behind the mesenteric root to the right upper abdomen or
through the right transverse mesocolon.
e third and fourth portions of the duodenum are detached from the pancreas by meticulous
dissection with ligation of these small and fragile mesenteric vessels. is dissection is performed
proximally up to the level of the papilla.
Precise localization of the papilla is important to facilitate dissection of the periampullary
region. is localization is accomplished by passing a bile duct probe into the duodenum via the
cystic duct remnant (aer cholecystectomy) or via a choledochotomy. Retrograde cannulation of
the bile duct with a probe via a lateral duodenotomy will also help the periampullary dissection.
In this region, the duodenum is dissected carefully from its attachments to the pancreas, thus
exposing the conuens of the common bile duct and the main pancreatic duct (. Fig. 36.1a).
Next, the extraduodenal bile and pancreatic ducts are transected close to the duodenum. is
step is shown in . Fig. 36.1b. If a long common channel (pancreatic and bile ducts) is present
and the duodenal disease does not extend past the ampullary region, this common channel can
be transected, leaving only one “ductal structure” for reimplantation into the neoduodenum. e
pancreatic and bile ducts are intubated separately with two catheters (
In the duodenum proximal to the papilla, the pancreas is densely adherent to the duodenum.
One can dissect and develop a narrow subserosal plane outside the muscularis propria of the
medial wall of the duodenum up to the distal part of the rst part of the duodenum where a “duodenal mesentery” becomes present. Alternatively, dissection can also be initiated at the proximal
duodenum and continued distally to the papilla. Small vessels are ligated. A careful search for the
separate minor pancreatic duct should be made; if found and identied, we recommend suture
ligation of this duct. Oen, the duct is not identied, and thus all vessels and “brous” connections
to the second portion of the duodenum should be ligated.
e duodenum is transected either 1 to 2 cm distal to the pylorus if this area is disease-free or
directly distal to pylorus. e resected specimen should be sent for pathologic examination with
intraoperative frozen section to exclude the presence of invasive malignancy.
. Fig. 36.1c).
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Chapter • Pancreas-Sparing Duodenectomy
Step2 (continued)
. Fig.36.1
Section II • Esophagus, Stomach, and Duodenum
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Step3
Reconstruction
e proximal jejunum, which will now become the “neoduodenum,” is passed either behind the
superior mesenteric vessels or retrocolically through the right transverse mesocolon.
e bile and pancreatic duct anastomoses are performed at an equivalent distance from the
pylorus as the native papilla. Some groups perform an intraluminal anastomosis via an enterostomy in the neoduodenum; others perform the anastomosis from a serosal approach. e ducts
are implanted into the neoduodenum via a 2-cm enterotomy opposite to the proposed site of
reimplantation. e anastomoses are done with interrupted, transmural, ne (6-0 or 7-0) monolament resorbable sutures (
available in the surgeon’s armamentarium. If a common channel can be preserved, one anastomosis will suce. In contrast, if the disease involves the distal ducts and/or ampulla, usually the
ductal transection leaves two ducts connected only by the interductal septum. In this situation
a single anastomosis can be fashioned by carefully including both ducts into the anastomosis
(. Fig. 36.3a). If the ductal transection leaves two individual ducts without preservation of the
interductal septum (an unusual situation), the best approach is to sew together the adjoining walls
of the ducts using 6-0 or 7-0absorbable suture material and then reimplant the joined ductal
structures as one anastomosis (. Fig. 36.3b).
A pancreatic stent is inserted into the neoduodenum using a hollow needle via a long submucosal tunnel and then externalized percutaneously through the abdominal wall. e access
enterotomy used to position the stent into the pancreatic duct is closed transversely, and the
pancreatic stent is le in situ, to be removed 4 to 6weeks aer surgery.
Gastrointestinal continuity is reestablished by end-to-end anastomosis of the neoduodenum
with either the proximal duodenum or the pylorus with a single layer of interrupted sutures. A
T-tube may be inserted in the common bile duct or a small tube positioned via the cystic duct
remnant. So drains are placed behind the neoduodenum. e complete reconstruction is shown
in . Fig. 36.4.
. Fig. 36.2). Several techniques for ductal reimplantation should be
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. Fig.36.2
Chapter • Pancreas-Sparing Duodenectomy
Step3 (continued)
. Fig.36.3
. Fig.36.4
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Section II • Esophagus, Stomach, and Duodenum
Standard Postoperative Investigations
Choledochostomy tube and pancreatic duct drain are le in situ for 6weeks postoperatively
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Cholangiography is performed prior to removal of these tubes/stents
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Postoperative Complications
Dislocation of pancreatic duct drain or tube choledochostomy
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Pancreatic and/or biliary stula
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Anastomotic dehiscence
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Pancreatitis
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Cholangitis
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Anastomotic strictures
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Tricks of the Senior Surgeon
Fixation of the pancreatic duct drain by a resorbable stay suture at the “neopapilla.”
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Tension-free anastomoses are mandatory.
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Do not compromise safety (tenuous high-risk pancreatic and bile duct anastomoses) in an
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attempt to perform PSD.
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