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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1841_Библиотеки_им_академика_М_И_Перельмана.pdf
PANCREATITIS
73
Fig. 1.58 Omentum is freed from the transverse colon. The omentum will often ‘sweep’ free and allow the lesser sac to be entered.
PANCREAS
74
Fig. 1.60 The plane
anterior to the PV is
then examined by
opening with fingers or
a large blunt instrument.
At this stage it will
become clear whether
there is any vascular
involvement.
Fig. 1.59 The tumour is further examined to assess its mobility and the superior
mesenteric vein is then examined after locating it at the inferior border of the
pancreas (by following the middle colic vein to its point of entry).
PANCREATITIS
75
Fig. 1.61 A routine
cholecystectomy is
performed, and the bile
duct identified in the
hepatoduodenal ligament
and dissected free.
Fig. 1.62 The proximal duodenum is stapled 3–4cm beyond the pylorus. The right
gastric artery is preserved if possible.
PANCREAS
76
Fig. 1.63 The duodenum
has been Kocherized and
the hepatic and gastrodu-
odenal arteries identified.
After placing a soft clamp
on the gastroduodenal
artery and ensuring the
hepatic artery pulse is
unaffected, it is ligated,
divided, and transfixed.
The bile duct is divided
and the distal end ligated.
Fig. 1.64 The duodenoje-
junal flexure is mobilized.
PANCREATITIS
77
Fig. 1.65 The pancreas is divided with a scalpel between soft clamps and then the
pancreatic head is rolled laterally and PV tributaries ligated and transfixed.
PANCREAS
78
Fig. 1.66 The displaced proximal jejunum is divided.
Fig. 1.67 The proximal jejunum is returned to its normal position to allow further
clearance of the portal vein.
PANCREATITIS
79
Fig. 1.69 Any residual branches of the SMA (or fibrous tissue) are divided.
Fig. 1.68 Branches of the
SMA are identified close
to the vessel wall, ligated,
divided, and oversewn.
PANCREAS
80
Fig. 1.71 The pancreatic anastomosis begins with the outer row of the posterior wall
where a continuous 4/0 Prolene suture is used. The back wall of the anastomosis
may need to be left loose initially if the position is difficult.
Fig. 1.70 The field after removal of the gallbladder, common bile duct, head of
pancreas, and duodenum and proximal jejunum.
PANCREATITIS
81
Fig. 1.72 After insertion of the anterior row of interrupted sutures in the
pancreatic duct a small enterotomy is made, the posterior row of sutures are
inserted (interrupted 4/0 Prolene), and a small piece of suitably sized ‘T’-tube is
placed across the anastomosis. The anterior row is then completed.
Fig. 1.73 The anterior outer layer of sutures is inserted by continuing the suture
from the back wall.
PANCREAS
82
Table 1.11 The development of pancreatic surgery for malignancy
1898: Halsted—papillectomy (reported 1899) (Cameron, 1997 )
1898: Codivilla—first one-stage pancreaticoduodenectomy (Codivilla, 1898 )
1912: Kausch—two stage pancreaticoduodenectomy (Kausch, 1912 )
1934: Taylor—body and tail resection (Gordon-Taylor, 1934 )
1935: Whipple and colleagues—80 patients with surgery for ampullary tumours including
2 two-stage pancreaticoduodenectomies (Whipple et al ., 1935 )
1937: Brunschwig—added head of pancreas cancer to the indications for pancreaticoduo-
denectomy (Brunschwig, 1937 )
1941: Whipple—describes a one-stage procedure (Whipple, 1941 )
1941: Hunt—describes ‘Whipple’s procedure’ (Hunt, 1941 )
1944: Priestly—total pancreatectomy for pancreatic cancer (Priestly et al ., 1944 )
Fig. 1.74 The completed reconstruction is shown (after a standard hepaticojejunos-
tomy and closure of any mesenteric defects).