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Preface
Hepatobiliary and pancreatic surgery is a demanding and technically challenging
area of practice. This book has been written to provide a practical guide to
surgeons and trainees on available management and operative strategies and
does not attempt to be an exhaustive tome. It represents a personal view of the
two authors based on their experience and, like much of surgery, even today
lacks a strong evidence base.
The hepatobiliary and pancreatic surgeon is faced with a multitude of clini-
cal scenarios and problems. In order to gain competence and reproducible
outcomes, standardizing surgical techniques to a core set of surgical proce-
dures helps not only increase one’s effective volume of surgical experience but
also facilitates training of surgeons to become more rapidly proficient in the
required operative interventions. This inevitably enables improved recogni-
tion of postoperative problems and complications, with prompt interventions
and management.
As surgical apprenticeships around the world continue to be faced with the
reduction in training time in a shorter working week, surgical skills need to be
increasingly codified so that trainees can reach a high level of proficiency as
soon as possible and sharper focus can be directed to providing the right
surgical solution to the range of clinical problems. This need to accommodate
accelerated training will continue into the foreseeable future and surgical
practice will need to reflect standardized solutions rather than boutique
techniques.
When considering the solutions presented in this book, some are, in the
authors’ view, non-negotiable and represent essential management principles
or technical points. On many occasions the approaches represent and reflect
the preferred technique but it is acknowledged that alternative options are
probably equally valid. Invariably many areas remain controversial, with
strong opinion often held, supported by little evidence or personal anecdote.
When this is the case, a strategy used is presented as a pragmatic solution.
The practice of hepatobiliary and pancreatic surgery requires a growing
familiarity with an increasing range of technical developments. Laparoscopic
techniques are now essential not only for gallbladder surgery but also for intra-
operative staging and disease. This needs to be coupled with competence in
intraoperative ultrasound, both laparoscopic and open. Familiarity with a
PREFACE
x
range of new technologies for ablation of hepatic tumours and methods of
liver parenchyma dissection, such as the harmonic scalpel, CUSA ® , and in-line
radiofrequency ablation, are important tools in the surgeon’s repertoire.
Comfort with surgical headlights and video cameras, and the use of magnifica-
tion loupes for small biliary, pancreatic, and vascular anastomoses will become
increasingly important. While not all hepatobiliary and pancreatic surgeons
will be trained to perform endoscopy, endoscopic retrograde cholangiopan-
creatography, or endoscopic ultrasound, it is essential that they understand the
value and shortcomings of these procedures and do not disadvantage their
patients or their care by ignorance or by ignoring the technology.
The geographical location of surgical practice will dictate the type of hepato-
biliary and pancreatic surgery that is possible. The most well-trained and expe-
rienced surgeon should never attempt any procedure without the appropriate
infrastructure within the hospital. Appropriate anaesthesia, intensive care
equipment, and imaging must be considered before surgery is undertaken.
Similarly, when a surgical situation alters intraoperatively or a patient arrives
into an emergency room, a strategy to either stabilize and transfer or wait for
trained assistance needs to be thought through in advance. For example, an
intraoperatively damaged bile duct may be better managed not by exporting
the patient but by importing an experienced colleague.
The line drawings included in the text are designed to illustrate the vital ele-
ments of the anatomy and procedures described. Exactly where they fit into
contemporary care is highlighted by the numerous flow diagrams, which pro-
vide a rational basis for management. We have adopted a problem-based
approach when constructing these flow charts. This inevitably results in some
overlap and duplication, but allows for a complete solution to any specific
presentation. Judgement, experience and skill all take time to acquire. It is our
hope that this book will help in the process.
Acknowledgements
Many colleagues and friends have ensured the successful completion of this
book. In particular, Associate Professor Franklin Bridgewater, who was invalu-
able for his meticulous and critical review of the content; we are indebted to
Remigi Rageth for helping us navigate the necessary electronic options and inter-
net; Brooke Sivendra, Clarice Chian, and Sheona Page for their help with the
endless logistics of such a publication and Sandra Ireland for bringing all the
separate elements together; most importantly we are indebted to our illustrator,
Vicky Dennison, who produced a consistently excellent representation of the
anatomy and procedures we wished to describe. Her background research and
attention to detail provided the framework that allowed us to produce the book
that we had imagined.
Ashley R. Dennison
Guy J. Maddern
This page intentionally left blank
Contents
List of figures xxi
List of tables xxxv
Section 1 Pancreas 1
Pancreatitis 2
Acute pancreatitis 2
Gallstones
4
Alcohol
5
Recurrent acute pancreatitis
6
Inflammatory masses
7
Pseudocysts
7
Minimally invasive treatment
8
Pancreaticocystgastrostomy
8
Pancreaticocystjejunostomy
10
Ascites and pleural effusions
15
Compartment syndrome
15
Laparostoma
16
Pancreatic necrosis
16
Pancreatic abscess
17
Retroperitoneal bleeding
17
Chronic pancreatitis
18
Large duct disease
21
Pancreaticodochogastrostomy
22
Strictures and focal disease
23
Expanded head
24
Small duct disease
24
End-stage disease with or without previous surgery
24
Total pancreatectomy and islet cell transplantation
26
Pancreatic trauma
28
Classification
30
CONTENTS
xiv
Conservative management 31
Surgical management
31
Delayed presentation
33
Pancreatic fistulae
34
Management
34
Established fistulae
36
Pancreatic tumours
36
Investigation
36
Pancreatic anatomy
37
Developmental anatomy
37
Surgical anatomy
38
Benign (non-neuroendocrine) lesions
40
Cystic tumours of the pancreas
41
Distal pancreatectomy
43
Spleen-preserving distal pancreatectomy for benign
disease
45
Distal pancreatectomy for malignant disease
49
Neuroendocrine tumours of the pancreas
51
Pancreatic adenocarcinoma
56
Determining operability
62
Biliary bypass procedure (hepaticojejunostomy)
65
Pancreaticoduodenectomy (Whipple’s procedure)
72
Laparoscopic pancreatic surgery
86
Section 2 Duodenum 89
Trauma 89
Trauma to the first and second part of the duodenum 89
Delayed presentation
92
Trauma to the third and fourth part of the duodenum
92
Delayed presentation
94
Duodenal bleeding 94
Benign bleeding 94
Malignant bleeding
95
Perforated duodenal ulcer 96
CONTENTS
xv
Duodenal tumours 97
Benign tumours 97
Malignant tumours
97
Duodenal ampullary tumours
97
Duodenal adenocarcinoma
102
Duodenal invasion from external malignancy
102
Duodenal diverticula 104
Section 3 Liver 105
Anatomical considerations 105
Liver trauma 106
Conservative management 106
Resection principles 111
Mobilization of the liver 113
Incision
113
The hepatic pedicle
116
Hilar dissection
116
Intrahepatic approach
123
Identification of segmental pedicles
125
Methods of parenchymal transection 125
Resection options
126
Segmental resections 126
Segment I (the caudate lobe)
126
Segment II
126
Segment III
126
Segment II and III resection
127
Segment IV
127
Segment V
129
Segment VI
130
Segment VII
130
Segment VIII
130
Traditional resections
130
Right hepatectomy (Segments V–VIII)
130
CONTENTS
xvi
Left hepatectomy 132
Extended left hepatectomy
132
Extended right hepatectomy (Segments IV–VIII)
133
Non-traditional options
133
Staged procedures
134
Portal vein embolization
135
Ablation
137
Local excision
139
Synchronous colon and liver resection 140
Laparoscopic liver surgery 140
Follow-up 141
Re-do surgery
141
Liver tumours 142
Investigation of a hepatic mass 142
Benign tumours
144
Biopsy of liver lesions
144
Hepatic cystadenomas and cystadenocarcinomas
144
Malignant tumours
148
Primary hepatocellular carcinoma
148
Ablation
151
Surgery
151
Metastatic colorectal carcinoma
152
Positron emission tomography (PET) scanning
155
Carcinoid tumours
157
Management of neuroendocrine metastases
160
Management of metastatic gastrointestinal stromal cell (GIST)
tumours
160
Non-colorectal, non-neuroendocrine metastases
164
Benign conditions 164
Portal hypertension 164
Ascites
167
Peritoneo-venous shunting
169
Preoperative management
169
Operative procedure
169
CONTENTS
xvii
Postoperative care 174
Oesophageal varices
175
Acute bleeding
175
Sclerotherapy
175
Gastric varices
179
Balloon tamponade
181
Devascularization procedures
185
Portosystemic shunts
187
Portocaval H-graft technique
188
Transjugular intrahepatic portosystemic shunt (TIPS)
191
Splenic vein thrombosis
192
Budd–Chiari syndrome
193
Liver abscess
194
Aetiology
194
Responsible organisms
195
Treatment
195
Recurrent or refractory abscesses
197
Simple liver cysts
197
Treatment
198
Hydatid disease
200
Diagnosis
201
Treatment
201
Polycystic liver disease
204
Treatment
204
Fenestration resections
206
Section 4 Gallbladder 209
Gallstones 209
Cholecystectomy for uncomplicated gallstones 211
Laparoscopic cholecystectomy
211
Open cholecystectomy
217
Possible bile duct stones
222
Known bile duct stones
223
Laparoscopic bile duct exploration
225
CONTENTS
xviii
Open bile duct exploration 229
Combined laparoscopic cholecystectomy and ERCP
235
Mirizzi’s syndrome
236
Postcholecystectomy problems
237
Immediate problems
238
Pain
238
Bile leaks from drains
238
Evidence of bleeding
240
Delayed postoperative problems
240
Jaundice
240
Abdominal sepsis
241
Late presentations and postcholecystectomy syndrome
241
Strictures
241
Pain
242
Postcholecystectomy syndrome
242
Acalculous disease of the gallbladder 242
Gallbladder tumours
243
Gallbladder polyps 243
Gallbladder cancer
244
Surgical options
247
The surgical procedure
248
Section 5 Biliary tract 253
Benign conditions 253
Sclerosing cholangitis 253
Primary duct stones
255
Inflammatory strictures
255
Polyps
257
Choledochal cysts
257
Caroli’s disease
258
Postsurgical intrahepatic stones
259
Dilated bile duct 260
Idiopathic 260
Ampullary stenosis
260