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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1841_Библиотеки_им_академика_М_И_Перельмана.pdf
CONTENTS
xix
Pancreatitis 260
Biliary dyskinesia
263
Long-term management of benign strictures 263
Trauma
264
Iatrogenic 264
Gallbladder surgery
264
Late presentation
265
Avoidance of injury
266
Endoscopic trauma
266
Endoscopic sphincterotomy
266
Balloon dilatation
266
Impacted baskets
268
Penetrating or blunt injury
270
Cholangitis 270
Following ERCP 270
Bile duct stones
271
Postsurgical cholangitis
271
Postsurgical stricture
271
Bilioenteric anastomoses
271
Access limbs
271
Bile duct tumours 273
Cholangiocarcinoma 273
Management
275
Surgical treatment
275
Resection for cholangiocarcinoma
276
Surgical bypass
280
Segment III bypass
280
Segment V bypass
280
Bibliography 283
Index
309
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List of figures
Figure 1.1 Management of acute pancreatitis. CBD, common bile duct; CT,
computed tomography; ERCP, endoscopic retrograde
cholangiopancreatography; EWS, early warning score; US,
ultrasound. 3
Figure 1.2 Initial inspection of the stomach to exclude other pathology. 9
Figure 1.3 Gastroscopy confirms the position of the pseudocyst and
allows the stomach to be collapsed to facilitate ultrasound
examination. 10
Figure 1.4 Guide wire inserted into the pseudocyst under ultrasound control
and the double J stent(s) follows over the wire. The stomach is
then reinflated to confirm the position and ensure drainage is
adequate. 11
Figure 1.5 The pseudocyst is identified and any viscera adherent to the
stomach wall freed. 11
Figure 1.6 Anterior vertical gastrotomy after ultrasound confirmation of
optimal position. 12
Figure 1.7 Suitable portion of the posterior stomach and fused anterior wall
of the pseudocyst identified; the pseudocyst contents are aspirated
to reduce pressure and contents sent for microbiology. 12
Figure 1.8 A Foley catheter is inserted and gentle traction applied, lifting the
stomach and pseudocyst forward and allowing a 2–3 cm disc to
be excised. 13
Figure 1.9 As the disc is excised, sutures are placed taking the full thickness
of the pseudocyst and stomach walls. Additional sutures may be
required to ensure haemostasis and accurate approximation. 13
Figure 1.10 Drainage of a pancreatic pseudocyst into a Roux loop. The
anastomotic technique is the same as for pancreaticocyst-
gastrostomy although because the walls are not fixed or fused the
disc has to be completely excised before sutures can be
inserted. 14
Figure 1.11 Transverse incision laparostoma with additional drains to
subphrenic space and pelvis. 16
Figure 1.12 Initial assessment of chronic pancreatitis. 19
LIST OF FIGURES
xxii
Figure 1.13 Surgical treatment of chronic pancreatitis. 20
Figure 1.14 The duct is opened longitudinally. 22
Figure 1.15 Stones are removed as far as possible. 22
Figure 1.16 A T-tube is inserted into the pancreatic duct. 23
Figure 1.17 Method of reconstruction after total pancreatectomy. The right
gastric artery is preserved to allow a pylorus-preserving approach.
The duodenal remnant is shown anastomosed end-to-end to the
neoduodenum (proximal jejunum) but it can also be performed
end to side if this produces less tension. 27
Figure 1.18 Management of pancreatic trauma. 29
Figure 1.19 Treatment of apparently minor pancreatic injuries in isolation
requires a thorough investigation of ductal integrity. 32
Figure 1.20 Virtually transected pancreas with clear ductal injury. Bleeding
from the portal vein may be impossible to control until the
transection is completed. This does not affect the recon-
struction, which requires Roux loop drainage due to the duct
injury. 32
Figure 1.21 Roux-en-Y reconstruction. After oversewing the head of the
gland, the distal portion is drained into the Roux loop. The
anastomosis is identical to that following a Whipple’s
procedure. 33
Figure 1.22 Management of pancreatic fistula. 35
Figure 1.23 Development of the pancreas from dorsal and ventral anlages.
Fusion of the two components produces the main and accessory
pancreatic ducts and explains the large number of variation. 38
Figure 1.24 The rich blood supply and relationships of the pancreas account
for the complex nature of surgery to the gland. 39
Figure 1.25 Classification of non-neuroendocrine cystic pancreatic
lesions. 40
Figure 1.26 Origin of pancreatic cysts. 42
Figure 1.27 Investigation and management of cystic lesions of the
pancreas. 44
Figure 1.28 The omentum is freed from the transverse colon to expose the
body and tail of the pancreas. 46
Figure 1.29 The gastrosplenic ligament is divided. 46
Figure 1.30 The neck of the gland is mobilized and slung just to the left of the
portal vein. 47
LIST OF FIGURES
xxiii
Figure 1.31 After freeing a sufficient length of pancreas by division of
branches of the splenic artery and tributaries of the splenic vein
the gland is transected with a linear stapler. 47
Figure 1.32 Dissection continues until the pancreas is completely free and can
be removed. All tributaries and branches are transfixed. 48
Figure 1.33 The head of the gland is examined and if the pancreatic
duct is found it is ligated or clipped. The gland is then
oversewn. 48
Figure 1.34 After initial examination of the tumour and frozen section
biopsies of any abnormal or suspicious lymph nodes, peritoneal,
or serosal nodules, the neck of the gland is mobilized and slung
just to the left of the portal vein. 50
Figure 1.35 The splenic artery and vein are ligated, divided, and transfixed
and the pancreas transected with a stapler at least 2cm proximal
to the tumour. Mobilization is completed by dissection in the
plane behind the splenic artery and vein and removing all fatty
and lymphatic tissue en bloc. The head of the gland is over-sewn
as shown in Fig. 1.33. 50
Figure 1.36 Indications and consequences of splenectomy. 52
Figure 1.37 Investigation and management of a suspected gastroentero-
pancreatic neuroendocrine (GEP–NET) tumour. 54
Figure 1.38 Investigation of a suspected pancreatic mass. 59
Figure 1.39 Treatment of a proven pancreatic mass. 60
Figure 1.40 Management of a proven pancreatic adenocarcinoma. 61
Figure 1.41 A thorough laparotomy may reveal peritoneal disease or evidence
of direct invasion into neighbouring structures such as the small
bowel mesentery. 62
Figure 1.42 Initial mobilization of the duodenum allows the tumour to be
assessed and will give an idea of size. Further mobilization may
demonstrate a lack of mobility due to involvement of surrounding
structures. 63
Figure 1.43 Full Kocherization of the duodenum allows retropancreatic nodes
(usually the first to be involved) to be sampled for frozen
section. 63
Figure 1.44 Bimanual palpation after full Kocherization allows a more
accurate assessment of size and mobility and gives an indication
of possible portal vein (PV) or superior mesenteric artery (SMA)
involvement. 64
LIST OF FIGURES
xxiv
Figure 1.45 A Tru-cut biopsy of the pancreatic mass is taken through the
duodenum for frozen section examination to confirm
adenocarcinoma. 64
Figure 1.46 The posterior wall of the gastroenterostomy is performed with
4/0 PDS. 66
Figure 1.47 The enterotomy and gastrotomy are created with diathermy. 66
Figure 1.48 The inner layer of continuous 4/0 PDS sutures is placed. 67
Figure 1.49 After completing the gastroenterostomy, the efferent limb is
divided with a stapler, 70cm distally. 67
Figure 1.50 The Roux loop is oversewn. 68
Figure 1.51 The anterior row of sutures (4/0 PDS, 16 or 20mm needle) is
placed in the bile duct from inside to out. 68
Figure 1.52 After completion of the anterior row, an enterotomy is made and
the posterior row of sutures is placed (from inside to out on the
small bowel and outside to in on the bile duct). 69
Figure 1.53 The Roux loop is ‘parachuted’ down and the posterior row of
sutures tied. 69
Figure 1.54 The anterior part of the anastomosis is then completed with the
sutures already placed in the front wall of the bile duct (outside to
in, on the Roux loop). 70
Figure 1.55 Completed anastomosis after inserting and tying the front row of
sutures. 70
Figure 1.56 The enteroenterostomy is completed 70cm below the bilioenteric
anastomosis. 71
Figure 1.57 Completed procedure after closure of mesenteric defects. 71
Figure 1.58 Omentum is freed from the transverse colon. The omentum will
often ‘sweep’ free and allow the lesser sac to be entered. 73
Figure 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). 74
Figure 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. 74
Figure 1.61 A routine cholecystectomy is performed, and the bile
duct identified in the hepatoduodenal ligament and dissected
free. 75
LIST OF FIGURES
xxv
Figure 1.62 The proximal duodenum is stapled 3–4cm beyond the pylorus.
The right gastric artery is preserved if possible. 75
Figure 1.63 The duodenum has been Kocherized and the hepatic and
gastroduodenal 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. 76
Figure 1.64 The duodenojejunal flexure is mobilized. 76
Figure 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. 77
Figure 1.66 The displaced proximal jejunum is divided. 78
Figure 1.67 The proximal jejunum is returned to its normal position to allow
further clearance of the portal vein. 78
Figure 1.68 Branches of the SMA are identified close to the vessel wall, ligated,
divided, and oversewn. 79
Figure 1.69 Any residual branches of the SMA (or fibrous tissue) are
divided. 79
Figure 1.70 The field after removal of the gallbladder, common bile duct,
head of pancreas, and duodenum and proximal jejunum. 80
Figure 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. 80
Figure 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. 81
Figure 1.73 The anterior outer layer of sutures is inserted by continuing the
suture from the back wall. 81
Figure 1.74 The completed reconstruction is shown (after a standard
hepaticojejunostomy and closure of any mesenteric defects). 82
Figure 2.1 Management of duodenal trauma. 90
Figure 2.2 A large defect in the second part of the duodenum, too extensive
for a safe primary closure. A 70 cm Roux-en-Y limb is mobilized
to close the defect. A T-tube is used to decompress the biliary
system. A feeding jejunostomy is inserted. 91
LIST OF FIGURES
xxvi
Figure 2.3 Ragged trauma to the third and fourth parts of the
duodenum. 92
Figure 2.4
Traumatized area is resected and healthy tissue identified. The
proximal end is oversewn and the distal end can be brought through
and anastomosed to the second part of the duodenum. 93
Figure 2.5 An ‘X’ stitch is inserted across the bleeding vessel in the base of the
ulcer and repeated as needed to achieve haemostasis. 95
Figure 2.6 Pancreatic adenocarcinoma in its advanced stages can erode into
the duodenal wall producing bleeding that can be very difficult to
control. 95
Figure 2.7 An omental plug can be used to cover a duodenal defect or
reinforce a primary closure (at either open or laparoscopic
repairs). 96
Figure 2.8 Management of duodenal tumour. 98
Figure 2.9 Longitudinal duodenotomy to expose the periampullary
tumour. 99
Figure 2.10 Identification of the papilla by cannulation with a catheter from
a choledochotomy. 99
Figure 2.11 Stay sutures inserted around the planned line of incision and
schematic representation of the duodenal wall and head of the
pancreas to show the extent of the local excision for an ampullary
tumour. 100
Figure 2.12 Stepwise incision of the common bile duct while securing it with
sutures followed by reimplantation of the openings of the bile and
pancreatic ducts into the duodenal wall. 101
Figure 2.13 Tumour in pancreatic wall and duodenum. Resection pre-
serves the ampulla and a ‘bubble’ of duodenal wall for
re-implantation. 103
Figure 2.14 Closure using a Roux-en-Y loop over the defect, a T-tube to
decompress the biliary system, and a feeding jejunostomy. 104
Figure 3.1 The functional division of the liver and the liver segments as seen
in the patient according to Couinaud’s nomenclature. 105
Figure 3.2 The functional division of the liver and the liver segments as
seen in the ex-vivo position according to Couinaud’s
nomenclature. 106
Figure 3.3 Assessment of liver trauma. 107
Figure 3.4 Manual compression of the liver. 108
LIST OF FIGURES
xxvii
Figure 3.5 The management of liver trauma. 109
Figure 3.6 The Pringle manoeuvre is applied by encircling the contents of the
hepatoduodenal ligament (portal vein, hepatic artery and bile
duct) with a sling or nylon tape. 110
Figure 3.7 Careful identification of bleeding points and suture repair of
hepatic veins. 110
Figure 3.8 Rooftop incision with possible vertical midline extension. 113
Figure 3.9 Forceful fixed upward retraction together with a slight degree of
‘head up’. 114
Figure 3.10 The inferior vena cava can be mobilized superiorly above the
hepatic veins and inferiorly above the renal veins to provide
venous control if required. 115
Figure 3.11 Vascular and biliary anatomy at the hilum. 116
Figure 3.12 Common variations in the biliary anatomy at the hilum and the
approximate frequency with which they occur: 1:57 % , 2:16 % ,
3:12 % , 4:5 % , 5:4 % , 6:2 % , 7:2 % , 8:1 % , 9:1 % . 117
Figure 3.13 Cholecystectomy is performed as the first stage of the hilar
dissection. 118
Figure 3.14 The hepatic duct is identified, isolated, and slung. 119
Figure 3.15 The portal vein is identified and slung. 119
Figure 3.16 The hilar structure can be viewed as a left hand with the thumb at
right angles to the fingers. The thumb represents the left main bile
duct and the fingers the division and orientation of the right-
sided ducts. 120
Figure 3.17 The right hepatic artery and portal vein are clamped producing a
line of demarcation along the central fissure. 121
Figure 3.18 The right hepatic artery and the right branch of the
portal vein have been divided producing a line of
demarcation. 121
Figure 3.19 Right hepatic artery, right branch of the portal vein, and right-
sided hepatic duct divided in preparation for a formal right
hepatectomy. 122
Figure 3.20 The left hepatic artery, portal vein, and hepatic duct divided in
preparation for a formal left hepatectomy. 122
Figure 3.21 The Glissonian sheath envelops the hepatic artery, bile duct, and
portal vein as they enter the liver parenchyma. 123
LIST OF FIGURES
xxviii
Figure 3.22 Following anterior and posterior incisions into the liver substance,
finger dissection can be used to free the sheaths from the
liver. 124
Figure 3.23 The right sheath is slung during mobilization. 124
Figure 3.24 Segmental supply to the right liver has been identified and slung
in preparation for individual clamping. 125
Figure 3.25 Mobilization of the sheath to segments II and III. 127
Figure 3.26 Segment IV demarcation as the sheaths to the right of the
ligamentum teres are ligated. 128
Figure 3.27 Inferior attachment of segment IV mobilized from the left main
sheath. A stapler is in position to occlude the right main sheath as
part of an extended right hepatectomy. 129
Figure 3.28 Mobilization of the right liver from its caval attachments with the
right hepatic vein slung. Note a large inferior right hepatic vein,
which has been ligated. 131
Figure 3.29 A stapler has been positioned to occlude the right hepatic vein
once the inflow has been divided. 131
Figure 3.30 For a left hepatectomy, the left main sheath needs to be ligated
and the left hepatic vein can be divided with preservation of the
middle hepatic vein to the left of the main fissure. 132
Figure 3.31 For an extended left hepatectomy it is necessary to staple across
the left main sheath and ligate the sheaths to Segments V and
VIII. The left hepatic vein is stapled and middle hepatic vein
ligated, divided, and oversewn as a stapler in this position is rarely
a practical option. 133
Figure 3.32 The line of resection for an extended left hepatectomy leaving
only Segments VI and VII. 134
Figure 3.33 For an extended right hepatectomy, the caval connections need to
be fully ligated, the right main sheath stapled, and the middle
hepatic vein (in sling) and right hepatic veins identified and
divided after mobilizing segment IV from its inflow sheath. 134
Figure 3.34 Widely dispersed disease within the liver. 135
Figure 3.35 All tumours on the left side of the liver resected or ablated
to remove ‘known’ left-sided disease. The right side is
undisturbed. 136
Figure 3.36 The liver is allowed to regenerate over a 6-8 week period. 136
Figure 3.37 The patient undergoes a standard right hepatectomy. 136