clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Local Postoperative Complications

■Short term:

–Pancreatic and gastrointestinal fistulae

–Recurrent peripancreatic abscess

–Colonic necrosis – abscess/fistula

–Intra-abdominal hemorrhage

–Sepsis syndrome

–Wound infection

■Long term:

–Endocrine pancreatic insufficiency

–Exocrine pancreatic insufficiency

–Incisional hernia

–Pseudocyst (rare); if present, usually from an isolated remnant or disconnected duct syndrome secondary to complete necrosis of the neck of the pancreas

–Recurrent pancreatitis (rare)

Tricks of the Senior Surgeon

Open Necrosectomy with Closed Postoperative Lavage

■Blunt necrosectomy: necrotic tissue is removed by blunt digital dissection without instruments; use of scissors increases the risk of excising still viable tissue, injuring portal, splenic, or mesocolic vessels, or causing difficult-to-control bleeding.

■Retroperitoneal necrosis: Even if the necrotic process in the retroperitoneum extends into the pelvis, blunt digital necrosectomy can be performed via an anterior, supracolic approach through the lesser sac dissecting inferiorly, following the necrosis.

■Biliary pancreatitis: ERC can be performed before necrosectomy in patients with gallstone pancreatitis, clearing the common duct of stones, and thereby only cholecystectomy is performed with exploration of bile duct omitted, reducing the risk of bile duct injury.

■Diverting ileostomy: With extension of the necrotic process behind the colon, we often perform a diverting ileostomy to reduce the risk of colonic fistula during the course of disease; intestinal continuity is restored 3months after discharge.

Necrosectomy and Closed Packing

■Have the recent CT in the operating room. It is your road map to be sure you do not leave collections of necrosis undrained.

■Bleeding inevitably ensues during the debridement. Unless this is copious, finish the debridement before attempting to stop it. It usually stops spontaneously or with the packing.

Planned Repeated Necrosectomy

■Resist operating early on patients with necrotizing pancreatitis, even with hemodynamic and metabolic instability. Make every effort to operate as late as possible, even with proof of infected necrosis, provided that the patient remains stable with maximal intensive medical therapy; the necrotizing process will have thus ceased and all viable and devitalized tissue will have defined. In such a case, a single complete necrosectomy and primary abdominal wall closure will be usually enough.

■Operative planning based on the preoperative CT is of paramount importance. All areas with fluid collections demonstrated on preoperative CT should

be sought for, unroofed, and debrided. Do not rely solely on visual and manual exploration of the peritoneal cavity and the retroperitoneum.

■The initial necrosectomy offers the best possible exposure, and thus every attempt at a complete and safe necrosectomy should be pursued at this time.

■Resist the urge to “debride” a possible “bridge” of tissue traversing the lesser sac cavity after blunt necrosectomy; this “bridge” most probably represents the middle colic vessels.

Percutaneous Necrosectomy

■Use of a “level 1” fluid warmer provides pressurized warm fluid for intraoperative irrigation.

■Be prepared to come back another day or two later rather than be overzealous with the initial or subsequent debridement.

■Significant bleeding may be controlled by balloon tamponade, while laparotomy access and surgical control is obtained.

■Discontinue the procedure if the patient shows signs of cardiovascular instability; resuscitate the patient, lavage the cavity, and come back another day.

Laparoscopic Staging of Periampullary Neoplasms

Kevin C. Conlon, Sean M. Johnston

Introduction

The global concept of preoperative staging of malignancies is to select, as best as possible, those patients who are or are not candidates for operative resection. In the case of periampullary neoplasms, we have good, non-operative “palliation” for patients with non-curable neoplasms. Because a celiotomy for a periampullary neoplasm that proves to be non-resectable is not therapeutic and obligates the patient to an “unnecessary” postoperative recuperation/recovery, preoperative staging laparoscopy can help to select those patients who are at highest chance for potentially curative resection and will prevent celiotomy in most of those with unresectable disease.

Indications and Contraindications

– 10-mm suction device

– Laparoscopic ultrasound probe (optional)

Procedure

STEP 1

The patient is positioned supine on the operating table. A warming blanket is placed underneath the patient, who is secured appropriately to the table.

Requirements:

■General anesthesia

■Orogastric tube for stomach decompression

■Urinary catheter (optional)

■Anesthetic equipment on boom or free standing cart

A multiport technique is used. The initial trocar (10-mm blunt port) is placed using an open cut down usually in the infra-umbilical area. After the skin and subcutaneous tissue is divided, the fascia is grasped between two forceps and incised with either

a knife or cautery, opening the peritoneum under direct vision. Some form of blunt, Hassan-type port is inserted, secured in place, and a pneumoperitoneum established with CO2 gas. An intraperitoneal pressure of 10–12mmHg is considered optimal. The laparoscope is inserted and an initial examination of the peritoneal cavity performed. If no obvious metastases are seen, further ports are inserted in the right (10mm and 5mm) and left (5mm) upper quadrant along the line of an intended incision.

The 30° angled laparoscope is placed in the umbilical port, with the two 5-mm ports used for graspers, scissors, and liver retractor. The right lateral 10-mm port is used for the blunt suction irrigator. This instrument is particularly useful for retraction and “blunt” palpation. The lateral port is also used for the laparoscopic ultrasonography.

A systematic examination of the abdominal cavity is performed, which mimics that performed during open exploration. Adhesions if present are divided to facilitate examination. Any peritoneal-based mass is biopsied with a cup biopsy forceps.

The sequence of examination is: (1) peritoneal cavity; (2) right and left lobes of the liver; (3) duodenum and the foramen of Winslow; (4) colonic mesocolon and ligament of Treitz; and (5) gastrohepatic omentum, lesser sac, pancreas, gastric pillar, and hepatic artery.

The right lobe of the liver is elevated with the retractor placed through the left upper quadrant port. The structures of the hepatoduodenal ligament can be dissected out and suspicious nodes biopsied if indicated.