
clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer
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SECTION 6 |
Pancreas |
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STEP 6 |
Examination of the colonic mesocolon (A-1, A-2) |
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The patient is now placed in 10degrees of head down tilt. The omentum and transverse colon are retracted or pushed toward the left upper quadrant. This allows examination of the ligament of Treitz.
A-1
A-2

Laparoscopic Staging of Periampullary Neoplasms |
925 |
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STEP 7 |
Examination of lesser sac |
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The patient is now placed supine. The left lateral lobe of the liver is elevated with a 5-mm retractor placed through the left upper port. The gastrohepatic omentum is grasped, elevated and incised. Care must be taken to identify and preserve an aberrant left hepatic artery if present (A-1).
With the lesser sac opened, suspicious nodes along the left gastric or hepatic arteries can be biopsied if indicated. The neck and body of the pancreas can be examined (A-2).
A-1

926 |
SECTION 6 |
Pancreas |
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STEP 8 |
Laparoscopic ultrasonography |
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The laparoscopic ultrasound probe is inserted through the right lateral port. The examination starts with scanning the left lateral lobe of the liver, examining segments I, II, and
IIIin turn. Examination of the right lobe follows (A-1).
The hepatoduodenal ligament is examined with identification of the common hepatic
duct, common bile duct, portal vein, and hepatic arteries (A-2). Visualization of these structures is aided through the use of color flow Doppler. The pancreas is then examined by slowly rotating the head of the transducer. The relationship of the tumor to the pancreatic duct and surrounding peri-pancreatic vessels (portal vein, superior mesenteric vein, superior mesenteric artery) can be determined.
A-1

Laparoscopic Staging of Periampullary Neoplasms |
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Postoperative Tests
■This should be an outpatient procedure.
■Laboratory investigation may be unnecessary.
Local Postoperative Considerations
■Monitor for usual problems after laparoscopy – shoulder pain, and infection/hernia at trocar site(s).
■Severe pain or fever should not occur and if present requires an aggressive evaluation for inadvertent injury to an abdominal viscus during the laparoscopic procedure.
Tricks of the Senior Surgeon
■Be patient and move slowly. Metastases are often small and may be missed with a cursory examination.
■Maintain hemostasis; blood absorbs light and obscures the anatomy.
■A single port examination is inadequate. Multiple ports are required for the appropriate exposure to be obtained.
■Mobilization of the duodenum is not required.
■Place the 10-mm port as lateral as possible in the right upper quadrant. This will allow the ultrasound probe to be placed directly at right angles over the hepatoduodenal ligament, making identification of the bile duct/vessels easier.

Distal Pancreatectomy
Richard H. Bell Jr, Erwin W. Denham (Distal Open Pancreatectomy with Splenectomy),
Ronald A. Hinder (Laparoscopic Distal Pancreatectomy)
Introduction
Although distal pancreatectomies for diffuse chronic pancreatitis have gone out of favor, there are still selected situations when a localized, anatomic distal pancreatectomy is indicated. The following two procedures describe open and laparoscopic techniques – each of which may have selected indications/contraindications.
Indications and Contraindications
Indications |
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Chronic abdominal pain due to chronic pancreatitis completely or predominantly |
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confined to body/tail of pancreas (e.g., due to post-traumatic/postnecrotic stricture |
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of main pancreatic duct) |
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Suspected adenocarcinoma of the body or tail of the pancreas arising in a back- |
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ground of chronic pancreatitis |
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Pancreatic ascites from ductal disruption of the body/tail region |
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Pancreatic pseudocyst in the distal body/tail region |
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Diffuse changes of chronic pancreatitis throughout the gland |
Contraindications |
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If diffuse changes are present in the gland with predominance of disease in the left |
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gland, distal pancreatectomy may occasionally be appropriate (e.g., alcoholic |
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pancreatitis with a left dominant, mid-gland stricture or a complex pseudocyst in |
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the mid/distal pancreas); however, the results are variable |
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For laparoscopic approach: left-sided sinistral portal hypertension, multiple |
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previous intra-abdominal operations with multiple adhesions |
930 |
SECTION 6 |
Pancreas |
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Preoperative Investigation and Preparation for the Procedure |
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History: |
Search for a history of pancreatic trauma and previous/current |
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alcohol abuse, chronic abdominal pain, steatorrhea, diabetes, family |
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history of pancreatitis or pancreatic cancer, and usage of pain |
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medication. |
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– If narcotic/alcohol dependency is active, encourage commitment |
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to undergo detoxification in a controlled chemical dependency |
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unit postoperatively. |
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Clinical evaluation: Abdominal tenderness or mass, splenomegaly (suspect splenic vein |
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thrombosis) |
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Laboratory tests: |
CBC, glucose, serum calcium, triglycerides |
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Imaging: |
– CT, MRI or EUS: Assess the extent of parenchymal disease |
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(should be confined to body/tail); if splenomegaly and/or gastric |
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varices are present–suspect splenic vein thrombosis. |
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– ERCP: Evaluate for a mid pancreatic ductal stricture and an |
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intrapancreatic biliary stricture. |
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Preoperative |
– If splenectomy is planned, immunize with pneumococcal |
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considerations: |
vaccine, Haemophilusinfluenzae type b vaccine, and meningo- |
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coccal vaccine 2weeks preoperatively. |
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– Entertain use of an epidural catheter for postoperative pain |
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control (preoperative narcotic dependence is a relative |
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contraindication, because the patient will need systemic levels |
of the narcotic).
– DVT prophylaxis with sequential compression devices and/or subcutaneous heparin (check with anesthesia regarding policy on heparin in patients with postoperative epidural analgesia).
– Prophylactic intravenous antibiotics are given 30min prior to incision.

Distal Pancreatectomy |
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Procedures |
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Distal Open Pancreatectomy with Splenectomy |
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Richard H. Bell Jr, Erwin W. Denham |
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STEP 1 |
Initial exposure, entering the lesser sac |
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Selection of a bilateral subcostal or midline incision depends on the angle of the costal |
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margin; ordinarily, a subcostal incision is preferred. |
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After full abdominal exploration, self-retaining retractor systems, like the Buckwalter, |
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aid by retracting the costal margin cephalad. |
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The lesser sac is entered by dissecting the greater omentum off the transverse colon |
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and retracting it rostrally with the stomach. |
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Ligate and divide the more distal short gastric vessels between the stomach and |
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splenic hilum; higher short gastric vessels are easier to manage once the spleen is |
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mobilized (Step 5). These maneuvers expose the body and tail of the pancreas. |
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Subsequent dissection is facilitated if the splenic flexure of the colon is fully |
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separated from the omentum and retracted inferiorly. |

932 |
SECTION 6 |
Pancreas |
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STEP 2 |
Identification of the superior mesenteric vein, mobilization of the inferior edge |
of the pancreas
The middle colic vein is followed downward to localize the superior mesenteric vein. The superior mesenteric vein should be freed below the edge of the pancreas and followed beneath the neck of the pancreas; this maneuver ensures easy division of the
neck of the gland later.
The peritoneum along the inferior border of the pancreas is incised; the body/tail of the pancreas is elevated by gentle sharp dissection behind the gland.


934 |
SECTION 6 |
Pancreas |
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STEP 4 |
Mobilization of the distal pancreas |
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The spleen and distal pancreas are mobilized to the patient’s right side; it is important to stay between the kidney and tail of pancreas, leaving Gerota’s fascia undisturbed posteriorly.
After initial mobilization, the hand enters the retropancreatic space created in Step3. Retroperitoneal attachments along the upper border of the pancreas are ligated and
divided until the origin of the splenic artery is reached; location of this artery is ascertained by palpation.
The spleen and pancreas are held upward and to the patient’s right, so the surgeon can visualize the posterior aspect of the gland and identify the splenic vein as it courses along the back of the gland.