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924

SECTION 6

Pancreas

 

 

 

STEP 6

Examination of the colonic mesocolon (A-1, A-2)

 

 

 

 

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

 

 

 

STEP 7

Examination of lesser sac

 

 

 

 

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

 

 

 

STEP 8

Laparoscopic ultrasonography

 

 

 

 

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

927

 

 

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

Chronic abdominal pain due to chronic pancreatitis completely or predominantly

 

 

confined to body/tail of pancreas (e.g., due to post-traumatic/postnecrotic stricture

 

 

of main pancreatic duct)

 

Suspected adenocarcinoma of the body or tail of the pancreas arising in a back-

 

 

ground of chronic pancreatitis

 

Pancreatic ascites from ductal disruption of the body/tail region

 

Pancreatic pseudocyst in the distal body/tail region

 

 

Diffuse changes of chronic pancreatitis throughout the gland

Contraindications

 

If diffuse changes are present in the gland with predominance of disease in the left

 

 

gland, distal pancreatectomy may occasionally be appropriate (e.g., alcoholic

 

 

pancreatitis with a left dominant, mid-gland stricture or a complex pseudocyst in

 

 

the mid/distal pancreas); however, the results are variable

 

For laparoscopic approach: left-sided sinistral portal hypertension, multiple

 

 

previous intra-abdominal operations with multiple adhesions

930

SECTION 6

Pancreas

 

 

 

Preoperative Investigation and Preparation for the Procedure

 

History:

Search for a history of pancreatic trauma and previous/current

 

 

alcohol abuse, chronic abdominal pain, steatorrhea, diabetes, family

 

 

history of pancreatitis or pancreatic cancer, and usage of pain

 

 

medication.

 

 

If narcotic/alcohol dependency is active, encourage commitment

 

 

to undergo detoxification in a controlled chemical dependency

 

 

unit postoperatively.

 

Clinical evaluation: Abdominal tenderness or mass, splenomegaly (suspect splenic vein

 

 

thrombosis)

 

Laboratory tests:

CBC, glucose, serum calcium, triglycerides

 

Imaging:

CT, MRI or EUS: Assess the extent of parenchymal disease

 

 

(should be confined to body/tail); if splenomegaly and/or gastric

 

 

varices are present–suspect splenic vein thrombosis.

 

 

ERCP: Evaluate for a mid pancreatic ductal stricture and an

 

 

intrapancreatic biliary stricture.

 

Preoperative

If splenectomy is planned, immunize with pneumococcal

 

considerations:

vaccine, Haemophilusinfluenzae type b vaccine, and meningo-

 

 

coccal vaccine 2weeks preoperatively.

 

 

Entertain use of an epidural catheter for postoperative pain

 

 

control (preoperative narcotic dependence is a relative

 

 

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

931

 

 

 

Procedures

 

Distal Open Pancreatectomy with Splenectomy

 

Richard H. Bell Jr, Erwin W. Denham

 

 

STEP 1

Initial exposure, entering the lesser sac

 

Selection of a bilateral subcostal or midline incision depends on the angle of the costal

 

 

margin; ordinarily, a subcostal incision is preferred.

 

After full abdominal exploration, self-retaining retractor systems, like the Buckwalter,

 

aid by retracting the costal margin cephalad.

 

The lesser sac is entered by dissecting the greater omentum off the transverse colon

 

and retracting it rostrally with the stomach.

 

Ligate and divide the more distal short gastric vessels between the stomach and

 

splenic hilum; higher short gastric vessels are easier to manage once the spleen is

 

mobilized (Step 5). These maneuvers expose the body and tail of the pancreas.

 

Subsequent dissection is facilitated if the splenic flexure of the colon is fully

 

separated from the omentum and retracted inferiorly.

932

SECTION 6

Pancreas

 

 

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.

Distal Pancreatectomy

933

 

 

STEP 3

Mobilization of the spleen (A-1, A-2)

 

The spleen is mobilized anteriorly by dividing the lateral peritoneal attachments.

 

 

Splenic attachments to the colon (splenocolic ligament) and diaphragm are then

 

divided.

 

Residual short gastric vessels from the upper pole of the spleen to the stomach

 

are divided; the stomach is retracted superiorly out of the field, fully exposing the

 

distal pancreas.

A-1

A-2

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SECTION 6

Pancreas

 

 

 

STEP 4

Mobilization of the distal pancreas

 

 

 

 

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.