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Pseudocysts of the body and tail of the pancreas usually are drained most easily by transgastric cystogastrostomy (Figure 13). The lesser sac is explored carefully to determine where the posterior stomach wall is adherent to the pancreas. This can be done either above the lesser curvature or by separating the greater omentum from the mid-transverse colon for a short distance. As shown in Figure 14, the field is walled off with gauze pads, and guide sutures are placed in the anterior wall of the stomach over the most prominent portion of the palpated cyst and where the cyst is most adherent to the stomach. An incision is made in the anterior gastric wall parallel to the blood supply. The margins of the gastrotomy are grasped with noncrushing clamps for exposure as well as hemostasis.

The cyst is localized by partial aspiration through the posterior wall of the stomach at the point where the cyst and stomach are intimately attached. Aspiration confirms the diagnosis and provides a specimen of the cyst fluid for culture as well as amylase and electrolyte determination (Figure 15). At this point, operative cystography can be performed to determine the size and extent of the cyst. The mucosa of the posterior wall of the stomach is grasped gently with fine-toothed forceps by the surgeon and the assistant, and the full thickness of the posterior wall of the stomach and the full thickness of the cyst wall are then incised (Figure 16) as a wedge biopsy. The contents of the cyst cavity are then aspirated with suction. The interior of the cyst is explored with the index finger, and biopsy of the cyst wall performed. All bleeding points are ligated with 0000 silk or absorbable sutures. Firm attachment between the cyst wall and stomach is essential rather than dependence upon suture approximation. All bleeding points should be suture ligated. A one-layer anastomosis using interrupted 00 or running 00 nonabsorbable sutures is performed (Figure 17A). It is imperative that the full thickness of the stomach as well as the full thickness of the cyst wall be included in each suture (Figure 17B).

Upon completion of the cystogastrostomy anastomosis, the gastrotomy is closed in two layers, using an inner layer of absorbable sutures and an outer layer of interrupted 00 horizontal mattress sutures (Figure 18). Cholecystectomy may ...

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