Plate 127

After the spleen and the tail of the pancreas have been mobilized outside the peritoneal cavity, the entire pancreas is palpated once again for evidence of tumor involvement. The pancreas can be divided with electrocautery to the left of the portal vein or, if need be, even to the right side of the portal vein, provided that a finger has been introduced between the vein and the pancreas to free its anterior margin (Figure 8).

The surgeon usually finds it advisable to make multiple serial sections of the pancreas in searching for additional adenomas and in determining whether his line of incision is free of tumor. Frozen section consultations may be obtained, although pancreatic tissue is difficult to evaluate under these circumstances, and the final diagnosis may have to be delayed until the permanent sections have been made.

The cut end of the pancreas is examined and the pancreatic duct is identified. The pancreatic duct is closed with a 0000 nonabsorbable monofilament suture (^6822835). The end of the pancreas is closed with interrupted overlapping 000 silk sutures of the mattress type (^6822836). Additional sutures are taken, particularly where there is persistent bleeding (Figure 10). Alternatively, the pancreas may be divided and secured with staples using a linear stapler.

A closed-system suction catheter made of Silastic is used to drain the stump of the pancreas. The drain is brought out either directly through a stab wound in the midportion of the abdomen or to either side through a separate stab wound incision. The incision is closed in the routine manner.

The postoperative care is routine except for repeated laboratory checks on the blood sugar and amylase levels. A mild degree of pancreatitis may occur, and colloids and other solutions should be given in adequate amount. A transient diabetic tendency may occur; on the other hand, it is difficult to determine in the immediate postoperative period what effect the surgical procedure will have on total pancreatic function. Oral replacement of pancreatic enzymes may be indicated. Determination of amylase in the drain output is necessary prior to drain removal. An amylase concentration less than serum is generally required for the closed-suction drain to be removed.

When total pancreatectomy is planned, the pancreas is not divided but used for traction as the head of the pancreas and the duodenum are excised in the Whipple operation. Systemic symptoms associated with the gastrinoma, a hormone-producing islet cell tumor, may be controlled partially, but rarely completely, for years by resection of a solitary tumor. Those associated with other apudomas (vipoma, glucagonoma, insulinoma, and so forth) may respond to local excision in the absence of malignancy and metastases.