Plate 129

The head of the pancreas is usually removed for malignancy involving the ampulla of Vater, the lower end of the common duct, the head of the pancreas, or the duodenum. Far less frequently, the procedure is carried out to manage intractable pain associated with a chronic calcific pancreatitis or for massive trauma when there is irreparable “burst” damage to the head of the pancreas, the ductal structures, and the duodenum. In the presence of malignancy, the resection is indicated in the absence of proven metastases and if the tumor is of such a limited size that the portal vein is not involved beyond the ability of the surgeon to accomplish a safe vascular resection and repair. Total pancreatectomy may be considered in some cases because of the tendency for multicentric foci of malignancy to develop as well as seeding within the pancreatic duct. This procedure also decreases the incidence of postoperative complications from the leakage of pancreatic juice from the anastomosis. The patient should be made aware of the problem of diabetes mellitus after operation as well as the need for daily pancreatic enzyme replacement.

Patients will have had imaging including CT, MRI, and possibly endoscopic ultrasound prior to the procedure. Some patients may have had biliary stents placed by an endoscopic or transhepatic route. Transfusions of blood products may be required preoperatively to restore the blood volume and decrease the tendency to hypotension and renal shutdown that may occur after operation. The electrolyte levels should be returned to normal and particular care should be taken that the INR is normal and that renal function is not impaired, as shown by creatinine and blood urea nitrogen levels. Blood should be available. The measured amount of blood lost should be replaced during the operative procedure, preferably via a central venous catheter. It is advisable to have a catheter in the bladder in order to follow the postoperative hourly output of urine. Antibiotic therapy should be started prior to operation. This is particularly important for patients with stents, as they are prone to wound infections.

A nasogastric tube is inserted. General anesthesia with endotracheal intubation is recommended.

The patient is placed supine on the table with the feet slightly lower than the head. Facilities should be available for performing a cholangiogram or pancreaticogram.

The skin should be shaved from the level of the nipples well out over the chest wall and down over the abdomen, including the flanks.

Diagnostic laparoscopy is indicated in some patients to identify metastatic disease that may have been missed by preoperative imaging. Pancreaticoduodenectomy for pancreatic or periampullary adenocarcinoma should not be performed if there are liver or peritoneal metastasis. A type of incision should be selected that will ensure the extensive and free visualization of the upper abdomen, especially on the right side. While an upper midline (Figure 1, A) incision that may extend below the umbilicus is useful, many prefer an oblique or curved incision that parallels the costal margins (Figure 1, B). When the xiphoid is long and the xiphocostal angle narrow, further exposure may be obtained by excision of the xiphoid process. On the other hand, very good exposures can usually be obtained by the oblique or curved incision, first carried out over the right upper quadrant and then extended across the midline and as far to the left as the surgeon believes necessary to ensure a liberal exposure. All bleeding points must be carefully clamped and tied to keep blood loss at a minimum, especially in jaundiced patients. Regardless of the type of incision used, the round ligament is divided (Figure 2). The contents of the curved clamps must be securely ligated to avoid bleeding from a vessel in the round ligament. Further mobility of the liver can be obtained if the falciform ligament is divided well up over the dome of the liver (Figure 2). Occasionally, there are small blood vessels present in it that should be ligated. After the falciform ligament has been divided, a self-retaining retractor can be inserted and the margins of the wound freed of all clamps after the ligation of their contents.

The type, location, and extent of the pathologic process now must be determined by thorough exploration. Evidence of metastatic spread to the liver, the lymph nodes around the celiac axis, and the region above the pancreas, as well as in the hepatoduodenal ligaments, should be sought by careful exploration.

When a very large gallbladder and common duct are encountered in the presence of an obstructive jaundice, it may be helpful to aspirate the contents of the gallbladder to enhance the exposure and at the same time to localize accurately the site of obstruction by injecting radiopaque contrast material into the biliary system. A point for the needle aspiration should be selected on the underside of the fundus, since this area may be required for a cholecystoenterostomy if resection is found to be contraindicated. Since the bile is often thick and inspissated, a rather large-bore needle, such as an 18- or 20-gauge, is useful, and as much bile as possible is aspirated. The needle is left in place, 50 to 150 mL of iodinated contrast medium is injected, and the patient is made ready for a cholangiogram. A purse-string suture is placed in the wall of the gallbladder around the needle so that the opening in the gallbladder can be closed as the needle is withdrawn.

While the surgeon is waiting for the return of the cholangiograms to be inspected, he or she can proceed with mobilization of the duodenum and head of the pancreas by the Kocher maneuver (Figure 3). The duodenum is grasped with one or more Babcock forceps and retracted medially as the peritoneum along the lateral wall of the duodenum is incised. Usually, it is not necessary to ligate vessels in this area; in the presence of jaundice, however, it is advisable to carry out a meticulous hemostasis. Finger or gauze dissection is used to push the posterior wall of the pancreas from the underlying vena cava and right kidney. An avascular cleavage plane can easily be developed (Figure 4). A column of peritoneum that remains forms the lower boundary of the foramen of Winslow (Figure 5). The surgeon can place this column of peritoneum under tension by inserting the index and middle fingers on either side of the peritoneum and should incise it very carefully, avoiding injury to the underlying vena cava. In the presence of recurrent ulceration in the region of the second part of the duodenum, considerable scarring and fixation in this area may be encountered.

After the posterior wall of the duodenum and head of the pancreas have been inspected carefully for evidence of tumor or metastatic involvement, further freeing of the second or third part of the duodenum is indicated to determine whether the lesion is operable. Care should be exercised in sweeping away the middle colic vessels that, surprisingly enough, frequently cross to the hepatic flexure of the colon high up over the second part of the duodenum (Figure 6).

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