STEP 2Blunt dissection of necrotic tissue
All fluid collections defined by CT images must be opened and evacuated by suction. Removal of necrotic pancreatic and peripancreatic fatty tissue accomplished by blunt digital dissection or careful use of instruments and irrigation is the goal sharp dissection is specifically avoided specifically to prevent uncontrollable hemorrhage. Necrotic tissue is systematically sought in the retroperitoneum behind the transverse, ascending, and descending colon, and down to Gerota's fascia all areas of...
Acknowledgments
The creation of an atlas covering the entire scope of upper gastrointestinal and hepato-pancreato-biliary surgery is undoubtedly dependent on a team effort, which is possible only with the support and enthusiasm of many individuals. First of all, an atlas is a series of drawings, which should transmit the appropriate knowledge in an artistic way. We are deeply indebted to Mr. J rg K hn, who so successfully undertook the daunting task of creating an entirely new and exhaustive visual depiction...
STEP 5Dissection of the Arantiusligament and exposure of the left hepatic vein
The anterior walls of the left and middle hepatic vein are usually exposed by extending the dissection of the falciform and coronary ligament to the vena cava. In order to access the posterior wall, the left hemiliver is lifted up and the lesser omentum is cut up to the diaphragm. Next, the Arantius' ligament ligamentum venosum is identified between the left hemiliver and Sg1. It runs from the left portal vein to the left hepatic vein or to the junction between the left and the middle hepatic...
Exposure
Caution is necessary because of inflammatory adhesions between the pancreas, transverse mesocolon, and posterior wall of the stomach. The pancreatic area is fully exposed necrotic areas are darker and more woody-feeling than viable tissue. Necrosis is usually not limited to the pancreas but also involves the peripancreatic and retroperitoneal fatty tissue as well pancreatic parenchymal necrosis is usually patchy and superficial with deeper parts of the pancreas still perfused and viable A-2 .
Laparoscopic Choledochotomy
The anterior wall of the CBD is additionally dissected within the porta hepatis, by using blunt or instrumental dissection avoiding the use of electrocautery close to the CBD . A longitudinal incision is made with a laparoscopic knife into the CBD after having blown up the CBD with saline solution through the transcystic cholangiographic catheter. The size of the incision is dependent on the size of the largest CBDS to be extracted from the CBD.
Prophylactic Drainage
The drain orifice through the skin is created by a penetrating cut with a scalpel A-1 . A Kelly clamp is inserted into the orifice A-2 and penetrates the abdominal wall diagonally A-3 . The hand serves as protection to prevent bowel injury. This technique creates a tunnel that helps to seal the abdominal cavity after drain removal. After clamping the drain tip, the Kelly clamp and drain are pulled through the abdominal wall from inside outwards A-4 . Others prefer to create the tunnel from...
STEP 6Local resection of the head of the pancreas
Working onward from the opened pancreatic duct, full-thickness slices of pancreatic tissue are excised to remove the anterior capsule of the gland and all intervening parenchyma down to the duct of Wirsung thickness of the remaining shell of the head of the pancreas is carefully assessed after each slice to determine the amount of tissue that needs to be removed. The posterior wall of the pancreatic duct of Wirsung in the head of pancreas marks the posterior extension of resection because it is...
Procedure Transduodenal Spincteroplasty with Transampullary Septectomy
The abdomen is entered through the incision for prior cholecystectomy or through a midline incision. Exposure is optimized by a Thompson retractor or some similar mechanical retractor. After exploration, the duodenum and head of the pancreas are mobilized by a generous Kocher maneuver the hepatic flexure of the colon is mobilized inferiorly, with care not to enter Gerotta's fascia. The head of the pancreas is mobilized from the underlying vena cava and the aorta in the avascular plane behind...
STEP 4 continuedAnastomosis of the IVC
b Side-to-side cavo-cavostomy. The donor suprahepatic IVC is closed as well with running polypropylene 4-0 suture, and a 6-cm-long cavotomy is made on the left posterior side of the donor IVC. This cavotomy should encompass the orifices of the major hepatic veins in order to obtain optimal venous allograft drainage and to permit later procedures such as transjugular biopsy or TIPS placement A-4 . A large anastomosis is made between the left posterior wall of the donor IVC and the anterior wall...
STEP 4Transection of duodenum and resection of gastrohepatic ligament
After detachment of the greater omentum, the right gastroepiploic vessels are identified and secured with clips at the level of the duodenum. Mayo's vein will locate the exact position of the pylorus. Identification of the pylorus can be facilitated by gentle palpation with a clamp in the postpyloric area. Care should be taken not to damage the pancreatic parenchyma as this will result in pancreatitis. Sharp dissection at the posterior side of the postpyloric part of the duodenum creates space...
Open Cystoduodenostomy
Specific indications include a pseudocyst in the head of the pancreas anatomically placed so that only a cystoduodenostomy is possible. The same approach setup as for cystogastrostomy above. The pseudocyst is visualized and palpated. The cyst is aspirated with a 22-gauge needle. A clear, opalescent, or brownish fluid should be obtained mucoid fluid suggests a cystic neoplasm. The syringe is removed from the needle, and a 11 blade knife is used to enter the cyst along the needle. A right-angled...
STEP 3Exposure of the gastroesophageal junction and myotomy
The muscular layer is closed over the mucosal staple line with interrupted 3-0 sutures. A 2- to 3-cm incision is made into the abdomen through the phreno-esophageal ligament at the anterior margin of the hiatus along the midlateral border of the left crus. A tongue of gastric fundus is pulled up into the chest. This exposes the gastroesophageal junction and its associated fat pad. The fat pad is excised. A longitudinal myotomy is performed along the anterior wall of the esophagus opposite side...
STEP 3Dividing the splenic attachments
While dividing splenic attachments, always attempt to stay closer to the spleen than to the opposite structure. Proceeding inferiorly along the gastrosplenic ligament typically includes dividing the left gastroepiploic artery. Taking down the splenic flexure and the splenocolic attachment usually facilitates this dissection A . The spleen is then gently and progressively retracted medially with the surgeon's left hand B . Using a laparotomy pad under the retracting hand, it is a relatively...
STEP 9Determination of the essential length
A colonic segment is selected suitable for interposition. The essential length is determined by the following procedure elevation of the colon in front of the abdominal wall, and measurement of the distance between the abdomen and the angle of the mandible by a suture, fixed at the root of the strongest vessel of the colonic mesentery A-1, A2 . The length of the suture is finally transferred to the colon and the resection margin is marked.
Introduction Haq
The earliest description of choledochal cysts is by Douglas in 1952 of a 17-year-old girl with jaundice, fever and a painful mass in the right hypochondrium. Choledochal cysts in Western countries have an incidence of around 1 in 200,000 live births. There is a higher incidence in Asia. Presentation is usually in childhood and 25 are diagnosed in the first year. Frequent association with other hepatobiliary diseases, such as hepatic fibrosis, has been noted. There is an association with an...
STEP 4Transsection of the right portal vein
The bifurcation of the portal vein should be convincingly identified. A small branch to the caudate process is often present. By ligating it, about 2 cm of length along the right portal vein is obtained to facilitate safe ligation of the right portal vein A-1 . Once the right branch of the portal vein is freed from the adventitial tissue, a right-angle clamp is passed around the vein A-2 . A vascular clamp e.g., small Satinsky clamp is placed distally and the right portal vein is ligated with...
Anatomical Resection of Segments 45 and 8
Figure A depicts the important anatomical structures for this resection. Hepatic parenchymal transection is done along the right and left intersectional plane i.e., the umbilical portion of the portal vein . The MHV is divided at its root. After removal of the left lateral section, landmarks including RHV and stumps of Pant and P4s are exposed B . For preparation of the right and anterior portal vein right hepatic artery, and identification of the right intersectional plane, see also steps for...
Atlas of Upper Gastrointestinal and HepatoPancreatoBiliary Surgery
Pierre-Alain Clavien Michael G.Sarr Yuman Fong Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surgery Panco Georgiev Associate Editor With 950 Illustrations EDITORS Pierre-Alain Clavien, MD, PhD University Hospital Zurich Raemistrasse 100,8091 Zurich, Switzerland Division of Gastroenterologie and General Surgery 200 First Street SW, Rochester, MN 55905, USA Department of Surgery Gastric and Mixed Tumor Service Memorial Sloan-Kettering Cancer Center 1275 York Avenue, New York, NY...
STEP 2Pancreatic exposure and mobilization
Exploratory laparoscopy is performed first to exclude local or distant extension of the neoplasm. The small bowel is removed from the operative field and the table rotated inclined with the left side up and in reverse Trendelenberg to obtain the best exposure. The lesser sac is exposed by opening the gastrocolic ligament widely inferior to the gastroepiploic arcade using an ultrasonic scalpel Ultracision, United States Surgical Co., CT or electrothermal bipolar vessel sealing device LigaSure...
Extended Kocher maneuver
The next maneuver involves an extended Kocher maneuver by mobilizing the entire right colon and the proximal as well as the distal duodenum this allows palpation of the head of the pancreas and, equally important, the wall of the duodenum. Intraoperative ultrasonography is performed in a systematic fashion with a near-field, high-resolution transducer. Small neoplasms within the pancreas are identified by their sonolucent nature compared to the more echo-dense pancreas. Although intraoperative...
STEP 1Access
The procedure should be performed on a table allowing operative cholangiography. There is no routine need for a nasogastric tube or Foley catheter. Typically there is no requirement for invasive anesthetic monitoring. Patients are placed supine, legs together with a slight reverse Trendelenburg position. There is little to gain by using a steep reverse Trendelenburg position. Safe access Open insertion of a Hasson cannula through a transumbilical incision. Eversion of the umbilicus creates...
STEP 1Setup transverse epigastric incision exploration entry into lesser sac
Plasma glucose concentrations should be checked every 20-30min with the patient off all glucose-containing fluids insulinoma patients only . The patient is best positioned supine with arms tucked at sides. A transverse epigastric incision is best. A third-arm mechanical retractor facilitates the exposure and allows a thorough abdominal pelvic exploration to be carried out. First, the gastrocolic omentum is mobilized off the transverse colon from left to right, entering the lesser sac the...
STEP 2Mobilization of the right lobe
The right lobe is mobilized by dissection of the anterior leaf of the coronary ligament and the right triangular ligament. The assistant retracts the liver inferiorly and to the left using a gauze swab. The finger blade Thompson which is retracting the stomach and duodenum should be removed during this part of the procedure. Approaching the cava, the ligament can be exposed by means of a right angle or a Kelly clamp A-1 . Ligaments can be well presented by passing a finger between the diaphragm...
Proximal Resection
Tina W.F. Yen, Douglas B. Evans Introduction Kausch was the first to describe a pancreatoduodenectomy, but Whipple, who described pancreaticoduodenectomy for pancreatic head adenocarcinoma in 1935 as a two-stage operation, has largely been given credit by the eponym. Waugh and Clagett modified the operation in 1946 to its current one-stage procedure. The operation involves the en bloc removal of the pancreatic head, duodenum, gallbladder, and bile duct, with the gastric antrum. Traverso and...
STEP 8Methylene blue test and cholangiography
After complete hemostasis, the integrity of the biliary tract is evaluated by a methylene blue test. The test can be performed through a gallbladder puncture combined with a manual choledochal compression. Biliary leaks are repaired by selective ligations. The opening of the gallbladder wall must be closed carefully cholecytorrhaphy . In case of limited liver trauma, a cholecystectomy is referred, allowing cholangiography through the cystic duct to detect biliary leaks into the fracture line.
STEP 2Manual compression of the liver
In case of active hemorrhage from the liver, the surgeon or ideally the assistant performs initial tamponade by manual compression for at least 10min. Then, two situations can be found 1. When the hemorrhage can be controlled by manual compression, a competent team is available for appropriate assessment, and the patient is hemodynamically stable without hypothermia or acidosis, a one-step intervention leading to definitive surgical repair can be decided see step 3 . 2. When the hemorrhage is...
STEP 1Preparation of the graft
As in this situation the cava remains with the right graft, side-to-side cavocavostomy is possible and yields optimal allograft outflow. The preparation of the graft consists of resection of the upper and lower inferior vena cava cuffs at a level beneath the first major hepatic veins draining the residual part of Sg1. A 6-cm-long cavotomy at the right posterior side of the inferior vena cava encompasses the orifices of the major hepatic veins A-1, A-2 .
STEP 12SMV reconstruction
When tumor involvement is limited to the SMV, we preserve the splenic vein-PV junction. Splenic vein preservation is possible only when tumor invasion of the SMV or PV does not involve the splenic vein confluence. Preservation of the splenic vein-SMV-PV confluence significantly limits the mobility of the PV and prevents primary anastomosis of the SMV after segmental SMV resection unless segmental resection is limited to less than 2 cm A-1 . Therefore, in most patients who undergo SMV resection...
STEP 6Removal of gallbladder
Once cholangiography is completed, the ureteric catheter is removed and the cystic duct is clamped. The gallbladder is then removed from the liver bed using hook diathermy. This is done through a combination of elevating the peritoneum, burning with the hook and pushing so that the gallbladder is removed toward the fundus and finally separated from the liver at the fundus. There is very little place for fundus-first laparoscopic cholecystectomy.
STEP 2Exposure and resection of the diverticulum
The esophagus is mobilized from its bed sufficiently to allow dissection of the diverticulum, which is most often located posteriorly. The diverticulum is isolated, grasped with a Babcock type forceps, and carefully dissected from its attachments until the entire sac is free and attached to the esophagus only at the neck. If the diverticulum has a wide neck, a large bougie 60F is passed down the esophagus, and the diverticulum is then stapled longitudinally using a stapling device TA and...
Cases of Isolated Right Hepatic Duct
In types E4 and E5 and B and C injuries the Hepp-Couinaud approach alone will not suffice, as there is an isolated portion of the biliary tree on the right side. The key to dissection is based on the fact that the main right and left bile ducts lie in the same coronal plane, invested in fibrous Wallerian sheaths. Also of importance is that the gallbladder plate, a layer of fibrous tissue on which the gallbladder normally rests, attaches to the anterior surface of the sheath of the main right...
STEP 3Preparation prior to pericystectomy
The central venous pressure should be below 3mmHg before starting the liver transection. A tourniquet is placed around the porta hepatis for inflow occlusion in case of bleeding. To prevent accidental spillage of the cyst contents, the whole space around the liver is packed using gauze swabs. A pack placed behind the right liver usually offers better exposure. The contents of the cyst should never be evacuated before resection. Stay sutures should not be placed in the cyst wall. However, stay...
STEP 10Standard procedure isoperistaltic reconstruction
In case of an insufficient vascular supply through the middle colonic artery, the vascular supply can be warranted through the left colonic artery, if a sufficient Riolan's arcade exists. This approach ensures an isoperistaltic reconstruction standard procedure . Care has to be taken not to injure the left colic vessels. Therefore preparation has to be done carefully and closely to the wall of the colon, and transection of the descending colon is always done without extensive dissection of the...
Procedure NonAnatomic DuodenumPreserving Head Resection The Beger Procedure
Duodenum-preserving pancreatic head resection was first described by Beger in 1979. The aim of the operation is a subtotal resection of the pancreatic head with removal of the inflammatory mass while preserving the duodenum, extrahepatic common bile duct, gallbladder, and stomach, as well as preserving a portion of the pancreatic parenchyma of the head of the gland. The head of the pancreas is exposed by dividing the gastrocolic ligament, with care taken to avoid injury to the gastroepiploic...
STEP 3Examination
A systematic examination of the abdominal cavity is performed, which mimics that performed during open exploration. Adhesions if present are divided to facilitate examination. Any peritoneal-based mass is biopsied with a cup biopsy forceps. The sequence of examination is 1 peritoneal cavity 2 right and left lobes of the liver 3 duodenum and the foramen of Winslow 4 colonic mesocolon and ligament of Treitz and 5 gastrohepatic omentum, lesser sac, pancreas, gastric pillar, and hepatic artery.
STEP 2Entering the lesser sac
The gastrocolic omentum is divided using an ultrasonic dissector harmonic scalpel , allowing access to the lesser sac behind the stomach. The stomach is retracted rostrally by the assistant, and the lesser sac and anterior surface of the pancreas are explored laparoscopically. The lesion in the tail of pancreas may then become obvious. Should the lesion not be obvious, laparoscopic ultrasonography can help localize the site of the lesion. Laparoscopic ultrasonography should also be used to...
STEP 7Drainage and duodenal fixation
An 18-Fr. closed suction drain is placed alongside the pancreas graft. The cecum is usually pexed or reperitonealized with either running or interrupted polypropylene sutures to avoid later cecal volvulus. Such lateral refixation is not necessary for portomesenteric venous drainage. If a simultaneous kidney transplant is to be done, the same intra-abdominal access can be used to expose the iliac vessels transperitoneally or a separate contralateral retroperitoneal approach is an alternative.
STEP 14A rare situation
Even after right hemicolectomy e.g., following complicated right colonic interposition , construction of an anisoperistaltic interposition is possible, if the middle colonic artery has been spared during the first operation. The left colonic artery and the first sigmoid artery are dissected A .Vascular supply of the interposition comes from the middle colonic artery. Reconstruction is performed with an ileo-sigmoidostomy. Alternatively, an interposition after right hemicolectomy and after...
Step 1 1
The biliary tree is intubated to accurately locate the papilla. Access to the biliary tree is gained through a small opening in the cystic duct remnant or, if necessary, the common bile duct the latter access can be avoided if you can confidently locate the ampulla by transduodenal palpation. A 3-Fr. tapered, urethral filiform probe or a small biliary Fogarty catheter is passed through the common bile duct and into the duodenum to locate the papilla. Suspicion of a common bile duct stone may...
STEP 3Caval anastomosis
A segment of 8mm externally reinforced polytetrafluoroethylene PTFE graft is used for the portacaval shunt. The graft is 3cm long from toe to toe and 1.5cm from heel to heel. The bevels of the graft are oriented at 90degrees to each other because the portal vein is not parallel to but rather oriented approximately 60 degrees to the inferior vena cava. The graft is placed in heparinized saline and negative pressure is applied in order to remove any air bubbles. A side-biting Satinsky clamp is...
STEP 1 continuedIsolation of the infrapancreatic SMV
Mobilize the right colon and hepatic flexure to expose the entire duodenal sweep. This step mobilizes the root of the small bowel mesentery by incising the visceral peritoneum to the ligament of Treitz. Incise the retroperitoneal peritoneum along the inferior border of the pancreas from the patient's left of the middle colic vessels toward the patient's right to expose the junction of the middle colic vein and the SMV. Divide the middle colic vein prior to its junction with the SMV to allow...
STEP 1Access and mobilization of the left hemiliver
The abdomen is opened through a subcostal incision and the round and falciform ligaments are divided. The left hemiliver is mobilized by dividing the left triangular and coronary ligament A . Once the left hemiliver is mobilized, the liver can be evaluated by ultrasound. After confirmation of the resectability, the Pringle maneuver is prepared for by opening the hepatogastric ligament as shown in the chapter Techniques of Vascular Exclusion and Caval Resection. At this point an aberrant left...
Management of the Duodenal Stump
One of the most serious complications in the postoperative period after gastrectomy is a leakage from the duodenal stump. Historically it has occurred most frequently in Billroth II resections following emergency surgery for duodenal ulcer perforating in the pancreatic head and less frequently after resections for gastric cancer. Causes of duodenal stump suture dehiscence are Attempt to close a severely diseased and scarred, edematous duodenal stump Blood clots in the duodenal bed leading to...
Incision
The usual incision is a J-shaped right upper quadrant incision shown as a solid line. The vertical length of the incision should be at least 6 cm. The incision can be extended to the left dotted line for increased exposure in large individuals . A midline incision may be suitable for thin persons. A large ring retractor is placed after clearing adhesions to the anterior abdominal wall. Schematic of the principles of the Hepp-Couinaud approach. This approach is adequate for types E1-E3 lesions....
Ultrasound Cutting Ultracision Ethicon EndoSurgery
The ultrasound cutting system includes an ultrasound generator with a foot switch, a reusable handle for the scalpel, and the cutting device with scissors. The electrical energy provided by the generator is converted into mechanical energy by the handpiece through a piezoelectric crystal system. The blade or tip of the instrument being used vibrates axially with a constant frequency of 55,500 Hz A-1,A-2 . The longitudinal extension of the vibration can be varied between 25 and 100 pm in five...
STEP 6Transection of the left and right hepatic ducts
The left hepatic duct is then identified and transected at the base of the umbilical fissure. Unlike the dissection for a hilar cholangiocarcinoma, the junction of the left and right hepatic ducts can usually be freed from the liver. Retraction of the left hepatic duct stump upward then allows a good look at the right hepatic duct from the posterior-inferior aspects. A stay suture is then placed on this duct before transection.
Staples
The most commonly used staples have a rectangular shape and are preloaded in cartridges. The staples are pushed through the tissue under the pressure created by closing the stapler. Once they reach the anvil, the staples are buckled or bent into the final B-shape. The B-form allows both the firm connection and sufficient vascularization of the adapted tissue. Note that the height of the staples after the instrument is fired is smaller. In order to achieve a safe anastomosis or closure, the...
STEP 5Cholangiography
Lateral retraction of Hartmann's pouch is maintained by a grasper, this time coming from the subxiphoid port. The cystic duct is incised through the right A . The cystic valve can occasionally make this difficult. A No. 4 ureteric catheter with an end hole is inserted through the Olsen-Reddick cholangiogram clamp into the cystic duct and the clamp closed around the duct B . Operative cholangiography is then performed with aid of C-arm fluoroscopy. Cholangiography confirms the biliary anatomy...
Omnitract
Although this retractor system needs precise installation, it offers excellent access for most incisions. The open frame system can easily be completed to a closed ring. This retractor can be used widely for intraperitoneal and retroperitoneal operations. Maintenance and cleaning are not too elaborate. The figure shows longitudinal A-1 and transverse A-2 laparotomy using the Omnitract system.
STEP 7Removal of uncinate process
Complete removal of the uncinate process from the SMV and its first jejunal branch which courses posterior to the SMA is required for mobilization of the SMPV confluence and identification of the SMA. The first jejunal branch of the SMV, which originates from the right posterolateral aspect of the SMV at the level of the uncinate process , travels posterior to the SMA, and enters the medial proximal aspect of the jejunal mesentery, giving off one or two branches directly to the uncinate process...