Khatri: Operative Surgery Manual, 1st ed.

, Copyright 2003 Saunders, An Imprint of Elsevier

Chapter 28 an!reati!o"duodene!tomy #$hipple
ro!edure%
EMBRYOLOGY
&he e!todermal epithelium of the duodenum gives rise to t'o pan!reati! (uds) In the ventral
mesentery is the ventral pan!reati! (ud, and opposite it is the larger dorsal pan!reati! (ud lying
'ithin the dorsal mesoderm) *e!ause of the retroperitoneal lo!ation of the duodenum, the
dorsal pan!reas !omes to lie on the posterior (ody 'all in the retroperitoneal position and 'ithin
the !on!avity of the duodenum) &he ventral pan!reas !omes to lie ad+a!ent to the larger dorsal
(ud due to the rotation of the stoma!h and the migration of the liver to'ard the dorsal (ody 'all)
,n!e (oth the ventral and dorsal pan!reas lie in the C"shaped !on!avity of the duodenum, they
fuse) &he ventral (ud forms the un!inate pro!ess, 'hereas the (ul- of the pan!reas is derived
from the dorsal (ud) &he main pan!reati! du!t #du!t of $irsung% is formed (y the distal part of
the dorsal du!t and the entire ventral pan!reati! du!t) &he pro.imal part of the dorsal pan!reati!
du!t either o(literates or persists as the a!!essory pan!reati! du!t #du!t of Santorini%)
ANATOMY
&he pan!reas is a retroperitoneal organ that measures appro.imately /0 !m in length and
'eighs appro.imately 80 g) It is a soft and lo(ulated organ that e.tends from the C"loop of the
duodenum to the hilum of the spleen) 1or des!riptive purposes, the pan!reas is divided into a
head, ne!-, (ody, and tail)
&he head of the pan!reas lies 'ithin the C"loop of the duodenum and inferiorly (ears an
un!inate pro!ess that passes to the left (ehind the superior mesenteri! vessels) &his
relationship is important 'hen en!ountering tumors in this region and during their rese!tion
'hile performing a pan!reati!oduodene!tomy) &he ne!- of the pan!reas lies at the level of the
portal vein and origin of the superior mesenteri! artery) &he (ody is a triangular segment of
pan!reas that travels up'ard and to the left) 1inally, the tail of the pan!reas travels up'ard
'ithin the splenorenal ligament to rea!h the spleni! hilum)
&here are important anatomi! relationships to the pan!reas that have surgi!al relevan!e) &hese
are des!ri(ed a!!ording to the different segments of the pan!reas) &he superior, lateral, and
inferior (orders of the head of the pan!reas are em(ra!ed (y the C"loop of the duodenum)
Stru!tures that lie anterior to the pan!reati! head in!lude the pylorus and the transverse !olon)
osteriorly, the head is near the inferior vena !ava and the !ommon (ile du!t) &he un!inate
pro!ess of the head of the pan!reas is !rossed anteriorly (y the superior mesenteri! vessels)
&he ne!- lies in front of the origin of the portal vein2 lying anterior to this are the pylorus and the
gastroduodenal artery) Immediately a(ove the (ody of the pan!reas is the !elia! a.is2 the
tortuous spleni! artery runs along its upper (order) &he spleni! vein lies along the posterior
surfa!e of the (ody of the pan!reas) At the inferior (order the t'o leaves of the transverse
meso!olon are atta!hed) &he anterior surfa!e of the (ody of the pan!reas is !overed (y the
peritoneum of the lesser sa!)
&he main pan!reati! du!t #the du!t of $irsung% traverses the main (ody of the pan!reas and
+oins the !ommon (ile du!t, entering the posteromedial aspe!t of the se!ond part of the
duodenum at the ampulla of 3ater, 'hi!h is surrounded (y the sphin!ter of ,ddi) &he a!!essory
pan!reati! du!t #the du!t of Santorini% drains the upper part of the head of the pan!reas and
opens appro.imately 2 !m pro.imal to the main du!t)
&he arterial supply of the pan!reas is derived from the (ran!hes of the !elia! a.is and the
superior mesenteri! artery) &he head of the pan!reas and the C"loop of the duodenum are
intimately supplied (y the pan!reati!oduodenal ar!ades) &he superior and inferior
pan!reati!oduodenal arteries are derived from the gastroduodenal artery and the middle !oli!
arteries, respe!tively) *oth the superior and inferior pan!reati!oduodenal arteries (ran!h into
anterior and posterior (ran!hes, 'hi!h !reate an arterial ar!ade around the head of the
pan!reas) 4igation of these vessels during rese!tion of the head of the pan!reas 'ould lead to
duodenal ne!rosis (e!ause the head of the pan!reas and the C"loop of the duodenum share
this (lood supply) Conse5uently, during the $hipple pro!edure (oth the head of the pan!reas
and the C"loop of the duodenum must (e rese!ted) &he spleni! artery provides numerous
(ran!hes to the pan!reas, in!luding the dorsal pan!reati! artery) &here are numerous !ollaterals
(et'een the small (ran!hes derived from the spleni! artery and the dorsal and transverse
pan!reati! arteries) &herefore, ligation of the spleni! artery does not re5uire splene!tomy, (ut
ligation of the spleni! vein does)
&he venous drainage of the pan!reas parallels the arterial supply and in!ludes the portal, the
spleni!, and (oth the superior and inferior mesenteri! veins) As indi!ated earlier, the superior
mesenteri! vein and the spleni! vein +oin (ehind the ne!- of the pan!reas to form the portal
vein) &he lymphati! drainage is along the lymph nodes situated ad+a!ent to the arteries that
supply the pan!reas) &hese lymph nodes eventually drain into the !elia! and superior
mesenteri! lymph nodes)
PREOPERATIVE PREPARATION
In addition to the routine assessment of the !ardia!, respiratory, and renal fun!tion of the
patient, it is vital to revie' the high"resolution spiral !omputed tomography s!an of the a(domen
and pelvis 'ith 3"mm !uts through the pan!reas) Attention is paid to the presen!e of lo!al
invasion of ad+a!ent vessels, parti!ularly the superior mesenteri! vessels and the portal vein)
6a+or vessel o!!lusion and7or en!asement, liver metastases, or enlarged !elia! a.is lymph
nodes are ominous signs of in!ura(le disease) Chest ."ray is also revie'ed) If the patient is
noted to have sepsis related to +aundi!e, preoperative (iliary drainage may (e advisa(le)
reoperative tissue diagnosis of a pan!reati! mass is unne!essary if it is !onsidered rese!ta(le
(y !omputed tomographi! findings)
Operative Procedure
POSITION
&he patient is pla!ed in the supine position) 8eneral anesthesia is a!hieved 'ith endotra!heal
intu(ation) A nasogastri! tu(e and a 1oley !atheter and se5uential pneumati! !ompression
devi!es are pla!ed) erioperative anti(ioti!s are administered) &he a(domen is shaved,
prepped, and draped in the usual manner) &he pro!edure (egins initially 'ith a diagnosti!
laparos!opy) If there is no overt eviden!e of peritoneal, omental, or liver metastasis, the surgeon
!an pro!eed 'ith e.ploratory laparotomy)
INCISION
A right su(!ostal in!ision e.tending to'ard the left side is made and !arried do'n through the
su(!utaneous tissue and anterior re!tus sheath) &he re!tus mus!le and the posterior re!tus
sheath are divided 'ith ele!tro!autery)
EXPOSURE AND OPERATIVE TECHNIQUE
&he ligamentum teres is divided (et'een !lamps and ligated 'ith 2"0 sil-) &he fal!iform
ligament is divided to the level of the inferior vena !ava, thus allo'ing (imanual palpation of the
liver) A thorough e.ploration is again underta-en, 'ith parti!ular attention to the presen!e of any
peritoneal implants or periaorti! or !elia! a.is lymphadenopathy) 4i(eral (iopsies of suspi!ious
peritoneal implants and enlarged lymph nodes that are (eyond the limits of normal rese!tion
should (e performed, (e!ause these !ontraindi!ate rese!tion) &he transverse !olon is lifted,
and the meso!olon is palpated +ust medial to the ligament of &reit9, (e!ause invasion in this
region 'ould involve the middle !oli! vessels, thus ne!essitating segmental !olon rese!tion)
,n!e eviden!e of distant metastasis has (een e.!luded, the ne.t step is to determine 'hether
the primary tumor is rese!ta(le2 this is done (y e.!luding invasion of the ad+a!ent vas!ular
stru!tures #inferior vena !ava, superior mesenteri! vessels, portal vein, and aorta% (y the tumor)
Ade5uate e.posure is essential, and the use of a self"retaining a(dominal retra!tor fa!ilitates
the pro!edure) 6o(ili9ation of the right !olon and the hepati! fle.ure is (egun to provide a!!ess
to the se!ond part of the duodenum) A 'ide :o!her maneuver is performed, and the duodenum
and pan!reas are elevated off the inferior vena !ava until the left (order of the a(dominal aorta
!an (e palpated) &he :o!her maneuver is e.tended (y !ontinuing mo(ili9ation of the third
portion of the duodenum until the superior mesenteri! vein is en!ountered) &he gastro!oli!
ligament is divided +ust inferior to the gastroepiploi! ar!ade to gain a!!ess to the lesser sa!) &o
improve a!!ess to the anterior surfa!e of the pan!reati! head, the right gastroepiploi! vein is
divided as it !rosses the ne!- of the pan!reas to enter the superior mesenteri! vein) &he middle
!oli! vein is identified and follo'ed do'n to its !onfluen!e 'ith the superior mesenteri! vein,
'hi!h 'as previously identified during the e.tensive :o!her maneuver) &he anterior surfa!e of
the superior mesenteri! vein is disse!ted under dire!t vision) ;sing a Cushing vein retra!tor, the
ne!- of the pan!reas is lifted, and entering this avas!ular plane, the superior mesenteri! vein is
tra!ed pro.imally to its !onfluen!e 'ith the portal vein)
,n!e suffi!ient inferior disse!tion has (een performed, the superior aspe!t of the disse!tion is
!ommen!ed) &his portion of the pro!edure is greatly fa!ilitated (y first performing a
!hole!yste!tomy) &he peritoneal refle!tion over the hepatoduodenal ligament is !arefully
opened, and the !ommon (ile du!t and !ommon hepati! artery are !arefully disse!ted and
vessel loops are pla!ed around them) &he adipose and nodal tissues in this region are
disse!ted to'ard the spe!imen) &he gastroduodenal artery is identified and ligated in !ontinuity
to fa!ilitate a!!ess to the portal vein at the superior aspe!t of the pan!reas) E.posing the
interfa!e (et'een the (ile du!t and the portal vein fa!ilitates the pro!ess of ade5uately
assessing rese!ta(ility, and this !an (e a!hieved (y dividing the !ommon hepati! du!t)
Even if the tumor is unrese!ta(le, the divided !ommon hepati! du!t !an (e used to !onstru!t
the !holedo!ho+e+unostomy) &hus, division of (oth the gastroduodenal artery and the !ommon
hepati! du!t untethers the first portion of the duodenum, 'hi!h !an no' (e retra!ted, thus
allo'ing further disse!tion, under dire!t vision, of the anterior surfa!e of the portal vein from the
superior aspe!t) Su!h e.posure 'ill eliminate the need for (lind finger disse!tion to assess the
plane (et'een the ne!- of the pan!reas and the portal vein) alpation (ehind the head of the
pan!reas is ne!essary to determine if the tumor has invaded the un!inate pro!ess, the posterior
aspe!t of the portal vein, or the superior mesenteri! artery # 1ig) 28/ %)
Figure 28-1 &he gastri! antrum, !ommon hepati! du!t, and gastroduodenal artery have (een divided) &o assess rese!ta(ility, the surgeon is
performing !areful digital e.ploration (y pla!ing the inde. finger (et'een the pan!reati! ne!- and the portal vein) S6A, superior mesenteri! artery2
S63, superior mesenteri! vein)
At this point if there is no eviden!e of en!roa!hment of the tumor to the ma+or regional vessels,
a de!ision to pro!eed 'ith formal rese!tion is made) &o ensure ade5uate regional
lymphadene!tomy, tissues over the medial (order of the -idney, the right renal vein, and the
inferior vena !ava must (e in!luded en (lo! 'ith the spe!imen) In a similar fashion, the
lymphati! tissue overlying the hepatoduodenal ligament and ad+a!ent to the superior mesenteri!
vein is s'ept to'ard the spe!imen) If the !ommon hepati! du!t has not (een divided during the
pro!ess of assessing rese!ta(ility, it !an (e done at this stage) &'o 0"0 rolene stay sutures
are pla!ed on the anterolateral aspe!t of the (ile du!t (efore its division) &he distal end !an (e
o!!luded 'ith a large hemo!lip) <e.t, if a standard pan!reati!oduodene!tomy is to (e
performed, the distal part of the stoma!h is mo(ili9ed and transe!ted 'ith a 8IA"=0 linear
stapler)
<e.t, the duodeno+e+unal fle.ure is lo!ated and disse!ted free from the retroperitoneum (y
dividing the ligament of &reit9 # 1ig) 282 %) Appro.imately /0 to /0 !m distal to the
duodeno+e+unal fle.ure, the peritoneal lining is s!ored 'ith ele!tro!autery and the vessels 'ithin
the mesentery are divided and ligated 'ith 2"0 sil- sutures) &he small (o'el is divided 'ith a
8IA">0 linear stapler #see 1ig) 282 %) 6o(ili9ation of the small (o'el is !ontinued, and it is
passed (eneath the superior mesenteri! vessels to'ard the patient?s right side)
Figure 28-2 &he ligament of &reit9 is sharply divided and the +e+unum is transe!ted 'ith a 8IA">0 linear stapler)
&he ne.t step is to transe!t the ne!- of the pan!reas, 'hi!h is (egun (y first pla!ing figure"of"
eight 2"0 sil- sutures appro.imately / !m apart at the superior and inferior aspe!t of the
pan!reas to !ontrol (leeding from the pan!reati!oduodenal arteries) &o avoid in+ury to the
underlying superior mesenteri! vein and portal vein, a narro' mallea(le or a one"fourthin!h
enrose drain is pla!ed and the pan!reas is divided 'ith a no) /0 s!alpel (et'een the
previously pla!ed hemostati! sutures) *leeding from the spe!imen side of the pan!reas !an (e
!ontrolled 'ith hemo!lips, 'hereas that from the (ody of the pan!reas is a!hieved 'ith suture
ligatures using 3"0 sil-)
&he !ut end of the head of the pan!reas and the divided stoma!h is retra!ted to'ard the
patient?s right) &his e.poses the anterior surfa!e of the superior mesenteri! vein and portal vein)
Several small vessels draining dire!tly from the head of the pan!reas into the superior
mesenteri! vein on the right side are en!ountered and are !arefully isolated, ligated in !ontinuity
'ith 3"0 sil-, and divided) &he un!inate pro!ess is divided either 'ith a &A"00 stapler or (et'een
!lamps and then ligated !arefully 'ith 3"0 sil- suture ligatures) *efore dividing the un!inate
pro!ess, it is 'ise to !he!- that there is no ma+or anomalous hepati! artery originating from the
superior mesenteri! artery) &he spe!imen !ontains the gastri! antrum, duodenum, head of the
pan!reas, distal !ommon (ile du!t, and pro.imal +e+unum and is sent to the pathology la( # 1ig)
283 %) 1ro9en se!tions of the margins of the (ile du!t, pan!reati! (ody, and un!inate pro!ess
are o(tained)
Figure 28- &he rese!ted spe!imen !ontains the gastri! antrum, duodenum, head of the pan!reas, distal !ommon
(ile du!t, and pro.imal +e+unum)
&he pan!reati! du!t is identified using a la!rimal pro(e) In preparation for the anastomoses, the
+e+unal lim( is passed through a defe!t in the transverse meso!olon) &o restore gastrointestinal
!ontinuity, pan!reati!o+e+unostomy is performed, follo'ed (y the !holedo!ho+e+unostomy /0 !m
distally) Appro.imately /0 !m distal to the !holedo!ho+e+unostomy, the gastro+e+unostomy is
performed)
&he pan!reati!o+e+unal anastomosis !an (e !reated in a variety of 'ays depending on si9e of
the pan!reati! du!t and the !onsisten!y of the pan!reas) If the pan!reati! du!t is enlarged,
usually a pan!reati!o+e+unal du!tto"mu!osa anastomosis is performed) 1irst, a posterior layer
of interrupted 3"0 sil- is pla!ed (et'een the pan!reati! !apsule and the +e+unum) <e.t, a small
enterotomy is made in the ad+a!ent +e+unum) At least four interrupted du!t"to"mu!osal sutures
are pla!ed using 0"0 polypropylene and then tagged 'ith fine @alsted mos5uito !lamps) A no) 0
1r stent is passed into the pan!reati! du!t and then (rought out through the +e+unum, via a small
in!ision, (efore these sutures are tied do'n) 1inally, the anterior layer of sutures is pla!ed
(et'een the +e+unum and pan!reati! tissue using 3"0 sil-) Appro.imately /0 !m distally, an
enterotomy is made 'ithin the same +e+unal loop, and an end"to"side !holedo!ho+e+unal
anastomosis is performed using interrupted 3"0 nona(sor(a(le monofilament sutures) An
additional anterior layer of seromus!ular sutures may (e used)
If the !ommon hepati! du!t is of small !ali(er, it !an (e stented 'ith a &"tu(e) &he third
anastomosis is then performed (et'een the stoma!h and the +e+unum in t'o layers 'ith inner
!ontinuous 3"0 a(sor(a(le sutures and outer interrupted 4em(ert"type sutures using 3"0 sil-)
Appro.imately /0 to 20 !m distal to the gastro+e+unostomy a standard feeding +e+unostomy is
pla!ed) ;sing t'o separate sta( in!isions in the right upper 5uadrant, /0"mm Aa!-son"ratt
drains are pla!ed ad+a!ent to the pan!reati!o+e+unostomy and !holedo!ho+e+unostomy to drain
potential anastomoti! lea-s) If a &"tu(e has (een used to stent the !holedo!ho+e+unostomy, this
is (rought out through a separate sta( in!ision in the right upper 5uadrant) &he defe!t in the
meso!olon is !losed (y means of !ontinuous or interrupted 3"0 a(sor(a(le sutures) &he
operative area is thoroughly irrigated 'ith 'arm saline)
If a pylorus"preserving pan!reati!oduodene!tomy is to (e performed, the first part of the
duodenum is !arefully mo(ili9ed from the head of the pan!reas and divided appro.imately 2 !m
distal to the pylorus using a 8IA"00 stapling devi!e) After the pan!reati! tumor has (een
rese!ted, the pan!reati!o+e+unostomy and the !holedo!ho+e+unostomy are performed as
des!ri(ed earlier, follo'ed (y an end"to"side duodeno+e+unostomy)
CLOSURE
&he a(dominal 'all is !losed in layers using /"0 monofilament a(sor(a(le sutures) &he drains
are se!ured to the s-in 'ith 3"0 nylon)
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