)f I

Contents

Gallbladder and Biliary Tract

Cbolecystectomy :1
Common Duct Exploration J()
Sph inctcroplasty, Including T ransampullary Common Duct Exploration l."i
Side-to-Side Choledochociuodeno'lomy 28
Resection of a Benign Bile Duct Stricture Wit h i<econst ruction Utili ting Siiaslic Transhepanc Biliary
Stcnts a nd Hepa ticojejunos tomy 38
Resec tion of a Prox imal Cholangiocarcinoma With Reconstruct ion Utilizing Silastic Transhepatic
Biliary Stents an d Bilateral Hepaticojejunostom ics 58
Resection of a Proximal ChoiangiocarcinolllCl With Hepa tic Lobectomy and Recon st ruction l :tiiizinga
Silastic Transhepat ic Biliary Stent and Hepat icojejullostomy 72
Prox imal Choiangiocarcinorn a: Palliation by Tran shepat ic Stcnting and Hepaticojejunostomy SJ
I~ esection of Hepatic Duct Bifurcat ion. Dilatation of In trahepatic Biliary Tree. and Prolonged
Stenling With Transhepatic Bil iary Stents for Sclerosing Cholangitis 94
Hepaticojej unostomy for Distal St ri cturing Seconda ry to Sclerosing Cholangitis lOll
Resect ion 01 Choledochal Cyst 116
Transhepat ic Slenling for Caroli 's Disease' l28
Wedge Resection of Liver and Regional Lymph Node Dissection for Carcinoma of the
Gallbladder I-U

The Liver

Anatomy of the Li\'er 152

:\onanatomical Liver Resect ions 156
Resection of Lateral Segment of Left Lobe of Liver 162
Resection 01 Left Lobe QI Lil'er J(jll
Resection of Right Lube of Li\'er 178
Resection 01 Right Lobe of Li\'er Plus \Iedial Segment 01 Left Lobe ITrisegmentectomy I 19(1
Insertion of Infusaid Pump for Hepat ic Artery Inlusion 20()
Resection of Simple C\,st of Lilw 206
\Ianagement 01 Hydatid Cyst Disease of Liwr 1](1
Draina~ ... f Li\"~;!" .-\b5('e3ses :!2.J
Portasyste mic Shu nts

Interposition Mesocaval Shunt 252

Distal Splenore nal Shunt 2 66
Portacaval Shunt 274
End·to·Side 276
Side·to·S ide 282
Interpos ition " H" Graft 286
Direct Mesocava l Shunt 288
Mesoa trial Shunt 2 98
Le Veen Shunt 312

The Pancreas

Longitud inal Pancreat icojejullostomy: PueslOw Procedure 326

End·to·End Pancreaticojejunostorny: DuVal Procedure 342
Distal Pancreatectomy fo r Chro nic Pancreatitis 350
Ninet y-Fi ve Percent Dista l Pancreatectomy for Chronic Pancreatitis 362
Ac:ces~ory Duct Papillolom y for Pancreas Divisum 366
Drainage of Panc reatic Pseudocyst into Roux·en·Y Jejunal Loop 370
Drainage of Pancreatic Pseudocysl into the Stomach 380
Drainage of Pancreatic Pseudocyst into the Duodenum 384
Pancreaticoduoden ectorny (Pylorus· Preserving Whipple Procedure) 386
Palliative Bypasses for Un resectable Periampullary Cancer 414
Distal Pancreatectomy for Tumor 428
Laparotomy for Insulinoma 436
Drainage of a Pancreatic Abscess 442
Diverricularizat ion of the Duodenum and Pancreatic Drainage for Combined DuOOer..a1 and Pancrr
Trauma 454
Pyloric Exclusion and Pancreatic Drainage for Combined Duodenal and Pancreatic Trauma ~
 Gallbladder and Biliary Tract

...... - ....'~ --''''''''''

......
Cholecystectomy

Operative Indications
atients with symptomatic gallstones are candidates for

P cholecystectomy. In the past even patients with asymptomatic

gallstones were thought to require cholecystectomy. Howe\'<7,
recent natural history data suggest that unless patients with
gallstones have symptoms referable to their biliary tract, the likeljbrxxJ
developing significant morbidity is low enough to justify merely t -
patient and performing cholecystectomy only if symptom arise. There::JaY be
exceptions to this rule. An individual living in or traveli ng to remorearea"
where medical care is not readily available may be a candidate for prophylactic
cholecystectomy if stones are present. Other factors such a diabe or other
systemic illnesses may also modify this decision. Most patients wilh
asymptomatic gallstones, however, are no longer considered candida
cholecystectomy.
Some patients with symptomatic gallstone disease may be man lIoith
extracorporeal shock wave lithotripsy. At present, however, thi represents only
a minority of patients with symptomatic gallstones; the majority are managed
by cholecystectomy. There are also other rare indications for cho ecystectomy.
other than symptomatic calculus disease. Individuals who are ha";';"""=
Infusaid pump inserted for the management of colorectal meta (0 the IDW

routinely undergo cholecystectomy. In addition, patient undergoir: palliative

transhepatic stenting of their biliary tree at the time of urgery also
undergo cholecystectomy because of the risk of subsequent cho eqs - -

Operative Technique
holecystectomy can be performed through a right ubcos . upper

C midline, or right paramedian incision. The right ubcos incision is

preferred. Once the abdomen is entered, the peritoneal ca -',- '"
explored for evidence of other pathology. When none' . the
surgeon proceeds with the cholecystectomy. Exposure i greatly facilitated if an
upper hand retractor is used to retract the skin, subcutaneous tissues. and
costal margin. A Deaver retractor then easily exposes the under"'<;'" ::he
liver (A).
Hepatic flexure of colon

3
 he hepatic flexu re of the colon is retracted in a caudal di rection,

T frequently with a Mi kulicz pad , and the stomach is packed medially,

also with a Mikulicz pad. A clamp is placed on the fund us of the
gallbladder, and it is gen tly retracted in a cephalad direction. Thesero a
overl ying the porta hepatis is opened and the portal struct ures identified (B).
The cystic duct is identified and looped with a vessel loop. If it is doubly
looped, this will prevent gallbladder stones from passing through the cystic duct
into the common duct du ring gallbladder manipulation (C).
Dissection of Calot's triangle allows identification of the cystic artery,
which arises from the common hepatic or right hepatic artery. This anatom y is
extremely variable, and this area has to be dissected carefully and completely to
clearly identify the cystic duct and cystic artery and to avoid injuring
anomalous structures. The right hepatic artery freq uently fo llows the cystic
duct and/ or gallbladder very closely before cu rving back up into liver
parenchyma, and for a 1· or 2·cm course it can easily be confused with the
cystic artery. The arterial anatomy has to be dissected such that the cystic
artery is clearly seen joining the gallbladder before one can be certain of its
identification. Likewise the cystic duct, which usuall y arises from the common
hepatic duct, may arise from the righ t hepatic duct or from one of the two
segmental ducts to the right lobe of the liver. This area has to be carefull y and
completely dissected to be certain of the anatomy.
If the anatomy cannot be clearly delineated, one shou ld stop further
dissection in th is area and proceed to mobilize the gallbladder from above
downward. When the gallbladder has been mobilized out of the liver bed, the
anatomy of this area will become clear. Early cholangiography, performed by
injecting contrast directly into the gall bladder or ductal system, may also be
hel pful.
he:Jabc a Cystic duct

Cystic a.
and duct
 transverse abdominal incision is made in the anterior axillary line,

A approximately 2 inches below the costal margin. In a particularly

cachectic individual with no subcutaneous tissues, the valve may be
inserted in the rectus sheath and covered by the rectus muscle. In
most instances, however, the valve is inserted lateral to the rectus sheath.
The transverse incision in the right axillary line is deepened down to the
external oblique muscles, which are spread in the direction of their fibers (C).
The internal oblique muscles are then separated in the direction of their
fibers (D), and the transversus abdominis muscle fibers on the peritoneum
exposed. In preparation for passing the tubing from the valve, in a cephalad
direction, a small opening is made through the abdominal wall muscle layers
into the subcutaneous space (D).
 ~_~ _ _ __ __ R hepabc a

~~'-_ _ _ ___ Cyshc duct

Cysbc a

Cystic a. and duct

Serosal
reflection - - - --J

Mobilized
gallbladder

L
 nee [he gallbladder has mobiJim:I out of the liver

O .
I bed, [he anatomy i generally dear, and if the cystic artery has not
been previou ly identified, control of that vessel can now be
accomplished. Controversy remain as to whether or not routine
cholangiography should be performed. Our bia i that selection hould be used
and that not all patients need undergo operative cholangiography. If one is
operating upon a patient with normal liver funct ion tests and a single, large
cholesterol gallstone, the likeli hood of common duct stones is so Iowa to be
negligible, and operat ive cholangiography is unnecessary. In a significant
proportion of patients undergoing cholecystectomy, however, uperative
cholangiography will be required.
After placing a tie proximally at the cystic duct-gall bladder junction, a
small opening is made distally in the cystic duct and a cholangiocatheter
inserted (H). The cholangiocatheter is secured with a 2-0 silk that i tied around
the dista l cystic duct containing the catheter and then passed through the
opening on the catheter.
After adequate cholangiography has been obtained, the cholangiocatheter is
removed, the cystic duct is doubly clamped and divided, and the gallbladder is
removed from the operative field (1).
The cystic duct stump is then ligated with a 2-0 silk (J ). Many urgeons
contin ue to use sil k, as we do; others are concerned abou t it acting a a nidus
for gallstone form ation and thus use a synthetic absorbable material.
The right upper quadrant is copiously irrigated with an an tibiotic
containi ng saline solution. Hemostas is in the bed of the li ver is achieved with
the electrocautery.
Whether or not to drain the liver bed and porta hepatis following routine
cholecystectomy rema ins somewhat con troversial (K). There are virtually no
significant liabilities from drain ing the operative site following elective
cholecystectomy, but many studies have shown it to be unnecessary. The only
reason for leaving a drain behind is if an unexpected bile leak occur from a
small , unrecognized bile ductule in the bed of the li ver; leaving drain in place
obviates the need for reexploration. If drains have not been placed, this can
present a serious life-th reatening complication. Even though rare, it seems to us
that the discomfo rt of a dra in is worth the avoidance of this unusual but life-
threatening complication. We prefer a closed suction drain left in place for
hours. If biliary drainage does not occu r, the drain is removed ju t prior to
discharge.
 _I

Cystic duct ---~~tiI'

Common
hepatic
duct
C-a -·adder fossa - -- - - -- - ----Jr-'ir.
Cystic a. and
duct stumps ----,~'7"
Common Duct Exploration

Operative Indications
ost common duct explorations for calculi are performed in

M conjunction with cholecystectomy. In the past, patients who bad

previously undergone cholecystectomy and presented with primary
or recurrent common duct stones were also treated surgically_
Now the majority of such patients can be managed non operatively with
endoscopic papillotomy. Thus today the only patients with common duct caIaili
who routinely are treated surgically are those patien ts with a gallbladder in
place who also require cholecystectomy.
The most common indication for common duct exploration today i the
radiographic demonstration of stones in the biliary tree. T he majority of
patients in our institution who present with jaundice have their biliary tree
anatomy and pathology delineated cholangiographically prior to surgery. This is
carried out preoperatively via either endoscopic or percutaneous tran hepatic
cholangiography. However, in the event that cholangiography has not been
performed preoperatively, operative cholangiography is performed at the timed
surgery in most patients who prove to have biliary tract stones. Common dud
exploration in the absence of preoperative or intraoperative cholangiography is
infrequent in our institution. At the time of elective cholecystectomy, if a tone
is unexpectedly palpated in the biliary tree or a dilated com mon duct is
unexpectedly found, the patient would undergo operative cholangiography to
demonstra te the entire biliary tree prior to common duct exploration.

Operative Technique
nce the decision is made to perform a com mon duct exploration. the

O duoden um is kocheri zed extensively (A). This allows one to palpate

the distal common duct as it traverses behind the first portion of the
duodenu m and head of the pancreas, prior to entering the di tal
second portion of the duodenum through the am pulla. It is impossible to
adequately palpate this portion of the biliary tree without extensive
kocherization. The common duct is cleaned fo r a 2· or 3·cm length, generaUy
between the cystic duct stump and the duodenum .
tay sutures of 5-0 synthetic nonabsorbable material are placed in the
common duct, and a choledochotomy is performed (B). The choledochotomy
hould be of ample length, at least 1 em, to allow ea y in trumentation of the
duct without traumatic exten ion.
lOnes are often pontaneou Iy evacuated a bile i ues forth from the
common duct opening. At the same time any tones that are palpated in the
distal common duct can be milked up toward the choledochotomy and reIIIO'13I
C,_
 , ___:;:?'- - - - - Cystic a and duct slumps

-'.C±,C- ----,----- - -- - Common duct

Cystic a. Choledochotomy
and
duct

Kocherized
duodenum

Common duct stone

II
 here are a variety of instruments that one can utilize to explore the

T biliary tree; generally we utilize all of these instruments in an effort

to completely rid the tree of biliary calculi. It is important that the
choledochotomy be made adequate in length, so that the instrument
used to extract biliary calculi do not traumaticall y extend the incision.
A variety of scoops with malleable handles can be used to pass distally
down to the ampulla and up into the intrahepatic biliary tree via both the right
and left hepatic ducts (D). These scoops come in a variety of sizes and can be
extremely effective in removing small stones or biliary sludge.
Randall Stone forceps are also utilized, and many surgeons use these
instruments initially in the duct exploration (E). These forceps come with a
variety of curves that range from almost straight, as pictured here, to righ t-
angled and even acute-angled. These instruments are very effective in grasping
larger, well-formed stones.
The biliary balloon catheter is particularly usefu l; it can be passed down
distally, through the ampulla, and then inflated to document patency of the
distal biliary tree into the duodenum. This is perhaps the safest way to
demonstrate an open ampulla. In using the balloon catheter, one has to be
careful that it is not overdistended. Experimental studies have demonstra ted
intrahepatic ductal disruptions and liver abscesses formed from overinflation of
the balloon. If one constantly moves the catheter to and fro as the balloon is
inflated, being certain that the balloon catheter remains mobile within the
ductal system, overinflation is unli kely. T he balloon catheter is particularly
effective in retri.eving intrahepatic stones (F).
 /

Inlrahepa 'c
stone

'---_ _ Small stones

and sludge

Randall
Stone
forceps

Bwary
balloon
catheter - -- - . .- 4

I I
 ne of the most effective maneuvers in ridding the biliary tree of

O stones and biliary sludge is irrigation using a small French cath

A #12 French catheter placed intrahepatically into the right and I
hepatic ducts, together with large volume irrigation with saline, is
extremely effective in ridding the entire intrahepatic biliary tree of mall st
(G). This maneuver can also be carried out distally.
Passage of the French catheter through the ampulla into the duodenum is a
safe way of demonstrating ampulla patency (H).
The use of Bakes dilators is controversial. Many surgeons feel that the
potential for creating false passages, injuring the ampulla, and/or initiating
postoperative pancreatitis is so great that these metal dilators should never be
used. Other surgeons feel it is acceptable to carefully and gently utilize the
smallest Bakes dilator to demonstrate patency of the am pulla only (and not for
dilatation). Our philosophy is that it is safer to demonstrate patency of the
ampulla with either a balloon catheter or a small French catheter. Ii neither of
these is effective in demonstrating patency of the ampulla, then very cautious
and gentle use of a small Bakes dilator is acceptable. Generally the Bake dilator
easily passes gently through the ampulla, and patency can be demonstrated by
seeing the "steel gray" end of the dilator pressed against the lateral wall of the
duodenum (1). We feel there is rarely an indication for the use of a Bak dilator
larger than a #3.
 Irriga 'on
catheter

_I

..>

Catheter tip ~3 Bakes

.a_--'-'_ _ _ _ through dilator
ampull a
_ats-g.,y

any biliary tract surgeons have adopted the routine use of

M choledochoscopy during common duct exploration. T hi can be

carried out with either a rigid right·angled scope or a flexible
fiberoptic instrument. Many studies demonstrate that operative
choledochoscopy significantly lowers the incidence of retained common duct
stones. The rigid scope is easier to use but allows one to visualize a relatively
smaller proportion of the intrahepatic and extrahepatic biliary tree (J).
The flexible scope is more difficult to use, but it allows the surgeon to
visualize a greater extent of the intra· and extrahepatic biliary tree (K).
With either instrument one can utilize balloon and basket catheters to
remove stones visualized in the biliary tree (insets).
Following completion of the common duct exploration, a T-tube should be
inserted routinely. Our preference is for the variety of T - tube with a larger
diameter external limb and a smaller diameter T. We further decrease the size
of the T by cutting off the back wall. A wedge should also be removed from the
back wall to allow collapse of the two T - limbs when the T -tube is removed (L
Following insertion of the T -tube, the choledochotomy is closed with a
continuous suture. Many surgeons feel that synthetic absorbable material,
either 4-0 or 5-0, should be utilized to eliminate the theoretical possibility of a
permanent suture material acting as a nidus for stone formation. Other,
however, have utilized silk, or even synthetic nonabsorbable material, without
any obvious adverse effects.
The T -tube should be brought straight out laterally, without sharp turns
to allow for easy instrumentation s ubsequently if a retained stone should be
identified (M).
Closing cholangiography should always be performed. If filling defect
suggestive of stones are seen, the duct exploration should be repeated. Except in
emergency situations, the surgeon should not rely upon postoperative mean of
stone extraction to substitute for a completely successful operative procedure. If
contrast does not enter the duodenum, glucagon should be administered. If
repeat cholangiography still does not demonstrate contrast in the duodenum,
the surgeon should consider opening the duodenum and performing a
sphincteroplasty (demonstra ted on pages 18-27) to be certain there is not a
ampullary stone. The area of the choledochotomy is drained with Penrose or
closed suction drains.
 J

Rigid
;.-_ _ _ choledochoscope

Biliary
f-_ _ _ balioon
calheler

0;--;.-----_ _ _ _ _ _ Choledocholomy
closure
Sphincteroplasty, Including
Transampullary Common Duct
Exploration

Operative Indications
phincteroplasty is an operative procedure that has been used in a

S variety of settings over the past several decades. For many years it was
utilized as treatment for recurrent acute and/or chronic pancreatitis.
This is now considered only a rare indication in an unusual instance
where the pancreatitis appears to emanate from a proximal pancreatic duct
structure. Some surgeons feel that sphincteroplasty should be added to
papillotomy of the accessory papilla when surgically treating a patient who has
recurrent abdominal pain secondary to pancreas divisum. Recently there has
been some enthusiasm for sphincteroplasty and septotomy of the pancreatic
duct orifice for the management of patients with refractory postcholecystectomy
abdominal pain, perhaps secondary to stenosis of the pancreatic ductal orifice.
Sphincteroplasty has also been utilized for calculus disease of the biliary
tract. If after a common duct exploration the surgeon is not certain that all of
the stones have been removed, some surgeons have s uggested opening the
duodenum and performing a sphincteroplasty so that any retained stones may
pass spontaneously. It is still used frequ ently for patients who have an impacted
distal common duct stone that cannot be retrieved from above through a
choledochotomy. A sphincterotomy is performed to disimpact the stone, and
most s urgeons will proceed to extend to the incision and convert it in to a form al
sphincteroplasty. Man y biliary tract surgeons utilize sphincteroplasty if a
patient is treated operatively for a recurrent or primary common duct stone.
Most of these patients are now managed with endoscopic papillotomy. If tha t is
unsuccessful and the patient requires laparotomy, most biliary tract surgeons
now feel that it is impor tant to add a drainage procedure to common duct
exploration and stone extraction in many of these patients. Sphincteroplasty
can be successfully used as the drainage procedure.
Finally, we have utilized sphincteroplasty in recent years as a means of
exploring a common duct for calcu li when the common duct is of normal or
s mall caliber. Common duct exploration through a choledochotomy and
subsequent T - tube insertion carries sign ificant morbidity if the diameter of the
bile duct is small. Exploration through the ampulla is a good alternative. T he
operative procedures of sphincteroplasty and septotomy will be demonstrated,
as well as retrograde common duct exploration through the sphincteroplasty
mClSlon.

Operative Technique
he abdomen i entered through a right ubcostal incision. If the

T gallbladder i in place, a cholecystectomy i perlormed (see pages 2-9).

After the gallbladder has been mobilized, if operative cboIangiograpby
is required. It IS performed.
 BIliary
balloon
catheter

-
~43i~ ____ __ _~~~~

~~,--,--_ _---' "---"-'=--';--_ _ _ Cystic

duct

.:!l~~-=-,2_-____:;;_;_~_. Head of
Pancreas

Kocherized
duodenum
Balloon
inflated in
duodenum

19
 fte r the decision has been made to perform a sphincteropla ty, a small

A opening is made in the cystic duct, and a balloon catheter i inserted

into the common duct, distally through the ampull a and into the
duodenum (A). The duodenum is then kocherized, and following
balloon inflation, the area of the ampull a can be identified by palpation. The
longitudinal duodenotomy is placed directly over the point where the urgoon
palpates the balloon .
After stay sutures of 3-0 silk are placed in the duodenum, the balloon
catheter is advanced beyond the ampulla so as not to perforate the balloon
the duodenotomy is performed (B).
The duodenotomy is performed with the electrocautery. After the
duodenotomy opening is made, by palpation the surgeon can identify the ballkx:lD
(C) and the location of the ampulla.
~ uu.ny _ _ _ _----;_ + -,

Balloon
advanced

.c
 nce the location of the ampulla has been identified, the

O i extended. tay sutures of 5- 0 synthetic absorbable rna . 3!i

placed at 3 o'clock and 9 o'clock on the ampulla. Using the ba!lioor
catheter as a guide, a sphincterotomy is performed at 11 120'
with the electrocautery (D). The opening is made 3 or 4 mm at a .
Once the ampulla has been opened, the ductal mucosa i utum:l1D
duodenal mucosa with a series of interrupted 5- 0 synthetic absorbable~~A
(E). T hese sutures are gathered in hemostats; their retraction .
exposure of the area (F).
After the initial sphincterotomy incision, the pancreatic orifice ,.".",-
identified with a silver probe (G). If one has difficulty in iden' .
pancreatic duct, secretin can be administered intravenou Iy.
T he sphincterotomy is extended, generally for 1 to 2 ern, wid! :un.=
synthetic absorbable sutures being placed to approximate duodeaal ~~ ...,.:.;o,~
mucosa. Finally an apex suture is placed when the diameter of the
sphincterotomy is deemed sufficient (G).
T he length of the sphincteroplasty incision will vary dependin''J .............
reason for its performance. If one is perform ing a sphincteropla ty IDf':rly
dislodge an impacted common duct stone, a larger incision i unnea:5S<!:}"c
the sphincteroplasty incision is large enough to disimpact the lone.
other hand , if one is performing a sphincteroplasty incision in a ~.,.,..t~.n...
dilated duct because of the concern of leaving behind retained 10 a
sphincteroplasty incision 2 to 3 cm in length may be carried out. One
careful not to extend the sphincteroplasty incision beyond the point wt:e::i~Clf
biliary tract and duodenum have a common wall. With careful appn:lrimtDl,
however, of the ductal and duodenal mucosa, risk of retroperitoneal or
intraperitoneal leakage is virtually eli minated .
If the sphincteroplasty has been carried out for what are believed m
symptoms related to the pancreas, from a stenotic pancreatic duct a
septotomy can be performed with Pott's scissors (H). This inci ion can C:'S~~
be extended for 4 or 5 mm, at which point the septum thicken a the<DIUSlem
the pancreatic and biliary tree diverges. Some feel that the pancreatic and
ductal mucosa should also be approximated with 5- 0 or 6-0 ynthetic
absorbable material.
Ampu lla

Biliary
balloon
catheter

Pancreatic
duct orifice

Probe in
It------ - - pancreatic
duct
 ollowing the completion of the phincteropla ty, the biliary balloon

F catheter is removed , the cystic duct is doubly clamped and divided.

the ga llbladder is removed from the operative field (I). The cy tic due;
stump is ligated with a 2-0 silk.
If the sphincteroplasty is being performed because of cholangiographic
evidence of biliary calculi in a normal size or small common duct, to avoid the
technical and mechanical problems of exploring a small duct through a
choledochotomy, we have utilized transampullary exploration. The common
duct can be explored with the sa me va riety of instruments as one utilizes with
the traditional duct exploration through a choledochotomy (see pages 10-17).
Biliary scoops, Randall Stone forceps (J), flushing through a French catheter
(K), and balloon catheter manipulation (L and M) can all be utilized.
At the end of the procedure one does not have to be concerned about placin",
a small T -tube in a small common duct. In addition, a sphincteroplasty ha
been performed, so if one does not retrieve all stones in the biliary tree, the
stones have a free course to pass spontaneously.
 Clamps on
cystic duct

.:.

Ligated ~
cystic duct
stump

~i------ Sphincteroplast)

Randall
Sto ne lorceps

~L-_ __ Balloon --.:.,_ _ _ _ Balloon

deflated inflated

Biliary
balloon
catheter
 he lateral stay sutu res are removed from the duodenum, and fay

T sut ures of 3- 0 silk are placed at each end of the duodenotomy

The duodenum is closed in two layers. The inner layer i a
continuous suture of 3-0 synthetic absorbable material placed in a
.

Connell fashion (0 ). Sutures are started at each end and are tied in the middle.
The outer layer is a row of interrupted 3-0 silk sutures (P).
The duodenotomy is drained with Penrose or closed suction drains .
 Inner layer 0
duodenolomy
closure

Ouler layer 01
duodenolomy
closure

Sphincleroplasty
Side-to- ide
Choledochoduodenostom

Operati e Indications
ide-to-side choledochcxlucxlenostomy, like phincteropla ty, is a

S procedure that has been used in the past for a variety of disease
processes. It is used much less frequently now than a decade or
ago. Side-to-side choledochoduodenostomy can be u ed for calculus
disease of the biliary tract if after common duct exploration one i unsure
the biliary tree has been cleared of stones. Performing a side-to- ide
choledochoduodenostomy will allow any retained stones to pa pontaIlEOns!y.
In the past the most common indication for this procedure ha been fur-
primary or recurrent common duct stones. Following choledochotomy and
extraction, a side-to-side choledochoduodenostomy has been advocated by""""'"
for primary common duct stones, to prevent recurrent stone formation or to
allow recurrent stones to pass spontaneously if they do recur. Tcxlay.
patients with primary common duct stones are treated by endoscopic
papillotomy.
Patients with distal biliary strictures are particularly good candida
side-to-side choledochoduodenostomy. An individual with chronic pan:cn:ruiUs
and a distal biliary stricture secondary to scarring and fibrosis of the hez «
the pancreas can often be managed by side-to-side choledochcxlucxlenos y.
Some surgeons have also advocated its use for palliation of biliary Obs:tructXll
from distal malignant disease that is unresectable, particularly in the case
where a cholecystectomy has previously been performed and the galIblarlrl.,.. i ..
not available for biliary decompression. Although there are theoretical objitrlil;;;;;
to placing the biliary anastomosis so close to the primary tumor, experience •
several centers has demonstrated that this can be an effective way of a - .
palliative biliary decompression. Side-to-side choledochoduodenostomy also
be an effective operation in patients with recurrent biliary symptom a
perivaterian diverticulum. Many have advocated diverticulum resection,
side-to-side choledochoduodenostomy is a safer, easier procedure.

Operative Technique
atients are explored through a right subcostal incision. These

P generally have had a prior cholecystectomy , and the old incision -

reentered.
Most biliary tract surgeons feel that the diameter of the patien
common duct should be at least l liz cm, and preferably 2 cm, before the
operation can be performed. If the procedure is being performed faT a
primary or recurrent common duct stone, the biliary tree i u ually
markedly dilated, with a large, often ovoid or cigar- haped brown primary
common duct tone lcxlged di tally (A). Complete biliary ob truction is
uncommon in these patient. and the bilirubin i u ually only mildly
elevated_
The adhl:9:1DS !-.-....".." OmentUID and the under urface of the IiYer
dh;ded- The . _ extrahepatic biliary tree are exposed via
sh.ari> a:IC ).
A

Cystic
duct
stump

Ampu lla _ - '_ _ _~

 dhesions and attachments between the hepatic flexure of the colon

A and the duodenum are divided sharply, and the duodenum is

kocherized (C).
Medial attachments between the omentum and duodenum are
also divided (D).
As much of the duodenum is exposed and mobilized as possible, so the
duodenum can be brought up on top of the common duct for a tension-free side-
to-side anastomosis.
Kochen:zed _ _ __ _ _----y
c:Uxlenu!:J

~--:'tr-.-------- pancreas
Head of

31
 he first portion of the duodenum is dissected off the anterior surface

T of the common duct fo r as great a length as possible, Once the

duodenum has been completelv mobilized and the extrahepatic
bi lia n ' tree exposed along its a nterior. lateral. and medial surfaces. a
choledochoromy is performed with the distal end extending to the point where
the biliar\' tree passes posterior to the first portion of the duodenum (inset and
E), The choledochotomy is initiall y made with a 15 blade: it is then extended
with Pott 's scissors, The length of the choledochotomy should be at least 2 em.
The diameter of the common duct should be at least 11/2 cm. and preferably 2
em, before this operation can be performed.
Once the choledochotomy has been performed, the duct is explored and
all calculi are removed (F). These patients generall y \\'ill have had
preoperative cholangiography performed either percuta neously or
endoscopically. Thus the exact number of stones and their location are often
known at the t ime of surgery. However, the various maneu vers that have
been previously described for common duct exploration (see pages 10-1, 1are
all carried out. Primary common duct s ton es are often bro\\'n , easily
crushable, and accompanied by sludge in the biliary tree that is best
removed by ir rigation.
Once the biliary t ree has been cleared of calculi , a longitudi nal
duodenotomy, the same length as the choledochotom y, is performed
in the duodenum directly adjacent to, but at right angles with, the
choledochotomy (F).
This anastomosi s is usuall y performed in one layer. Although synthetic
absorbable s utures have been advocated by some biliary surgeons, we use
3-0 silk, with all knots placed on the outside. The apex sut ure in the
choledochotoiny is placed firs t. A 3-0 silk is passed from ou tside the bi liary
tree to within and then passed from within the duodenum to the out side and
secured (F).
After this apex suture has been placed, lateral stay sutures of 3- 0 silk
are posit ioned. These pass from outside in at the mid port ion of the
choledochotomy and from inside out at the two ends of the duodenotomy.
These s utures are then gathered in a hemostat as demonstrated (G, see H),
holding the two ends of the s ut ure , as well as the mid por tion that passes
between the duodenum and the common duct. This nicely aligns t he
duodenu m a nd choledochotomy for su bsequent sut ure placement.
 d

~ _ ___ Common duct

stone

~_ _......_....,._ _ -'-_ _ _ Duodenotomy

Lateral
slay
suture

/ _ _ _ _ _ Apex suture

\
 nterrupted sutures of 3-0 ilk are then placed. alway pa ing from '

I in on the common duct ide and from in ide out on the duodenal ide,
and cuning each suture as it is placed (H).
When this layer has been completed out to the ends of the
duodenotomy and the midlateral aspects of the choledochotomy. the tay
sutures are secured (1). The anterior row is then placed, by pa sing a UMe
firs t from outside in at the mid portion of the duodenotomy and then from
inside out at the most proximal portion of the choledochotomy (1). T his suture .
gathered in a similar fashion by holdi ng both ends and the mid portion of the
suture in a hemostat. Again this nicely aligns the duodenotomy and
choledochotomy so that the anastomosis can be completed.
The anastomosis is completed with a series of through-and-through
interrupted 3-0 silk s utures (J).
_.

Posterior
row

Apex Suture

Posterior
row
 he final three or four sutures of the side·to·side

T choledochoduodenostomy are held until all sutures are placed, and

then they are secured (K). This is a side·to· side anastomosis, which is
performed by pulling the first and second portions of the duodenum
on top of the common duct and then carrying out the anastomosis. The
anastomosis can easily be palpated through the duodenum when the procedure
is completed and should be widely patent (L).
The anastomosis is demonstrated diagrammatically in M. The theoretical
shortcoming of the procedure is also nicely depicted. There is a segement of
biliary tree that extends from the choledochoduodenostomy down to the
ampulla. It has been reported that vegetable material from the duodenum can
pass into the biliary tract through the side·to·side anastomosis and become
impacted distally, producing nonspecific right upper quadrant symptoms
referred to as "the sump syndrome." This is a theoretical disadvan tage of the
operative procedure, but one that is rarely encountered. The biliary tree is
generally not decompressed with aT- tube.
The area of the choledochoduodenostomy is drained with either Penrose or
closed suction drains.
 Completed
Side-ta_side
anastomoSis
Resection of a Bemgn Bile Duct
Stricture With Reconstruction
Utilizing Silastic Transhepatic Biliary
Stents and Hepaticojejunostomy

Operative Indications
enign bile duct strictures can follow a variety of clinical situations.

B Scarring and fibrosis of the head of the pancreas in chronic

pancreatitis can result in a distal biliary stricture. Rarely,
inflammatory disease of the gallbladder can involve the extrahepatic
biliary tree and result in a stricture. The majority of benign strictures, however ,
follow operative trauma, usually during cholecystectomy.
If the stricture involves the mid or distal portion of the biliary tree, the
repair is straightforward. The proximal biliary segment is dissected, and a
mucosa-to-mucosa anastomosis is performed between the common hepatic duct
and a Roux-en-Y jejunal loop. Long-term stenting is not necessary, but
decompression with aT-tube or a preoperatively placed transhepatic catheter is
of benefit for one or two months, during which time healing of the
hepaticojejunostomy takes place.
Many, if not most, extrahepatic injuries that occur during cholecystectomy,
however, involve the common hepatic duct proximally, near or even involving
the bifurcation. These high strictures are more difficult to manage. In recent
years the majority of patients referred to our institution with
postcholecystectomy strictures have had multiple ligaclips in the porta hepatis,
and these usually are found to be responsible for the stricture (A).
It is our practice to perform preoperative percutaneous transhepatic
cholangiography on all patients with suspected strictures. At the time of
cholangiography, a Ring catheter is inserted. In most instances, if continuity
between the proximal and distal biliary tree has not been totally disrupted, the
Ring catheter can be passed through the stricture distally into the duodenum.
Occasionally it is necessary to decompress the proximal biliary segment
externally for a day or two and then at a second setting pass the catheter distal
to the stricture into the duodenum. Identification of the proximal biliary
segment and stricture and placement of a trans hepatic Silastic biliary stent, if
used, are made much easier at the time of surgery if a Ring catheter is in place.

Operative Techniques
ost patients with benign biliary strictures will have undergone a

M cholecy tectomy through a right subcostal incision. Patients are

prepped and draped so that the Ring catheter is accessible in the
prepped operative field during the procedure. The abdomen i
reentered through the old right ubcostal inci ion.
Upon Teen' e abdomen multiple adhesion are encountered,
particuJarly IHlltUll the tu:;;), colon, stomach, duodenum, and the under
surface of the m-a--_ Thse are . both sharply and bluntly (8).
 A
"'~-------- SlIlIC1Il"'_<!_ - "....,a

Cystic duct stump _ _ _ __ _ ~\ \

I
Ring
cath eter into
duodenum _ _ _ __

• CO \\
, );
~

Adhes.,ns
betlteen liver
and omentum
 y palpating in the pona hepari for rhe pre\·iously placed Ring

B catheter , iden tificarion of the biliary tree is greatly facilitated.lnrhe

past, partIcularly If the patIent had been operated upon several tlffies,
this dissection often took hours. Wi th the catheter in place, the
dissection proceeds rapidly, and within a relatively short time the proximal
biliary segment ca n be identified.
Once the extrahepatic biliary tract has been identifi ed, it is cleaned and
mobilized, and then it is encircled with a vessel loop (C). Dissection then
proceeds proximally up towards the bifurcation. Th e proximal biliary segment
is frequently surrounded by a dense inflammatory reaction with fibrosis.
Multiple ligaclips often add to the difficulty of the dissection. Wi th the biliary
tree identified and encircled, it can be retracted and the portal vein and hepatic
artery exposed.
When one approaches common hepatic duct th at appears reasonably
normal , the anterior wall of the duct is opened (D) and the Ring catheter
extracted (E).
Occasionally biliary calculi and sludge will form above the benign stricture;
this is removed via biliary scoops and with irrigation (F).
 Strictured
common duc~
(conta ining Ring
catheter)

f
Openmg normal
coovnon hepatic duct

Sludge
and
small
Ring catheter _ I stones
 nce all the calculus material has been removed, stay utu res are

O placed in the proximal biliary segment, and the back wall of the
common hepa tic duct is divided (G).
The distal strictured portion of the biliary tree is dissected free
down to the point where the common duct passes posterior to the duodenu m
(H). At th is point the duct is divided and the strictured extrahepatic biliary [ract
removed from the opera tive field.
The distal biliary tree is closed with a series of interrupted 3-0 silk utures,
in th is instance placed in a vertical mattress fashion (I).
The curved end of the Ring catheter is amputated. The Ring catheter,
which has previously been prepped an d draped in the operative field, is then
pulled through the chest wall in to the peritoneal cavity to expose its entry site
on the diaphragmatic surface of the liver (J).
 )

of common
hepatic
duct
,I

Common duel
closure

IrJ

Ring
catheter

43
 t thi point the urgeon prepares to replace the Ring came fT ;i-" a

A transhepatic ilastic biliary tent. In order to avoid losing rhe tra I..
a catheter should break or become dislodged during the fT. a
guidewire is placed through the Ring catheter. Utilizing a ;: 12 Co c
catheter with the tip cut off , the catheter is placed over the guidewire on lO
Ring catheter and sutured in place with 2- 0 silk. T he Ring catheter is then
pull ed out th rough the superior surface of the li ver , thereby po itioning the
Coude catheter in the right hepatic duct (K).
The Ring catheter is removed , the guidewire is advanced, and a it ·c
transhepatic biliary stent (# 16 French) is sutured into the flanged end of the
Coude catheter (L). By withdrawing t he Coude catheter out the top of rhe \~.
the Silastic transhepatic biliary sten t is placed in the appropriate position i "-
right and common hepatic ducts.
 ....
K

, r- -- - Ring catheter

,-'---_ _ __ Guidewire

1+- - -- - Coude caIhe!er

•
f( +-____ S.1as!Jc biliaty sIerI

_ __ _ _ GUIdewwe
 a Ring catheter has not been placed preoperati\'ely, other techniqu are

I utilized to place the Silastic transhepatic biliary stent. After the proximal
biliary segmen t has been dissected an d the stricture resected, the biliary
tree can be instrumented with a Ra nda ll Stone forceps passed up to within
1 or 2 cm of Glisson's capsule. The clamp is then forced out through Gli son'
caps ule and a Silastic stent s utured to it (M). By withdrawing the Ra ndall tone
forceps, the Silastic stent is pl aced.
An altern ative is to pass an elongated Bakes dilator up through the
intrahepatic bil iary tree and out through the superior s urface of the liver (i
and then to suture the Silastic stent to the olive tip. A hole dri lled in the olive
tip aids in securing the stent to the instrument.
By whatever means, once the transhepatic Silastic biliary stent ha been
placed , it is positioned so that the portion of the stent with mul tiple ide hoI j-
contained within the liver and in that portion which is to be placed in the Roux-
en·Y loop (N). The part of the stent that emana tes from the superior urface of
the liver obviously con tains no side holes.
One can place a mattress suture around the egress site of the sient on the
superior surface of the li ver with a 1-0 synthetic absorbable suture. Recently -e
have fo und that this suture is not absolu tely necessary and that biliary leakage
out through the superior surface of the liver around the stent is un u ual.
 Bakes
dilator

1;/ '1
&lashc _ _ _ ' /
botiary
slent

Side
.I holes In ·
S rastic bili
stent ary
Mattress
suture
 Roux.en.y jejunal loop 60 cm in length is constructed. A proximal loop

A of jejunum, just distal to the liga ment of Treitz, is divided between

intestinal clamps at a convenient arcade. This can also be performed
conveniently wi th a GIA stapler. The small bowel mesentery is
divided down towards the root.
The Roux·en·Y loop is brought in to the right upper quadran t in a retrocolic
position, through the transverse mesocolon directly on top of the second an d
third portions of the duodenum (0 ).
Q

,
Ligament
of Treilz

_ --,"_ Transverse
colon

Middle COI IO-_= ;'"

vessels

Duoden,um

Distal
jejunum

1
I
I
I
Slone
clamps

,
 nteric continuity is reestablished with an end-to-side

E jejunojejunostomy. This is performed 60 cm distal to the end of the

Roux-en-Y loop.
The end-to-side anastomosis is carried out with an outer
interrupted layer of 3-0 silk and an inner continuous layer of 3-0 synthetic
absorbable material. After the posterior row of interrupted sutu res has been
placed, the end of the proximal jejunum in the in testi nal clamp is removed with
the electrocautery (P).
An enterotomy is made along the antimesenteric border in the Roux loop at
the point of the end-to-side anastomosis. The posterior inner layer is carried out
with 3-0 synthetic absorbable material placed in a continuous over-and-over
locking fas hion (Q). This suture is continued as the inner anterior layer and is
placed using a continu ous Connell stitch (R).
The outer anterior layer is completed with interrupted 3-0 silk sutures (S).
The defect in the small bowel mesentery is closed wit h in terrupted 4- 0 silk
sutures, as pictured here, or with a continuous 4-0 suture (T ).
The end of the jejunal Roux loop is closed in a similar fash ion, with an
inner continuous layer of 3-0 synthetic absorbable material placed in a Connell
fashio n and an outer in terrupted layer of 3-0 silk.
 p

Proximal
jejunum
Enterotomy

Inner layer of
posterior row
Outer layer
of postenor row of
end -to-side
jejunojejunostomy

Inner layer of
anterior row

s
Closure of
mesentery
/
~/
/ /~~.'/
,
/ /
/.
Outer layer of
anterior row

, -

51
 he Roux-en-Y loop is brought into the right upper quadrant in a

T retrocolic fashion through the root of the transverse mesocolon, on

top of the second and third portions of the duodenum. If the two end
silk sutures of the outer layer closure are left long, these aid in
positioning of the loop (U).
If the loop is 60 cm in length and the division in the small bowel mesentery
is long enough, the Roux-en-Y loop will comfortably rest in the right upper
quadrant without tension ('f).
 _ _ Middle
colic vessels

Hepatic duct
bifurcation -en-Y
Duodenum
v Silastic
biliary
stent

"-_ _ _ _ _ _ Portal v.

r-- - - - -- Common hepatic a.

- ---,O;€I--- - - Raux -en- Y

jejunal loop
 he hepaticojejunostomy i performed in one Iayer_ me n:;

T
>

perform thi ana omosi in two lay , usin a :anery _ u·ure

materiaL In thi e.xample we will demonstrate a one-layer
ana tomosis with mterrupted 4-0 ynthetic absorbable material tba
ha proven to be entirely satisfactory.
The posterior row is placed fi rst between the proximal biliary egment and
the Roux-en-Y jejunal loop, prior to performing an enterotomy and X'). The
sutures pass in to the submucosal layer of the jejunum and then through and
th rough the proximal bi liary segment. The proxim al biliary segment often i no
a complete rim of good mucosa, especially if the patient has had attempt at
prior repairs. This is the principle reason for using a transhepa ic ilastic
biliary stent and leavi ng it in for a prolonged period during healing and wound
contracture.
Once the posterior row has been positioned, the sutures are all secured, and
an enterotomy is performed with the electrocau tery \f). The sutures are divided
and the Silastic transhepatic biliary stent is placed through the enterotomy into
the Roux-en-Y loop (l ).
The anterior row of the anastomosis is completed with a single layer of
interrupted through-and-through 4-0 synthetic absorbable sutures (M ). Thi
anastomosis is not strictly speaking a mucosa-to-mucosa anastomosis, because
the posterior row was placed before the enterotomy. However it fun ction a a
mucosa-to-mucosa anastomosis and is easier to perform than if an enterotomy i
made first (BB).
 x

,/
,/

1
Posterior row of
hepaticojelunostomy

Sliasbc
biliary
stent

Enterotomy

. rowol
r., " tio:ojejunostomy

Completed
anastomosis _ _ _ _~=--

~~ ----~-----­
_ in
 he Roux-en·Y loop is tacked to periportal material on the uode.

T .
.
surface of the liver to insure that there i no ten ion on the
anastomosis . The Roux·en·Y loop is also tacked to the opening in the
transverse mesocolon, to prevent small bowel herniation (CC).
The end of the Silastic biliary stent that emanates from the uperior
surface of the liver is brought out through a stab wound in the right upper
quadrant. It is sutured in place at the skin using 5-0 stainless steel wi re. It is
placed to bile bag gravity drainage.
A Silastic sump drain is left near the top of the li ver at the egress ite of the
transhepatic biliary stent. It is brought ou t through a stab wound in the right
upper quadrant. The hepaticojejunostomy is drained with either Penrose or
closed suction drains.
At five days cholangiography is performed through the Silastic stent. and if
no leaks are evident at the anastomosis or at the superior surface of the live..
the stent is clamped. Th is can be accomplished by either placing a three·way
stopcock on the end or a heparin lock. The patient is taught to irrigate the tube
three times a day with a 20 ml of saline.
T he stent is left in for a 12-month period to allow wound healing and
contractu re to proceed, in the face of a relatively nonreactive large bore, thick·
wa lled Silastic stent. Even though the biliary stents are made of Silastic and are
relatively nonreactive, bi liary sludge can collect and occlude side holes. For thi
reason the stents are changed every three or four mon ths as an outpatiem
procedure. Under fluoroscopy a guidewire is placed into the Roux·en·Y loop
through the lu men of the old stent. The old stent is removed and a new one
easily slipped in place. At the end of one year the stent can be removed with
virtual certainty that a stable anastomosis between the proximal biliary
segment and the jejunum has been created th at will function obstruction·free
indefi nitely.
If the benign stricture involves the hepatic duct bifurcation, it is nee ary
to resect the bifurcation and to perform bilateral hepaticoj ejunostomies.
Preoperatively Ring catheters shou ld be placed in both the right and left hepatic
ducts. Follow ing bifurcation resection , Silastic stents are placed in both the
right and left hepatic ducts and bilateral hepaticojejunostom ies performed in the
manner just demonstrated.
cc

Hepat.cote u'o.5IOI_

Sllasbc bi ary
stent In
Jejunum

( -'
I
Transverse colon \
~

End-Io-side
jejunojeJmoslcmy

/
 ..K€~ectionof a Proximal
olangiocarcinoma Ith
Reconstruction Utilizing Silas tic
Transhepatic Biliary Stents and
Bilateral Hepaticojejunostomies

Operative Indications
it h the frequent use of endoscopic and percutaneou

W chol angiography over th e past decade, an increasing number m

pa tients with prox imal biliary tumors have been identified.11Je;e
small neoplasms, referred to as Klatskin tumors, are mall
ad enoca rcinomas that are near or in volve the hepatic duct bifurcation. Today
an y indi vidua l presenting with jaundice, who on CT scan or sonography is
found to have dilated intrah epatic ducts with a collapsed extrahepatic biliary
tree and gallbladd er, is highl y suspected of ha ving a prox imal
cholangioca rcinoma.
We fee l tha t such patients should undergo percutaneous cholangiography.
with insert ion of Ring catheters into th e right and left hepatic ducts, througlt
th e tumor, and distall y into th e duodenum. In ou r ex peri ence virtually al l
patients can ha ve these catheters placed bilatera ll y through the tumor and into
th e du odenum , despite the initial cholangiogram demonstrating complete
obst ruction at the bi furca tion, Patients wit h prox imal cholangioca rcinoma are
staged preoperatively with cholangiograph y and angiograph y. If on
cholangiograph y tu mor clearl y ex tends up into th e hepatic parenchyma of both
lobes, the patients arc palliated with th e I~ i ng ca th eters and not explored. In
addit.ion, if angiograph y demonstrates encasement of the common hepatic artery
or main portal vein, pati cnts are fcltto be unresectabl e and are not explored.
However, if onl y onc branch of the hepatic artery or porta l vein is in volved or
tumor extends in to on ly one lobe, pa tients may still be resecla ble if hepatic
lobectomy is added . After preoperative staging, approximately 80 percent of
pa ticnts presenting with cholangioca rcinomas are cand idates for resection.

Operative Technique
atients are prepped and draped so that the surgeon ha access to both

R "9 catheters

/
•
P Ring catheters in the operati ve fi eld. A right subcostal incision i used..
Atthc time of laparotomy th e abdomcn is explored for evidence of
tumor disseminat.ion. In our ex perience li\'er metastases or peritoneal
Implants are uncommo n. In addit ion. lymph node in volvement is unu ual.lf a
patient is unresectable. it generall y is because of local in volvement of
parenchyma of both the right and left lobes or involvement of the common
hepatic artery or main portal vein .
At the time of laparotomy initially the tumor usually cannot be vi lIalired
or even palpated. The gallbladder and extrahepatic biliary tfee appear nonna.I
(A). HoweYeI'. if one palpates high in the hilum of the liver. by feeling for the
diveJgt1Itt mthe Ring catheters. the area of the bifurcation and tuInm' can be
identified
 A

Tumor
\ invoMlg
hepalicdld
bifurcalion

Gallbladder - - - - ---t-'+

Hepatic
flexure
of co lon

Duodenum
 WO maneuver greatly aid in exposure and di ection of the hepatic

T duct bifurcation. The first is mobilization of the gallbladder. If the

gallbladder has not been removed previously, the cy tic artery i
identified, doubly clamped, divided, and ligated, and the gallbladder i-
mobilized out of the li ver bed (C). This greatly improves acce to the
bifurcation. In addition early in the dissection of the porta hepati , the di tal
extrahepatic biliary tree is dissected and looped with a vessel loop (C).
Identification and dissection of the common duct is facili tated by having the
Ring catheters in place, particularly if the patient has been operated upon
previously.
Once the distal common duct has been mobilized, the anterior wall i
opened and the Ring catheters extracted (D). The duct is then completely
divided. The distal common duct can either be ligated or closed with inrerruprro
3-0 silk sutures placed in a vertical mattress fashion, as demonstrated here
These two maneuvers, mobilization of the gallbladder and early divi ion of die
distal common duct, greatly aid in access to and dissection of the bifurcation.
GaWb" - ,
fossa

"If.:--:;--- - - Mobilized
gallbladder

!
, /I' -
- .~

Tumor involving
hepatic duct
Common _ _ _ __ bifurcation
duct

; ,- - - - CJvip." "on ?II

~i>:;:~5t------ Distal common

duct

Duodenum _ _~_
 arly division of the common duct allows one to dissect the bifurcation

E both anteriorly and posteriorly as the proximal biliary segment is

being retracted in a cephalad direction (F). Retraction is aided by
having the Ring catheters in place. The bifurcation of the biliary tree
and the tumor rest on the bifurcation of the portal vein and hepatic artery.
Dissection of this area without dividing the distal biliary tree, thus allowing
retraction of the proximal biliary segment in a cephalad direction, is not only
difficult, but also hazardous.
As the bifurcation is dissected both posteriorly and anteriorly, the right and
left hepatic ducts are identified and dissected and are looped with vessel loops
(G). There often is no visible tumor mass. However, by palpating the
bifurcation, thickening and firmness are easily identified.
One palpates for the Ring catheters above the bifurcation and above tumor
through normal right and left hepatic ducts. The right and left hepatic ducts
are divided, the Ring catheters are extracted, and the specimen can then be
removed (H).
The distal common duct margin, as well as the right and left hepatic ducts,
are marked with different color sutures to aid the pathologist in checking the
microscopic margins (inset). Generally frozen section margins are not sent;
these have not proven to be accurate. Often, even with the entire specimen, on
permanent section s, the extent of the tumor is difficult to delineate.
F

Mobilized
gallbladder

J
l
~~~~~,: ""'-1~f-- Portal v. bifurcation
R. hepalic duel

i!ii;;;~~-=:::::~- R. and I.
hepatic aa.

Oversewn _ __ --:_
common
duct

Duodenum _ _ __

Bifurcation of I
/
r. hepatic duct
,

:/ .I

Tumor

R. hepatic duct
Specimen
L hepatic dud

Commooducl
 oth the right and left hepatic ducts are intubated with Silastic

B transhepatic biliary sten ts. The Ring catheters that were placed
preoperatively are brought in through the chest wall in to the
abdominal cavity. In order not to lose the tract if one of the catheters
should break or become dislodged, cardiac gu idewires are placed through the
Ring catheters. A #12 Coude catheter, with the tip excised, is then passed over
the guidewire and Ring catheter and sutured in place (I). By withdrawing the
Ring catheters, the right and left hepatic ducts are in tubated with the Coude
catheters.
T he Silastic trans hepatic biliary stents (#16 French) are then placed over
the guidewires into the flanges of the Coude catheters. By withdrawing the
Coude catheters, the transhepatic biliary stents are appropriately positioned.
The portion of the stents that extend outside the porta hepatis or reside in the
liver contain multiple side holes, while the portion of the stent that emanates
out through the top of the liver contains no side holes. Horizontal mattress
sutures of #1 synthetic absorbable material can be placed around the egress site
of the stent on the superior surface of the liver (J).
 Silastic
,, _---,-_ _ _ _ biliary _ _ _ __
eoude stent
cath eters

t \, I~I

Guidewire

(
Mattress suture
 ften the point of division of the right hepatic duct is close to the

O bifurcation of the anterior and posterior segments. If this i? the case,

the spur is divided and one anastomosis is performed (K). A Roux·en-
Y loop 60 cm in length is then constructed, as demonstrated on pages
48-53. The Roux-en -Y loop is brought into the right upper quadran t via a
retrocolic route, on top of the second and third portions of the duoden um.
The anastomosis is performed in one layer, using interrupted 4- 0 synthetic
absorbable sutures. The entire back row is placed prior to securing any of the
sutures. Each suture passes first through the jejunal loop and then through the
duct from outside in (inset). Thus the knots of the posterior row wi ll be placed
on the inside. However, since we utilize synthetic absorbable material, this is of
no long-term concern. Each suture is individually placed on a hemostat, and the
hemostats are placed in order on a long clamp (L).
 i".;:- - - - Hepatic a.

Portal v.

\ \
\
I
 nce the posterior row of each hepaticojejunostomy has been placed,

O the sutures are secured. Bilateral enterotomies are made adjacent to

the posterior row of sutures using the electrocautery (M).
The posterior row of sutures, except for the two end sutures, are
then divided, and the Silastic stents are placed in the Roux-en-Y loop via each
enterotomy (N). Each interrupted 4-0 synthetic absorbable suture is placed for
the anterior layer of both hepaticojejunostomies, before securing the sutures (0 ).
These sutures are simple sutures placed through and through the jejun um and
then through and through the duct (inset). Once all sutures of the anterior row
of both hepaticojejunostomies have been placed, they are tied .
o

Roux -en -Y _ _ __ _ _~
I"I'lllalioop
 nce the anterior rows of both hepaticojejunostomies have been

O secured, the sutures are cut. The Roux-en-Y loop is tacked to the
undersurface of the liver with interrupted 3-0 silks to insure that
there is no tension on the anastomosis. The Roux-en-Y loop is
sutured to the rent in the transverse mesocolon with interrupted 4- 0 silks to
preven t herniation of small bowel (P).
Each Silastic transhepatic biliary stent is brought out th rough a stab
wound in the right or left upper quadrant, and is sutu red to the skin with 5-0
stainless steel wire. The stents are connected to allow bile bag drainage through
gravity. The egress site of each stent on the superior surface of the liver is
drained with a Silastic sump brought out through separate stab wounds in the
right and left upper quadrants.
The bilateral hepaticojejunostomies are drained with Penrose or closed
suction drains brought out through a stab wound in the mid abdomen. The
stents are left to gravity drainage for five days, at which time cholangiography
is performed. If there are no leaks from the superior surface of the liver or at the
anastomosis, the tubes are internalized by placing three-way stopcocks or
heparin locks on the ends of the catheters. The patients are then taught to
irrigate the stents three times a day with 20 ml of saline.
We routinely deliver 5,000 rad of external beam radiotherapy to the area of
the tumor bed postoperatively. When this has been completed as an outpatient
procedure, the patient is readmitted and iridium 192 seeds are lowered down
through the bilateral trans hepatic biliary stents and left in place for
approximately 48 hours, to boost the radiation dosage an additional 2,000 rad
locally. T he iridiu m seeds are then removed. The transhepatic Silastic biliary
stents are left in permanently.
The s tents are changed every three or four months as an outpatient
procedure. This is carried out under fluoroscopy by placing a guidewire down
through the old stent into the Roux-en·Y loop. The old stent is then removed,
leaving the guidewire in place. A new stent is easily slipped in place over the
guidewire and then the guidewire removed.
The stents are left in place permanently because even though substantial
prolongation of survival is achieved with this operative procedure, most patients
are not cured and eventually local tumor will recur. If the Silas tic stents are not
in place, biliary obstruction will result. It is our feeli ng that survival is
prolonged by having the most liver parenchyma drained for the longest period of
time. We feel this is achieved by leaving the stents in permanently. The stents
are well tolerated by patients and require minimal care.
p - - -- - - bEry

--"'t-~-4+~--- Roux-en-Y
jejunal loop

Hepaticojejunostomies

=='-:-:-=-==-"::"_':::"~=_---=-_Transverse me$ocolon
tacked to jejunal loop

'N.....I.-_ _ _____ End-to-side

jejunojejunostomy

71
 Resection of a Proximal
Cholangiocar:cinoma With Hepatic
Lobectomy and Reconstruction
Utilizing a Silastic Transhepatic
Biliary Stent and
Hepaticojejunostomy

Operative Indications
ccasionally patients with proximal cholangiocarcinoma will e

O tumor extension only up into one lobe or the other (A). In add! - ~
is not infrequent in such instances to have one branch of the r.2
vein or one branch of the hepatic artery encased or occluded _
tumor. Such patients may still be resectable, if hepatic lobectomy is added ~a
extirpation of the bifurcation and extrahepatic biliary tree. One i aware . --,1,
possibility prior to laparotomy because of preoperative cholangiographica::lc
angiographic findings.

Operative Technique
he patient is explored through a right subcostal incision, often ,

I·.
/,
T extended up to the xiphoid in the midline or over to the left of ri.ll:
abdomen as a left subcostal extension. It is particularly importam
that these patients preoperatively have Ring catheters
inserted bilaterally.
The initial operative procedure is as described for the resection of a
,/
proximal cholangiocarcinoma without hepatic lobectomy. The gallbladder is
mobilized to improve exposure of the bifurcation (B), and the distal common
duct is divided so that the proximal biliary segment can be reflected in a
cephalad direction (C) to facilitate bifurcation dissection.
 li

\.~\-.,,~_ _ _ _ Ring caIheIeIs

r .
, "'~)

Gallbladder
fossa
Cystic a.
and duct

- ,,L-_ _ Mobilized
gallbladder

Duodenum _ _---:-_

- -- ""-- - - - Ring
catheters
O Llaix:hotomy

Proximal
.. ,..L._ _ _ _ L hepa:!ic
common duct -------1~
duct

Portal v. Oversewn distal

common duct
R and I.
hepaoc aa.
 nce the hepatic duct bifurcation has been mobi lized and dissected off

O the bifurcation of the portal vein and the hepatic artery, it is seen
that tumor extends well up into the left lobe of the liver , probably
also involving the left branch of the hepatic artery and portal vein
(D). On the right, however, normal duct can be identified by palpating the Ring
catheter above tumor at the bifurcation. The right hepatic duct is divided and
the Ring catheter exposed and extracted (D).
The left branch of the hepatic artery is identified, dissected, doubly ligated,
and divided (E). The left branch of the portal vein is dissected free and doubly
clamped with straight Cooley clamps; the branch is then divided and the
proximal end oversewn with a continuous 5- 0 synthetic non absorbable s uture
(F). The distal end up towards the left lobe of the liver can also be oversewn
with a continuous 5-0 suture, or it can merely be ligated if length permits.
 .. I
~

•
•
\ J

~,L--- Common dud

L. hepatic duct
Divided
r. hepatic _ _.--tlI\
duct L hepa -ca

Portal v. bifurcation

R. hepatic _ _""-
duel
-'-'-_ _ R. and L hepatic aa.

.\ __ _ _ Ring catheter

Distal common
duct

Tumor extending along

~_ _ _ _ _ L hepatic duct

i-- -- - - Divided L hepatic a.

L branch of portal v.
divided

!Il
 he left lobe of the liver is mobilized by dividing the triangular and

T falciform ligaments (G).

The hepatic veins are identified, and the left hepatic vein is
dissected free (H).
The left hepatic vein is doubly clamped with acutely curved Cooley clamps,
divided, and each end oversewn with a continous 5- 0 synthetic nonabsorbable
suture (I). The left lobe of the liver has now been completely devascularized.
 G

FalcLUi

Suprahepatic L.lobe
inferior of liver
vena cava
Stomach Spleen
OIapIvagm - - -- ----...11

~----------_ L. hepatic v.

Divided
I. hepatic v.

71
 variety of techniques are available for going through hepatic

A parenchyma. In this example, parallel rows of # 1 chromic catgut

sutures are placed in a mattress fashion approximately 1 cm on either
side of the plane that is to be divided between the right and left
hepatic lobes. This plane generally extends from the gallbladder fossa to the
hepatic veins as they enter the inferior vena cava. The liver parenchyma
sutures should be snugged down to compress liver but not so tight as to cut
through or necrose liver.
The line of division is first marked with electrocautery (J). Generally two or
three sutures are placed on each side (K), and then the hepatic parenchyma is
divided with the electrocautery (L). Two or three more sutures are then placed
and more parenchyma divided with the cautery. This is perhaps the most
bloodless way of dividing hepatic parenchyma; generally the entire liver can be
transected with virtually no blood loss (M).
The catgut is wedged on large liver needles that can be controlled better if
most of their curve is straightened. Other methods for dividing hepatic
parenchyma, including using the Cavitron, will be demonstrated in other
procedures.
J

f )
\
Dividing
parenchyma

Divided I. hepatic v.

Devascularized
I. lobe
 hen division of the parenchyma has been completed, the specimen

W is removed from the operative field. The entire extrahepatic

biliary tree including the bifurcation has been resected, along with
the left lobe of the liver (inset). The tumor involves the bifurcation
and clearly extends up into left hepatic parenchyma. Hemostasis is completed
on the resected raw area remaining on the right lobe of the liver using both the
electrocautery and figure-of-eight sutures of 3-0 synthetic absorbable material.
Because the stay sutures are compressing hepatic parenchyma, very little
hemostasis is generally required (N).
 Specimen

L hepatic v.

Tumor extending
into I. lobe _ _ _ _ _
of liver
Ring
catheter

' -_ _ _ L. hepatic a.

'----_ _ L. bran ch of portal v.

./

1 - - - - - Oversewn l. hepatic v.

' - - -_ _ Middle hepatic v.

Liver sutures _ _ _

4 -"--- - Resected surface of liver

'1"1-1-- -- Caudate lobe

R. hepatic duct
Oversewn
I. branch
of portal v.

::~~~~~~~=-- ____
R. branch of portal v.
"-_ _ _ _ -,,-_ _ _ R. hepatic a.
I. hepatic a.

~S~~:-J~t'l0ve,,;e"1n distal common duct

_ _ _ _ _ __ _ Duodenum
 tilizing the preoperatively placed Ring catheter, a Silastic

U transhepatic biliary stent is placed. A guidewire is inserted through

the Ring catheter, and then a #12 Coude catheter with the tip excised
is placed over the guidewire and sutured to the Ring catheter. The
Ring catheter is then withdrawn from the top of the liver, thereby placing the
Coude catheter. A #16 Silastic transhepatic biliary stent is then placed over the
guidewire and sutured to the Coude catheter. The Coude catheter is withdrawn,
thereby placing the Silastic trans hepatic biliary stent (0 ).
A Roux-en-Y loop 60 em in length is constructed, as previously
demonstrated on pages 48-53. It is brought up into the right upper quadrant in a
retrocolic fas hion on top of the duodenum. A hepticojejunostomy is performed
using one layer of interrupted 4-0 synthetic absorbable suture. The techn ique of
this anastomosis was demonstrated in the prior procedure (see pages 66-69).
A horizontal mattress suture has not been placed around the egress site of
the Silas tic stent on the superior surface of the liver. This is optional. Some
surgeons feel that bile leakage is made less likely by s uch a suture; bile leakage,
however, is rare, as long as side holes in the biliary stent are not positioned near
the surface of the liver.
The end of the Silastic stent that emanates from the superior surface of the
liver is brought out through a stab wound in the right upper quadrant, sutured
to the skin with 5-0 stainless steel wire, and connected to depend.ent bile bag
drainage. The egress site of the biliary stent is drained with a Silastic sump
brought out through a separate stab wound in the right upper quadrant. The
resected surface of the liver and hepaticojejunostomy are drained with a Silastic
sump drain and either Penrose or closed suction drains brought out through
separate stab wounds in the mid abdomen. The Roux-en-Y loop is sutured to the
rent in the transverse mesocolon to prevent small bowel herniation (P).
Postoperatively cholangiography is performed at five days and if no bile
leaks are present, the stent is internalized by placing a three-way stopcock or
heparin lock on the end of the stent. Patients are taught to irrigate the stents
three times a day with 20 ml of saline.
Postoperatively patients are given adjuvant therapy with 5,000 rad of
external beam radiotherapy to the area of the porta hepatis. When this is
completed, the patient is readmitted to the hospital for approximately 48 hours
so that iridium 192 seeds can be lowered down through the biliary stent and
positioned in the area of the anastomosis. An additional 2,000 rad of
radiotherapy are delivered locally.
The Silastic trans hepatic biliary stents are left in permanently. Even
though an occasional cure is possible, most patients will develop recurrent
tumor; thus having the stent in place will prevent recurrent biliary obstruction
and prolong urvival maximall y. The stents, however, are changed every three
or four months prophylactically because of biliary sludge accumulation and
obstruction of the side holes. T his is easily and quickly carried ou t as an
outpa .em procedure under fluoro copy in the Catheterization Laboratory.
 Q

SiIaslic
biliaJy
sterol
p
Middle hepatic v.

Hepaticojejunostomy

Roux·en-Y
jejunal loop

Silastic
-~a.--!!...,-- biliary
stent

~--'-'-'-----'--_ _ Transverse mesocolon

tacked to jejunal loop

Duodenum
Proximal Cholangiocarcinoma:
Palliation by Transhepatic Stenting
and Hepaticojejunostomy

Operative Indications
ll patients with proximal cholangiocarcinomas are staged

A preoperatively by percutaneous cholangiography and angiography. If

it appears that a patient is not potentially resectable for cure,
palliation is achieved with Ring catheters, and the patient is not
explored. Such patients can receive palliative irradiation following tissue
confirmation of their disease.
Of those patients explored who are thought to be curable, at the time of
surgery only half will be resectable. The others at the time of laparotomy will be
unresectable because of tumor extension into both lobes or involvemen t of the
common hepatic artery or main portal vein .
In such instances we feel that it is appropriate to replace the Ring catheters
with Silastic transhepatic biliary sten ts and to perform a hepaticojejunostomy.
The thick-wall, large-bore Silastic transhepatic biliary stents provide better
palliation than the Ring catheters alone. They are more comfortable, are
tolerated better by patients, and less frequently are associated with
complications such as hematobilia and liver abscess. Because of their internal
diameter, they also are less likely to occlude with biliary sludge.
Placing these Silas tic stents is not worth a laparotomy in a patient who
clearly is incurable by preoperative staging. However, if a patient has been
explored with the hope of a curative resection, and it is not possible, this
procedure is appropriate and indicated.

Operative Technique
he patient is explored through a right subcostal incision. T he two

T Ring catheters are prepped into the field so they are accessible to the
surgeon.
When tumor extension is found into both lobes of the liver (A), it
is important to confirm the diagnosis by biopsy. T his may be difficult on frozen
section, because of the fibrotic sclerosing natu re of the tumor. Nevertheless the
surgeon should persist so that rad iotherapy can be deli vered postoperatively.
In preparation for removi ng the gallbl adder , the cystic artery is identified,
doubly clamped, di\'ided, and ligated. At the sa me time the common hepatic duct
i mobilized and looped with a vessel loop (B).
 Cystic duct

Gallbtadder Biopsy of I. hepatic ducl

Encircling common
'#'-,,&-_ _ _ _ _ _ hepatic duct
vessel loop

DMded cys:x: a
 he gallbladder is mobilized, the common hepatic duct is divided, and

T then the distal common duct is divided, removing the gallbladder and
a segment of extrahepatic biliary tree (C). The distal common duct is
either ligated or oversewn with interrupted 3-0 silks.
One is now left with a short segment of common hepatic duct,
cholangiocarcinoma involving the common hepatic duct and bifurcation and
extending up into both lobes, and Ring catheters in both the right and left
hepatic ducts (D). It is important that the gallbladder be removed.
With the large-bore, thick-wall Silastic stents residing in the biliary tree,
obstruction of the cystic duct by edema or by the stents themselves is common,
and acute suppurative cholecystitis can occur. Since the distal biliary tree is of
normal size, it cannot accommodate the two large Silastic stents, and it is
necessary to construct a Roux-en-Y jejunal loop as a receptacle.
 ,

Dividing common dld

Mobilized
gallbladder
I.
D

Tum or extending into

~d~~:..!.----- bolh lobes
~~~\-_ __ _ _ _ Common hepatic duel
-"---,--- -- Portal v.
~-i-.-=--=:.....,,---- Hepatic a.

common
-~
duct

( UJ
 he curved ends of the Ring catheters are cu t off. The catheters are

T then brought into the peritoneal cavity through the chest wall. A
guidewire is inserted into each Ring catheter to maintain the tract in
case a catheter breaks or becomes dislodged during the following
manipulations.
A #12 Coude catheter with its tip cut off is then placed over the guidewire
and Ring catheter and sutured in place (E).
The Coude catheters are drawn up through the tumor, thereby dilating it
and placing the Coude catheters into the right and left hepatic ducts. Often this
is repeated with the next size Coude catheter, for instance #14, before placing
the #16 French Silastic transhepatic biliary stent. Wi thou t progressive
dilatation, one may have difficulty in placing the Silastic trans hepatic biliary
stent. Using progressively larger Coude catheters, the t umor is easily dilated
and the Silastic stents placed (F).
 E

_ _--C.;!-~_ _ _ __ _ _ _ Tumor extending inIo

both lobes 0/ liver

Ring catheters \ .)

Coude
catheter

I
/.
J';r Sitastlc
bitiary
I stent
'_~ng
, C<CJheter /
_ _ GUldewtre
 nce both Silastic transhepatic biliary stents have been positioned, a

O Roux·en·Y loop 60 cm in length is constructed as previously

demonstrated on pages 48-53. The anastomosis is performed with a
single layer of interrupted 4-0 synthetic absorbable materiaL The
posterior row is placed prior to performing an enterotomy (G). The sutures pass
into the submucosal layer of the bowel and are through·and·through on the duct
side. Thus the anastomosis is not actually mucosa·to·mucosa, but funct ionally
it acts as one.
After the back row has been placed and the sutures secured, an enterotomy
is made with the electrocautery (H). The posterior row of sutures is divided, and
both stents are placed into the Roux·en·Y loop through the single enterotomy.
The knots of the posterior layer are on the inside, but since the suture material
is absorbable, this is of no consequence.
The anterior layer of the anastomosis is completed with a single
interrupted layer of through·and·through sutures of 4-0 synthetic absorbable
material (I). All such sutures are placed and then secured.
 ~
b6ary
- - sIEnIS

Posterior row of
hepaticojejunostomy

;:t ,
jejunal loop

,
,
: \

,
,
\ Anterior row of
hepa ·cojejunos\DlnJ

Enterotomy

91
 oth Silastic transhepatic biliary stents are brought out through stab

B wounds in the right and left upper quadrants, sutured to the skin
with 5- 0 stainless steel wire, and connected to gravity bile bag
drainage. Both egress sites on the superior surface of the liver are
drained with Silastic sump catheters, brought out through separate stab
wounds in the right and left upper quadrants. The anastomosis is drained with
Penrose or closed suction drains brought out through a stab wound in the mid
abdomen.
The Roux·en·Y loop is sutured to the under surface of the liver with
interrupted 3-0 silks, and it is sutured to the rent in the transverse mesocolon
with interrupted 4-0 silks (J).
Postoperatively the stents are placed to bile bag drainage by gravity. At five
days cholangiography is performed, and if there are no bile leaks, the stents are
internalized by placing three· way stopcocks or heparin locks on the ends.
Patients are taught to irrigate the stents three times a day with 20 ml of saline.
The Silastic trans hepatic biliary stents are left in permanently to maintain
patency of the biliary tree. The stents are changed every three or four months
as an outpatient procedure, however, to prevent side hole occlusion with biliary
sludge. This is accomplished by passing a guidewire t hrough the old stent into
the jejunal loop and then removing the old stent, leaving the guidewire in place.
A new stent is placed into the jejunal loop, over the guidewire, and the
guidewire is removed.
Postoperative radiation can be delivered in a fashion similar to that after a
curative resection: 5,000 rad are delivered to the hepatic duct bifurcation via
external beam radiotherapy, and then the patient is readmitted for the delivery
of internal radiation via iridium 192 seeds lowered down through the lumens of
the Silastic biliary stents. Such seeds are left in place for approximately 48
hours to deliver an additional 2,000 rad. This palliative procedure can prolong
survival for as much as two years following the ini tial presentation.
 J

-'-_ -':=--_ Tumor ex-~

both IOOes CJ' • "'"

_~¥ _ ______ Roux-en- Y e ur.a

Sase
boary
s;.ent

Transve rse ------"'~if'

mesocolon tacked to ,,
jejunal loop

•\
,,

/ '
\
,
\

Transverse colon

P-"----- - End-la-side
jeJunojejunoslomy

,,
Resection of Hepatic Duct
Bifurcation, Dilatation of Intrahepatic
Biliary Tree, and Prolonged Stenting
With Transhepatic Biliary Stents for
Sclerosing Cholangitis

Operative Indications
clerosing cholangitis is an idiopathic disease that commonly affects

S middle-aged males and is often associated with inflammatory bowel

disease_ Patients with sclerosing cholangitis generally have diffuse
involvement of the intra- and extrahepatic biliary tree, with multiple
benign inflammatory strictures (A). Even though the stricturing involves the
intra- and extrahepatic biliary tree diffusely, the area of most severe
involvement is often the hepatic duct bifurcat ion.
Most patients present with intermittent painless jaundice and pruri tis_
Patients with sclerosing cholangitis can have prolonged, variable, and episodic
clinical courses. However, when persistent jaundice develops , it is a sign of a
poor prognosis. Such patients should undergo liver biopsy. If biliary cirrhosis is
present, the patient is a candidate for liver trarrsplantation_
However, if biliary cirrhosis is not present, and there is a dominant
bifurcation stricture, the patient should be considered for resection of t he
hepatic duct bifurcation, dilatation of the intrahepatic biliary tree, long-term
stenting with transhepatic biliary stents, and bilateral hepaticojejunostomies_
This procedure is based on the premise that the bifurcation stricture and the
proximal obstruction that results playa major role in the progressive
parenchymal disease that eventually leads to hepatic fai lure_ The functional
significance of the bifurcation stricture is often difficult to determine because of
the lack of proximal dilatation. In patients with sclerosing cholangitis the entire
biliary tree tends to be fibrotic, and it often does not dilate proximal to a
stricture_ Biliary tract surgeons have been slow to recognize the functional
significance of these bifurcation lesions_
T hus, patients with sclerosing cholangitis who have developed persisten t
jaundice over a period of several months and are demonstrated
cholangiographically to ha"e a dominant stricture involving the hepatic duct
bifurcation, and who on li ver biopsy do not have biliary cirrhosis, are thought to
be e.xceUem candidates for bifurca tion reconstruction and long-term stenting.
I'Teoperao\-e percutaneous cholangiography should be performed and Ring
catllet.tT.; bould be inserted into both the right and left hepatic ducts, through
£he bifurca - !kJicrure, and imo (he duodenum . These are placed
~. Il(){ W decompress (he h\-perbilirubinemia, but [0 aid the surgeon
in the . procedure.
 Ring catheters

+--- Bifurcation stricture

Gallbladder _ __ _

\
Duodenum _ __ _ __
 Operative Technique
atients are explored through a generou right subcostal incision. At Gt'

'1 ng catheters
P ti me of laparotomy the abdomen i explored. The cholangiographic
diagnosis of sclerosing cholangiti is highly accurate. However, mere -..
an in creased incidence of cholangiocarcinoma developing in patien
with sclerosing cholangi tis; thus the abdomen should be explored for evidence '
tumor. T he en tire extrahepatic bi liary tree is often sclerotic and fibrotic a
demonstrated here (B). T he gallbladder, however, grossly appears normal.

/
The bifurcation of the biliary tree can usually be identified high in the
porta hepatis by palpating fo r the poin t where the two Ring catheters diverge
into the right and left hepatic ducts (B).
 B

Hepatic duct
bifurcation

Gallbladder - -r-,,:,-'

Hepatic flexure Duodenum

of co lon
 fter dividing the cystic artery, the gallbladder is mobilized to improve

A access to the hepatic duct bifurcation. The extrahepatic biliary tree is

dissected, and the common duct is encircled with a vessel loop (C).
The distal common duct is divided, the two Ring catheters are
extracted, and the distal bile duct is either ligated or closed with a series of
interrupted 3-0 silk sutures.
The proximal biliary segment is reflected in a cephalad direction, and the
extrahepatic biliary tree is dissected off the hepatic artery and portal vein (D).
The bifurcation of the hepatic duct rests on the bifurcation of the portal
vein and the hepatic artery. Reflecting the proximal biliary segment so the
biliary tree can be dissected both anteriorly and posteriorly makes this a safe
dissection.
The right and left hepatic ducts are dissected free and looped with vessel
loops. The right and left hepatic ducts are then divided and the specimen
removed from the operative field (E).
c

\
~\
l -- - Common duct
(
Mobilized
gallbladder

Hepalic duct _ _ _ _"--,-

bifurcation

:4'- - He::-=2..
~':-_ Pcr12I Y.

common
duct

L hepatic duct

99
 he next step involves dilatation of the fibrotic strictu red intrahepatic

T biliary tree. Ring catheters have previously been placed through the
right and left hepatic ducts. The Ring catheters are retrieved through
the chest and the abdominal wall and brought into the peri toneal
cavity. A guidewire is placed in the lu men of the Ring catheter to avoid losing
the tract if a catheter breaks or becomes dislodged in the next series of
manipulations.
A #12 Coude catheter is placed over the guidewire and on to the Ring
catheter after cutting off the curved distal tip of the Coude. The Coude is
sutured to the Ring catheter and then drawn up through the liver, th us dilating
the intrahepatic biliary tree (F).
A #14 Coude catheter is then placed over the guidewire and sutured to the
#12 Coude catheter. Further dilatation is accomplished by pulling the #12 Coude
catheter out through the top of the liver, thereby placi ng the #14. This can then
be repeated with a #16 Coude catheter.
Finally, when a #16 Coude catheter has been placed, a #16 Silastic
transhepatic biliary stent is sutured to the Coude and positioned by
withdrawing the Coude catheter (G). This series of manipulations not only
dilates the strictu red intrahepatic biliary tree, but also positions the Silastic
transhepatic biliary stents used in the reconstruction .
 c

'---- R. hepatic dud

;L- - -- - L. hepatic duct

Larger
Goude catheter

,.c,_ _ _ __ Small
Goude catheter

\
G
, _ _ _ _ Guidewlre

11-'""-- - -- - Large Goude cathe '"

SI aSLC biliary - - - - - -_ _ __
s:...."

101
 he Silastic transhepatic stents have both been positioned (H).

T Mattress sutures of #1 synthetic absorbable material may be placed

on the superior surface of the liver around the egress sites of the two
stents to minimize the likelihood of bile drainage. T he process of
dilating the intrahepatic biliary tree is greatly simplified by having Ring
catheters in place.
If Ring catheters have not been inserted preoperatively, it is necessary to
dilate the intrahepatic biliary tree after bifurcation resection with instruments
such as Bakes dilators. This can be extremely tedious. One has to proceed
cautiously to avoid making false passages. If a false passage is made, it is
virtually impossible to get beyond the fa lse passage to dilate biliary tree up
within the liver. However, by proceeding very cautiously, dilatation can
eventually be performed.
Once the intrahepatic biliary tree is dilated, the Bakes dilator can be
pushed out the diaphragmatic surface of the liver and a Silastic stent sutured to
it. The stentis positioned by withdrawing the Bakes catheter out the hilum of
the liver (I). Securing the Silastic stent to the Bakes dilator is facilitated by
having a hole drilled in the end of the olive tip.
H

1"'-- - -- L. hepatic duct

, T S ilastiC biliary stents

A. and I. hepatic ducts

Olive tip of
Bakes dilator
Sa! es dilator

103
 RoUX-en-y loop 60 cm in length is constructed as previously described

A on pages 48-53. It is brought into the right upper quadrant in a

retrocolic position on top of the second and third portions of the
duodenum.
Bilateral hepaticojejunostomies are then performed. These are constructed
in one interrupted layer using 4-0 synthetic absorbable suture material. The
sutures pass into the submucosal layer of the jejunum and through and through
the duct. The entire posterior row is placed for each hepaticojejunostomy before
the sutures are secured. The intestinal sutures are placed in the posterior row
prior to performing an enterotomy, so strictly speaking, it is not a mucosa-to-
mucosa anastomosis, although functionally it acts as one.
Each suture is grasped in a separate hemostat and lined up in order on a
longer clamp (J).
Once all the sutures have been placed, they are secured. The knots of the
posterior row are on the inside, but since the suture material is absorbable, this
is of no long-term consequence.
Bilateral enterotomies are performed with the electrocautery (K).
The posterior row of sutures is divided, and the Silastic trans hepatic biliary
stents are placed through the enterotomies into the Roux-en-Y loop (L).
The anterior rows of both hepaticojejunostomies are completed utilizing
through-and-through simple sutures of 4-0 synthetic absorbable material (M).
 . 1
.~

I
"
f.

R. hepatic duct

Posterior
rows of
anastomoses

Enterotomies

Roux-en - Y
jejunal loop

Silastic biliary stents

MerU
rows 01
ana::.stai-

I
 oth silastic transhepatic biliary stents emanating from the top of the

B liver are brought out t hrough separate stab wounds in the right and
left upper quadrants, sutured to skin with 5-0 stainless steel wire,
and connected to gravity bile bag drainage. Both egress sites on the
superior surface of t he liver are drained with Silastic sump drains brought out
through separate stab wounds in the right and left upper quadrants.
The Roux-en-Y loop is sutured to the under surface of the liver with
interrupted 3-0 silks, and to prevent small bowel herniation, the Roux·en-Y loop
is sutured to the defect in the transverse mesocolon with interrupted 4- 0 silk
(N). The hepaticojejunostomies are drained with Penrose or closed suction
drains. Postoperatively the stents are left to gravity drainage for five days.
At five days cholangiography is performed, and if no leaks are apparent, the
stents are internalized by capping them with three-way stopcocks or heparin
locks. The patients are taught to irrigate the stents three times a day with
20 ml of saline.
It has been our practice to leave the Silastic stents in permanently. The
stents, however, are changed every three or four months as an outpatient
procedure. Patients come in and under fluoroscopy a guidewire is placed
through the old stent into the Roux·en-Y loop. The old stent is removed, leaving
the guidewire in place. A new stent is then slipped in place over the guidewire
and the guidewire removed.
Patients with sclerosing cholangitis tend to form biliary sludge more
rapidly than patients with other disorders. Therefore it is occasionally
necessary to change the stents more frequently than every three or four
months. Patients who have done well for several years, with no difficu lty, have
had their stents removed, assuming their disease is in a quiescent arrested
stage. However, for many patients the stents are left in permanently to prevent
inevitable restricturing.
This operative procedure has been demonstrated to prolong survival and to
result in a prolonged drop in serum bilirubin. If a patient's disease subsequently
progresses, this procedure does not obviate liver transplantation. Several of our
patients have su bsequently undergone successful liver transplantation.
 --~+---:-;!=';----_ Roux-en-
jejunal loop

fF- - - - -- Hepa cOlel" ~

I Transverse m'es.x:c>lo<o
lacked 10 le,una 1000

'f-,~~------- End-Io-side
jejunojejunostomy

101
Hepaticojejunostomy for Distal
Stricturing Secondary to Sclerosing
Cholangitis

Operative Indications
he majority of patients with sclerosing cholangiti have biliary

T strictures involving both the intra- and extrahepatic biliary

mentioned in Operative Indications for the prior procedure, !:be
severe stricturing is often at or near the hepatic duct b-
Some patients with sclerosing cholangitis, however, have a variant in
-

strictu ring is confined to the distal biliary tree (A). These patients can be
-

conveniently managed with a distal biliary tree resection and a proximal

hepaticojejunostomy_Operative indications for such patient would -u rltu tb
development of persistent jaundice or recurrent cholangitis_
If liver biopsy demonstrates biliary cirrhosis, liver tran plantari
be considered. If cirrhosis is not present, however, a biliary recon :;.
hepaticojejunostomy should be considered.

Operative Technique
he patient is explored through a righ t subcostal inci ion. Many

T patients will have been operated upon previously; often they

undergone a cholecystectomy with insertion of aT-tube for-
prolonged T -tube drainage.
At the time of exploration for hepaticojejunostomy, if the gallbladder- -
in place, it is removed. The duodenum is extensively kocherized (8)-
 ~---- CamJon h<lpaIic a.:Jd

DIseased disIaI
COIiitiO. doc:t

Gallbladder ______ --
Duodenum __________

B Gallbladder
fossa

Kocherized duodelll.m

l ,:::~:-,.---:=------'---- Pancreas

109
 any of these patients wi ll have had Ring catheters inserted

M preoperatively at the time of percutaneous cholangiography.

However, with the disease confined distally in the extrahepatic
biliary tree, this is option;;l and often a Ring catheter will
not be inserted.
The extrahepatic biliary tree is dissected free, and the distal common duct
is mobilized and looped with a vessel loop (C).
The dissection is carried proximally to the point where the hepatic duct
appears grossly normal. The common hepatic duct is mobilized and a transverse
anterior choledochotomy performed (D).
At this point an optional step includes choledochoscopy with either a right·
angled rigid scope (E) or a flexible fiberoptic choledochoscope. Since patients
with sclerosing cholangitis are prone to develop cholangiocarcinomas,
choledochoscopy at the time of this procedure can be important.
 ormaJ common hepabc duct

~1I1il1iii;:::-------v----- Diseased distal

rll common duct

.;:;;~~:- _ _ _ _ __ _ _ _ _ _ _ _ Head ofPancreas

-=~~~ _____________ Duodenum

Endoscopic view of
hepatic duct
bifurcation
Choledochotomy

~a
and duct _ _ _ _-"'---_ _ \',

Hepatic duct
bifurcation

Choledochoscope

II:
 fter the bifurcation has been visualized, the choledochoscope can be

A passed distally and biopsies obtained (F and G). This can be an

important step for, if a cholangiocarcinoma is present, appropriate
management would include a pancreaticoduodenectomy. If the frozen
sections are benign, one can proceed with the hepaticojejunostomy.
Division of the common hepatic duct is completed. The common duct is
mobilized and divided as it disappears behind the first and second portion of the
duodenum into the head of the pancreas (H).
The distal common duct is oversewn with 3-0 silk (1).
 Diseased
. / ~ distal common
/1' duct

I
'/

Endoscopic
view of diseased
common duct

Normal common hepatic duct

Excision of diseased
distal common duct

::3
 RoUX-en-y loop 60 cm in length is constructed as previously

A demonstrated on pages 48-53. It is brough t into the right upper

quadrant via a retrocolic route on top of the second and third portions
of the duodenum.
The hepaticojejunostomy is then performed. In many instances a single-
layer anastomosis using synthetic absorbable 4-0 suture material will be the
procedure of choice. In this instance a two-layer anastomosis is demonstrated.
A posterior outer layer of interrupted 4- 0 synthetic absorbable sutures is
placed (J). These sutures are then secured and an enterotomy performed. The
outer posterior layer of interrupted synthetic absorbable sutures is divided.
An inner posterior interrupted layer of 4-0 synthetic absorbable sutures
through and through both duct and bowel is placed and secured (K).
Using a hemostat placed in the common hepatic duct, a small
choledochotomy is made for insertion of aT-tube (L). A #16 T -tube is prepared
for insertion by cutting one of the T -arms very short and cutting multiple
windows in the distal limb.
A small right-angle clamp is passed through the choledochotomy out the
end of the common hepatic duct and the long limb of the T - tube grasped (M).
The long limb is pulled out through the choledochotomy and the tube
appropriately positioned (N). If the choledochotomy is snug around the T -tube,
no sutures are necessary. A 5-0 synthetic absorbable suture at each end of the
choledochotomy is optional. The distal limb is placed in the Roux-en-Y jejunal
loop.
The two layers of the anterior row of the anastomosis are then placed.
Each row is carried out with a series of in terrupted 4-0 synthetic absorbable
sutures. The inner layer is placed through and through both bowel and duct
such that the knots are on the inside inverting the mucosa (0). The outer layer
is placed with the knots on the outside (P).
The anastomosis is drained with Penrose or closed suction drains. The
T - tube is placed not as a stent, but to decompress the biliary enteric
anastomosis . Postoperatively, when cholangiography demonstrates the
anastomosis to be intact, it is clamped and generally left in for only several
weeks prior to removal.
 ,.
t
Enterolomy

Roux-en -Y
Jejunal loop

Bdra
holes
in
T~

Outer layer
of anterior
row
 Operative Indication
holedochal C) ts are thought to be congenital and in the past were

C recognized most frequently in infancy or during the first decade of

life. The triad of an abdominal rna ,pain, and jaundice was
associated with the diagnosis. In recent years, however, the entity bas
been diagnosed far more frequently in adulthood than in childhood.
There are a variety of classifications of choledochal cyst , but by far the
most common type of cyst consists of a fusiform dilatation of the extrahepatic
biliary tree that includes portions of both the common hepatic and commoo bile
ducts. An anomalous high junction between the pancreatic duct and biliary tree
has been recognized in a large percentage of these patients. Currently it is felt
by many that reflux of pancreatic juice into the biliary tree results in
destruction of the integrity of the bile duct wall and subsequent dilatation.
Because most patients are symptomatic at the time of diagnosi of a
choledochal cyst and because of the considerable risk of the development of
cholangiocarcinoma, all choledochal cysts should be resected and biliary
reconstruction carried out. In the past choledochal cysts were drained into
adjac~nt stomach, duodenum, or into a Roux·en·Y loop. This is no longer
acceptable management because of the risk of cholangiocarcinoma. Thu in
each instance the cyst should be resected.
The presentation today in adulthood is more frequentl y that of mild
abdominal symptoms, occasionally associated with hyperamylasemia, than of
jaundice. The diagnosis of a choledochal cyst is often suggested by sonography
or CT scan in a patient being worked up for abdominal pain. The diagnosi can
be confirmed by endoscopic retrograde cholangiopancreatography or
percutaneous trans hepatic cholangiography.

Operative Technique
rior to surgery Ring catheters are inserted percutaneously into the
•

P intrahepatic biliary tree and then passed into the cyst and distally
through the ampulla into the duodenum. If the cyst encroaches upon
the hepatic duct bifurcation and bifurcation resection is anticipated,
Ring catheters are placed in both the right and left hepatic ducts and advanced
into the duodenum (A). If there is a significant segment of common hepatic duct
that appears normal beyond the bifurcation , only one Ring catheter is inserted.
The patient is explored through a right su bcostal incision. The cy t will be
immediately evident. Frequently it extends well behind the first and second
portions of the duodenum, and it is necessary to dissect serosa extending from
the duodenum onto the cyst to adequately expose the cyst (B).

16
 Gallbladder _ _ _ _ __

Duodenum _ _ _- ;: -_

L'--ff-- - - - - Choledochal cyst

ffe''d-'--------- Gastrohepatic ligament

__~~~~~~~z-_ _ ________ Duodenum

epaoc flexure
oi colon
 he gallbladder usually arises from the mid portion of the cystic

T dilatation of the biliary tree. The cystic artery is identified, doubly

clamped, divided, and ligated. The gallbladder is mobilized out of the
liver bed.
The cyst is dissected free of overlyi ng serosa (C). This generally requires
mobilization of the duodenum off the anterior wall of the cyst and blunt and
sharp dissection of the remaining cyst. There is rarely any significant
inflammatory reaction surrounding the cyst, and the major adjacent structures
are easily dissected free. The fusiform dilatation often extends well down
posterior to the duodenum and head of the pancreas, and the dissection of the
biliary tree needs to proceed virtually to the point of the common duct entering
the posterior aspect of the pancreas to remove all of the cyst.
Once the cyst is completely mobilized it is encircled with a vessel loop and
the dissection carried distally as far as possible (D).
The anterior wall of the distal common duct is opened with the cautery and
the Ring catheters extracted. The posterior wall of the biliary tree is then
divided furt her and the distal common duct oversewn with interrupted
3-0 silks (E).
Occasionally the distal segment will still be quite dilated at the point where
it passes into pancreas and is no longer safely dissectable. If that is the case, one
needs to amputate the cyst and merely close the wide· mouthed ductal opening.
One has to be careful about dissecting the biliary tree too far distally in
pancreas, for fear of injuring the pancreatic duct, which often joins the biliary
tree in an anomalous high location.
 Mobil zed - -- - - cysI
g2 bladder

Ring catheter

(
AI1g ca;he·er _ _ _ _ __ _ _~!.'\

Distal common
duct

Duodenum Oversewn distal

commonducl

119
 nce the choledochal cyst has been divided distally, it is reflected in a

O cephalad direction and easily dissected free from the hepatic artery
and portal vein (F). These are generally fresh aerolar planes that
dissect bloodlessly and rapidly.
The dissection is carried up to the bifurcation both anteriorly and
pcsteriorly. In some instances the cyst extends up to and involves the
bifurcation, and there may be strictu ring at the bifurcation where the right and
left hepatic ducts join. If that is the case the right and left hepatic ducts have to
be dissected out and divided and the bifurcation resected.
In this instance the common hepatic duct appears to reconstitute fairly
normally before the cystic dilatation of the choledochal cyst. Therefore the
common hepatic duct is divided just distal to the bifurcation and the specimen
removed from the operative field (G).
F :-'\_ _ _ _ Postenor aspect
of choledochal cyst

Hepat·Ie duct bifurcation

Common
hepatic duel
/Hepatica.

/
Portal v.

.,.
\

121
 he cyst has been resected and a Roux-en-Y loop 60 cm in length is

T constructed_ The construction of a Roux-en-Y loop has been

previously demonstrated on pages 48-53.
The curved tips of the Ring catheters are amputated (H). In this
instance, since the bifurcation was not resected, one Ring catheter insertion
preoperatively could have sufficed.
 ... -- ..
~ ~ -

Opening in
transverse
mesocolon

_ --"'-_ _ _ Proximal
J8jtnJm

Roux-en -Y
J2Pl2IIoop
 he Roux-en-Y loop is brought into the right upper quadrant in a

T retrocolic position on top of the second and third portions of the

duodenum. It easily rests without tension in the porta hepatis.
The hepaticojejunostomy is performed in a single layer using
mU ltiple interrupted 4-0 synthetic absorbable sutures. The posterior wall is
placed in jejunum prior to making an enterotomy (I). The sutures are placed
into the submucosal layer of the jejunum and through and through the duct. All
sutures are placed before they are tied.
Once the sutures are secured, an enterotomy is carried out in the Roux-en-
Y loop with the electrocautery (J).
The posterior layer of sutures is then divided and the two Ring catheters
inserted into the Roux·en·Y loop (K). These are not exchanged for transhepatic
Silastic bi liary stents because the proximal biliary segment is normal, and a
good mucosa-to-mucosa anastomosis can be performed. The two Ring catheters
are not used as stents, but will be left in for a month or six weeks merely to
decompress the biliary anastomosis during healing. The stents will then be
removed during an outpatient visit.
The anterior row of sutu res is placed using a single layer of interrupted 4-0
absorbable synthetic sutures placed through and through both duct and bowel.
All sutures are placed before they are tied (L).
As mentioned previously, in this instance since the common hepatic duct
was normal, only one Ring catheter would have needed to be placed.
 . _----;----",_ _ _ _ Rng ~caI
-..,~s

/
/

Posterior row
of anastomosis

Ente rotomy
)

Roux -en-Y
jejunal loop

Rng ca:heler - - -- - -

Anterior row
K --. of anastomosis

125
 he Roux-en-Y loop is tacked to the under surface of the liver using

T interrupted 3-0 silk sutures. The Roux-en-Y loop is tacked to the rent
in the transverse mesocolon with interrupted 4-0 silk sutures to
prevent small bowel herniation (M).
The two Ring catheters were placed preoperatively and already have exit
sites through the left upper quadrant and the right chest. The catheters are
placed to bile bag drainage by gravity.
Five days after surgery cholangiography is performed; if no leaks are seen,
the catheters are internalized by placing stopcocks or heparin locks on the ends.
Patients are taught to irrigate the catheters three times a day with 20 ml of
saline_ The catheters are removed four to six weeks following surgery. The
anastomosis is drained with either Penrose or closed suction drains.
 f-_ _ _____ Roux-en-y "'luna Ioo~

, ',
,,
,,
,, ,,
, ,,
Transverse ,,
mesocolon tacked
to jejunal loop "
. ,,
,, ,,
,, ,
'-
\
,
I
Transverse colon !

......-... ...... - .. ...;...

ltA~-------- End-to-side
jejunojejunostomy
 Transhepatic Stenting For Caroli's
Disease

Operative Indications
aroli 's disease is a rare disorder that is poorly understood. "

C thought by many to have an association with choledochal

disease. Caroli's disease consists of intrahepatic cystic <!ita!2: • G
the biliary tree, is seen in adults, and is thought by some to
congenital. It is usually bilateral (A), but it can involve only the left i" t:!r.i~~
biliary system.
Recent series have suggested that Caroli's disease i seen freqn
association with extrahepatic choledochal cyst disease. Patien geIlff<!lIy
present with symptoms of cholangitis and jaundice, and have an u" 1CR2Slrl
of cholangiocarcinoma.
Some day the presence of Caroli's disease may be an indica .
transplantation. Currently the treatment of choice, if only the left dn<:taJS1S~
is involved, is either transhepatic stenting or left hepatic lobectomy" WI,...,..
disease is bilateral, both the right and left intrahepatic ductal sy!':tP~SCla::::.C.!1l
stented with Silastic trans hepatic biliary stents.
Prior to surgery patients with bilateral Caroli's disease hould have
catheters inserted percutaneously into both the right and left intrabepa;ic
ductal systems, distally into the biliary tree, and through the ampulla "
duodenum.
R ng catheters
Operative Technique
/' atients are explored through a righ t subcostal inci ion, "
/
P extended over to the left. At the time of laparotomy the liver
extrahepatic biliary tree should be carefully examined for evi'ide;:n~G
cholangiocarcinoma. Generally the liver will be normal in aIWear.iCX:E.
The gallbladder is mobilized, the extrahepatic biliary tree is di§!'! :m
and the diatal common duct is looped with a vessel loop. The distal m::::n1OC
duct is then divided with the electrocautery (B).
--?-e-- : ::.:c:=.
:ys:s

Common duct

Ring
catheters

Duoderun

gallbladder
 ollowing division of the distal common duct, the Ring catheters are

F extracted and the distal biliary segment oversewn with a series of

interrupted 3-0 silks.
The proximal biliary segment is dissected up to the common
hepatic duct. The hepatic duct is divided, and the specimen is removed from the
operative field (C).
Since both right and left hepatic ducts will be stented with large·bore,
thick·walled Silastic transhepatic stents, the extrahepatic biliary tree and
ampulla will not accommodate these stents. Therefore the extrahepatic biliary
tree is excised, and after stent placement, is anastomosed to a Roux·en·Y
jejunal loop.
Generally it is preferable to cut off the distal curved tips of the Ring
catheters (D).
c

Division of common
hepatic duct

.-",~ _ _ _ _ __ _ Oversewn distal

common duct

_ _ _ _ _ _ _ Duodenum

Common
hepatic
duct

Ring cathete rs

Ring catheters
[-'3
"
Hepatic a

~ Portal v.

\~\
\. \ .z..L-_ _ Oversewn c £,o
.\ . common dI;c:-

~\\....,.'
 uidewires are threaded through the Ring catheters on both the right

G and left to insure that the pathway is maintained if a catheter should

break or become dislodged in the subsequent manipulations.
The Ring catheters are then backed out from the top of the liver.
Using the guidewires, a flexible choledochoscope can be inserted to examine the
intrahepatic biliary tree (E). This is important since there is a significant
incidence of cholangiocarcinoma in Caroli's disease. Suspicious areas can be
biopsied (F and inset).
 \\----l---G.roe-e

Flexible choledochoscope

,
~-------- C~~moo

EndoscopIC V1ew

-'-__+-_ BIopsy 01
SUSpjnn'lS IesicD

\-- - - - - -- - - - - - GIrl aft:

133
 ollowing choledochoscopy the Ring catheters are reinserted over the

F guidewires down through the common hepatic duct. A #12 Coude

catheter, with the tip amputated, is threaded over the guidewire and on
to the Ring catheter and sutured in place. The Ring catheter is
withdrawn, thus placing the #12 Coude catheter in its tract.
The transhepatic Silastic biliary stent, which is a #16 French catheter, is
then sutured in place over the guidewire into the flange of the #12 Coude. The
Coude is withdrawn, thus placing the Silastic transhepatic biliary stent (G).
The side holes are positioned so that they reside within the li ver and in
that portion of the stent that extends beyond the common hepatic duct (H).
 G

. .--------------_______ G~~

I - -- -- -_ _ __ __ Ring cathelEr

~~----_______ Smrul caooe

catheter
' 1'--:':'1- -- Larger
Goude catheter

_ _ __ _ _ _ _ _ _ Silastic biliary stent

i

./ o,---- j - - Gommon hepa5c

__+-_ Portru v.

_ - j - _ Hepatic a

"7:- -- - Goude
catheter

\ - -_ _ _ _ Guidewire ,

Sllasbc biliary
s ents

' 35
 RoUX-en-y jejunal loop 60 em in length is constructed as previously

A described on pages 48-53. It is brought into the right upper quadrant in

a retrocolic fashion, on top of the second and third portions of the
duodenum, so that it rests without tension adjacent to the biliary tree.
A single-layer anastomosis is performed using interrupted 4-0 synthetic
absorbable material. The posterior layer is placed prior to making an
enterotomy (I). These sutures pass into the submucosal layer of the bowel and
through and through the duct. Each is held in a hemostat.
Once the sutures are all placed, they are secured, and an enterotomy is
performed using the electrocautery (J),
The back row of sutures is divided and the stents are placed in the Roux-
en-Y loop (K).
The anastomosis is completed with an anterior row of interrupted 4-0
synthetic absorbable sutures placed in a simple through-and-through fashion.
All the sutures are placed before they are secured (L).
 ,
, ,
\

Common hepax duct

, I

, ,

Posterior row of
"- anastomosis
r
(

r
-
Enterotomy
~

Roux -en- Y
lejunal loop
o:';l
'/'

I
I

13,
 he Roux·en·Y loop is tacked to the undersurface of the liver with 3-0

T silks to be certain there is no tension on the anastomosis. The Roux·

en·Y loop is tacked to the rent in the transverse mesocolon with
interrupted 4-0 silks to prevent herniation of small bowel (M).
The Silastic transhepatic biliary stents are brought out through stab
wounds in the right and left upper quadrants, sutured to the skin with 5-0
stainless steel wire, and connected to dependent bile bag drainage. The egress
sites of both stents on the superior surface of the liver are drained with Silas tic
sump catheters brought out through separate stab wounds in the right and left
upper quadrants.
It is optional whether or not a large mattress suture is placed around the
exit site of the biliary stent to decrease the likelihood of bile drainage. Since bile
drainage is so infrequent, this suture is often not placed. The
hepaticojejunostomy is drained with Penrose or closed suction drains.
Postoperatively cholangiography is obtained through the stents on the fifth
postoperative day. If there are no bile leaks, the stents are internalized by
placing three·way stopcocks or heparin locks on the ends. The patients afe
taught to irrigate the catheters three times a day with 20 ml of saline.
The stents are left in permanently in patients with Caroli's disease in an
attempt to achieve adequate drainage and prevent episodes of cholangitis and
jaundice. Whether or not transhepatic stenting decreases the likelihood of the
development of cholangiocarcinoma is unknown. The stents are changed as an
outpatient procedure every three or four months.
u

I
i2(
~'---' _ _-"--=-_ _ _ _ HepaticoJeJunoslomy

_ _ _ _ _ _ __ _ _ _ Roux -en-Y JeJunal loop

,
, ,,
\,'
,

Transverse mesocolon
/ ,
tacked to jejunal
loop
,,
,, ,,
\\
\ , '., \
, ,
, ,, ,,
, I ,
Tran sverse colon '1'...... _ -

,\
,

End-to-side
jejunojejunostomy

l~
 uring long-term follow-up, the transhepatic stents provide access for

D repeat choledochoscopy to look for evidence of the development of

cholangiocarcinoma. Guidewires can be placed through the stents
into the Roux-en-Y loop and then the biliary stents removed (N).
Using the guidewire a flexible choledochoscope can be placed through the
skin opening and guided down into the intrahepatic biliary tree. Suspicious
areas can be biopsied (0 and inset).
 .--"~_+ _ _ __ Roux -en -Y
jejunal loop

Guoeewrres _ __ ~_---LI~
""'\\
!
Hepalicojejunoslomy ------~.,....:H

Endoscopic view
01 hepabcojejtJnoslDrrly

I
 edge Resection of Liver and
Regional Lymph Node Dissection for
Carcinoma of the Gallbladder

Operative Indications
arcinoma of the gallbladder is in most presentations an incurable

C disease, and the surgeon's role is mereI.y a palliative one. In many

instances patients with carcinoma of the gallbladder present wt.h
obstructive jaundice, with tumor extending beyond the gallbladder
into the liver, and with involvement of the extrahepatic biliary tree. uch
patients are best palliated by the percutaneous insertion of transhepatic Ring
catheters to decompress the obstruction.
An occasional patient presents with biliary tract symptoms and gaIl:sraaes
and undergoes an elective cholecystectomy. At the ti me of pathological
examination of the gallbladder, an incidental adenocarcinoma will be found.
These patients with "incidental" gallbladder cancer are the only ones with a
reasonable chance for cure.
Occasional patients present between these two extremes, where the
neoplasm still appea rs to be confined primarily to the gall bladder, surroun
liver parenchyma, and regional lymph nodes (A). Al though the vast majority
these patients will not be cured , some clearly will benefit from a regional
procedure.

Operative Technique
atients are explored through a right subcostal incision. At the time of

P laparotomy the diagnosis of carcinoma of the gallbladder may be total!

unsuspected, the patient presenting with biliary tract symptom and
undergoing surgery for presumed calculus disease. The majority of
patients (greater than 90 percent) with carcinoma of the gallbladder have
gallstones.
At the time of exploration the surgeon may be suspicious of the thickened
whitish gallbladder that is firmer than in the typical patient with chronic
cholecystitis (B).
 laIge

Duodenum _ _'--_

~dd er ____~~~~__

Hepabc eXUIe
0/ colon

Duodenum

1-
 Cholecystectomy is proceeded with as previously demonstrated on

A pages 2-9.
If frozen section confirms the clinical suspicion of carcinoma of
the gallbladder, the operative procedure should be extended with a
wedge resection of the gallbladder bed in the liver and a regional lymph node
dissection.
The hepatic flexure of the colon and omentum are dissected free and
retracted inferiorly (C).
Using the electrocautery the margins of the wedge resection can be outlined
on the liver, surrounding the gallbladder bed (D).
 ~~--------- Common hepatic
ducl

Duodenum

Peoa c
"'BXure
of Common
colon
--"'F.---::-"-- - hepatic
Scoring liver _ _ ---.f-___I duct
for wedge
resection

ro
=

I -
 he wedge resection can be performed utilizing a variety of

T techniques. Many surgeons prefer the Cavitron for such

nonanatomicalliver resections. In this example we demonstrate a
technique of utilizing a series of overlapping #1 chromic catgut
mattress sutures to compress surrounding hepatic parenchyma (E).
The actual resection is then carried out with the electrocautery (F).
The chromic catgut sutures compress liver parenchyma, th us achieving
hemostasis without actually compressing the liver to the point where liver
necrosis occurs. T his technique results in a virtually bloodless wedge resection.
Small bleeding points or small bile ducts are further controlled with suture
ligatures.
Overl apping ~_ _ __ _ Wedge resection
mattress sutures of gallbladder fossa

I -
 ollowing the local wedge resection of liver, a regional lymph node

F dissection is carried out, removing all lymph nodes and surrounding

areolar tissue from the bifurcation of the common hepatic duct down to
the distal common duct and medially along the hepatic artery over to
the celiac axis (G,H). Most nodes are actually posterior to the biliary tree.
The area of the liver resection is drained with a Silas tic sump catheter. The
periportal area is drained with Penrose or closed suction drains.
Some oncologists recommend postoperative radiotherapy and chemotherapy
as adjuvant therapy.
SI;e 0/
;edge - ----T- -'-
resec ·on

/
Duodenum

1';"-- - -- Celiac aXIs

1':-- - -- Site of regIonal

lymph nodes
The Liver
Anatomy of the Liver

he liver occupies the entire right upper quadrant of the abdomen, and

T the left lobe extends well beyond the midline into the left upper
quadrant. The liver ranges in weight from 1,200 to 1,600 g in the
adult and is the single largest organ in the body. Its anterior and
superior (diaphragmatic) surfaces are covered with peritoneum. Superiorly, on
either side of the inferior vena cava, but primarily on the right, are the bare
areas with no serosal covering. The smooth topographic appearance of the
anterior and superior surfaces of the liver is interrupted only by the falciform
ligament emanating from the umbilical fissure (A). From the posterior view (B),
the relationship of the caudate and quadrate lobes to the inferior vena cava and
hilar structures can be appreciated. These topographic landmarks are of little
importance when performing an anatomical resection based on the segmental
and lobar anatomy of the liver.
The segmental and lobar anatomy of the liver is determined by the
sequential branching of the hepatic artery, portal vein, and biliary tree as they
enter liver parenchyma in the hilum of the liver. All three of these major
structures follow roughly parallel courses in the liver. In the porta hepatis the
hepatic artery, portal vein, and biliary tree bifurcate just before entering the
liver. This major bifurcation of these three structures divides the liver into right
and left lobes. Once in liver parenchyma the right hepatic artery, right portal
vein, and right hepatic duct bifurcate into anterior and posterior branches,
dividing the right hepatic lobe into anterior and posterior segments. The left
hepatic artery, left portal vein, and left hepatic duct travel on the undersurface
of the liver on the left for several centimeters (the hilar plate) before entering
the liver parenchyma. Once these three structures enter the liver they bifurcate,
with one branch continuing laterally to define the lateral segment of the left
lobe, while the other branch swings back medially to define the medial segment
of the left lobe.
The liver is drained primarily by three hepatic veins that do not follow the
segmental or lobar anatomy of the liver. The right hepatic vein drains most of
the right lobe, and the left hepatic vein drains most of the left lobe. The middle
hepatic vein drains portions of the right and left lobes. The three veins enter the
inferior vena cava at the superior aspect of the liver, just below the diaphragm.
Occasionally the middle vein will join the right or left vein before entering the
inferior vena cava. There are also multiple smaller veins that enter the inferior
\'ena cava directly from hepatic parenchyma, below the three major hepatic
vem.
 Rhe;>aX Y. L hepancy.

Lateral
segment
structures

Posterior
segment
structures

Left lobe

Medial
segment
structures

- -- - - - -- - - Falciform
ligament

' -- - - - -_ __ Hepatic a.

t. ..- -- - -- -__ Portal v.

Gallbladder

Inferior vena cava

Common duct

' - -0
-"
 he gallbladder, arising from the biliary tree via the cystic duct, rests

T in a fossa on the undersurface of the liver. If one draws an imaginary

line from the gallbladder fossa to the junction of the hepatic veins
and the inferior vena cava, that line identifies the junction between
the right and left lobes. The falciform ligament identifies the boundary of the
medial and lateral segments of the left lobe. Topographically, there are no
landmarks that identify the anterior and posterior segments of the right lobe.
A more detailed description of the hepatic segmental anatomy of the liver
has been made by Couinaud. His French description (inset) designates the
caudat~ lobe as segment I. The left lateral segment is divided into superior (II)
and inferior (III) segments. The medial segment of the left lobe is designed as IV.
The anterior segment of the right lobe is further divided into superior (VIII) and
inferior 01) segments, and the posterior segment is likewise further divided into
superior (Vll) and inferior (VI) segments. Although this more detailed
classification allows one to better describe the location of a lesion in the liver or
the boundaries of a nonanatomical resection, it adds little to the classic
segmental description for determining major anatomical resections.
 w.

;".;... m,rerlO( vena cava ,

Caudate lobe _ __ _
.-c
r

LeH lobe
Atght lobe

Falciform
ligament _ _ __ _--'=~

Quadrate lobe _ _ _ _ __ _--\

Portal v.

Common duct

Inferior vena cava

155
 onanatomical Liver Resections

Operative Indications
variety of lesions that require liver resection are of urn
a

A that a formal segmental or lobar resection i not necessary.

include both benign and malignant lesions. Another indicatio:J.
nonanatomical resection is the presence of the lesion in bo:.b
the liver. In unusual circumstances a patient with bilateral lobar 1esi0llS ......~.
be considered a candidate for nonanatomical resection. Also, a pati
previously undergone a segmentectomy or a lobectomy might presen
subsequently with a lesion in the remaining lobe that could be lese r.,1 • a
nonanatomical technique. Finally, patients with cirrhosi , who are
candidates for a formal hepatic lobectomy, may undergo nonanatomical
resections in an effort to preserve liver parenchyma.
Hemangiomas, hepatic adenomas, and fibronodular hyperplasia arear;:~g
those benign lesions that can require a nonanatomical hepatic resection oo=:se:
of symptoms or because of the concern of malignancy. Small or m .
colorectal metastases or hepatomas account for the maj ority of maligrrar:;
lesions that might require a nonanatomicalliver resection.

Operative Technique
variety of incisions can be used , including an upper midline, a .•

A subcostal, an extended right subcostal, or as pictured here, a

subcostal incision.
If one is to remove lesions from both lobes of the liver , ;ide
exposure is required. An upper hand retractor, attached to a frame tha .
anchored to the operating room table, is most helpful in providing €XIXJS::::re.
"-'

abdomen is explored thoroughly to be certain there is no other intra·alxIDilm2!

pathology. If not, one proceeds with the liver resection.
There are two broad categories of nonanatomicalliver resections.
is close to or involves a portion of the edge of the liver, generally it can
removed with a wedge resection. If the lesion is not on or near the anterior
of the liver, then a wedge resection is not possible and a tailored nOillmabr.J~"!!
resection is performed while being certain that there is at lea tal em =ri!J::u:l
normal tissue surrounding the lesion to be removed.
Two lesions are pictured here (A). One is in the lateral segmen of L"1f:Je'"
lobe of the liver and is amenable to a wedge resection. T he second .
, straddles the boundary between the medial egment of the left lobe of 0...;.'"' ....'"
and the anterior segment of the right lobe of the liver. T hi lesion · DOt
amenable to a wedge resection and a nonanatomical resection will hare
tailored to remove it.
 line of resectIon

Gallbladder Stomach

Duodenum
 variety of techniques can be utilized in performing liver resections.

A Several of these techniques will be demonstrated in this chapter. In

this instance the technique of placing large compressing liver sutures
and using the electrocautery will be demonstrated.
After marking out a 1 em margin of normal tissue surrounding the lesion in
the lateral segment of the left lobe of the liver, a series of overlapping horizontal
mattress sutures are placed. These sutures are #1 chromic catgut on large liver
needles. The sutures are more easily placed if most of the curve is removed from
the large liver needle (inset).
The mattress sutures are placed approximately 1 em away from the
previously scored line of resection (B). These sutures are secured so that the
liver parenchyma is compressed, but not cut through or crushed.
Once the entire wedge has been completely surrounded with the chromic
catgut liver sutures, a suture is placed in the liver parenchyma to be removed,
for easier handling (C).
Then, utilizing the electrocautery, the wedge resection is performed. One
has to be careful to maintain at least a 1 em margin surrounding the lesion. If
the previously placed liver sutures have been secured appropriately, the wedge
resection performed with the electrocautery can be carried out with virtually no
blood loss.
Once the specimen has been removed, it is sent to pathology to check for
the adequacy of gross and microscopic margins. In addition, biopsies for
margins may be taken from the remaining liver in any area in which the
margin is suspicious (D).
Generally the electrocautery will be adequate to achieve any additional
hemostasis that is needed, although occasionally suture ligatures are required.
 Falc fform
ligament _ _ _ __ _ _ -:-

Stay suture
 The llEXI s:e;J -- be
<= be b)- a series of m-erlappmg liver st_~es c::ffi:l~~ E} C!:~1i:"
ca:gut on large liver needles_ It - more diffirutt to pIare
around a lesion £hat cannot be resected as a wedge. TIle St:l:!mS a;::e frl;H far
hemosta i and for preventing bile leaks, but if the ult:ra!;o;tic cssa::3"
u ed, many urgeon would not use them.
A stay suture is placed in the liver parenchyma [0 be re9::cEd.
retraction (F).
Using the ultrasonic dissector, the lesion i resected, aI.lo\\ -
1 cm margin of normal liver around the lesion. A izable ,-e:,:;eJS
radicals are recognized, they are ligated on the liver ide and clipped
specimen side (G and inset).
It is necessary to employ the suction adjacent to the ultrasOnic crs:se:coc
Blood loss may be somewhat increased, compared to u ing the eI'eCInx=:oy
liver sutures are not placed first. This technique, however, allows one
identify all sizable vascular and biliary structures and to control them sec~:ly_
The lesion is sent to pathology for adequacy of gross and miooscopic
margins. Both areas of resection are drained with Penrose, clo ed -
sump drains.
 Gallbladder Stay suture

Ultrasonic
dissector

Overlapping
mattress

1
Resection of I.a:f-.a-,;o~
Lobe of Liver

Operative Indications
he lateral segment of the left lobe of the liver i the only

T the four classic segments of the liver that i easily resected

anatomically. The lateral segment is represented topograpbicaDy
that liver parenchyma lateral to the falciform ligamenl Any -
benign or malignant, that resides in the lateral segment of the left lobe of.
liver can easily be resected. Hemangiomas, hepatic adenoma , and fi.bJ:w0Ct~
hyperplasia are the benign lesions that one would encounter most frollUfm'!_?
with colorectal metastases and hepatomas being the most common Iml~:;z:::t
lesions. The morbidity and mortality following resection of the lateral sq;u;,;~
of the left lobe of the liver is so low that many surgeons will proceed -
resecting this portion of the liver if a lesion is unexpectedly encountered
time of laparotomy, even if the possibility of a liver resection ha not bee:l
discussed preoperatively with the patient.

Operative Technique
atients undergoing anatomical liver resections can be approached

P through a variety of incisions. A right subcostal, an extended -

subcostal, a bilateral subcostal, or a midline incision (a pictured
are all acceptable incisions.
Whenever a major liver resection is anticipated, the chest should be
prepped and draped so that the incision can be extended with a median
sternotomy if necessary. Although rarely necessary, occasionally adequate
exposure of the hepatic veins is greatly facilitated by the addition of a -
sternotomy. This would only rarely be necessary when one is resecting the
lateral segment of the left lobe, since the hepatic veins are not di ected
In this instance, the lesion is confined to the lateral segment of the 1
of the liver (inset). In performing this resection, no hilar structures or hep2dic
veins will be exposed or divided.
Once the incision is made and the abdomen adequately explored so
has determined that the only lesion present is in the lateral egment of the
lobe, one proceeds with the dissection. Exposure ca n be greatly facilitated fur"
liver resections by the utilization of the upper hand retractor, which aIlow
constant retraction of both costal margins from a frame attached to the
operating room table.
The falciform and triangular ligaments are taken down (A).
 -="L-'---- - - - + - - line 01. Ii.

---------------4--F~~~

~---------_I-- p v.
.....'-"-_ __ _ _ _ Biliary tree

[ -:-'-_ _ _ __ Inferior vena cava

Coronary ligament

Falciform
ligament
 he line of resection, just lateral to the falciform ligament, is scored

T with the electrocautery (B). At least a 1 cm margin should be

allowed.
If one has adequately mobilized the left lobe of the liver, by
taking down all attachments, parallel rows of #1 chromic catgut sutures can
easily be placed in an overlapping horizontal mattress fashion (C). A row of
sutures is placed on each side, approximately 1 cm from the anticipated line of
resection. Chromic catgut sutures wedged on large liver needles are used. The
sutures are more easily placed if most of the curve is taken out of the liver
needle. Two or three such mattress sutures are placed on either side of the line
of resection, starting at the anterior edge of the liver.
Using the electrocautery, the parenchyma is then divided (D). If the sutures
have been placed properly, division of the parenchyma can be performed with
virtually no blood loss. The sutures are secured so that liver parenchyma is
compressed, but not cut through or crushed.
 r - -- - - Overlapping mattress std!Jres
r -- -- Falciform ligament
r-- - Line of resection

Falciform
ligament

' - - - D,v,ded
gas1rohepabc
ligament

Stomach

Gallbladder

cautery/.

I
 wo or three additional liver sutures are placed on each side of the line

T of resection, and then additional parenchyma is divided (E). The

overlapping position of these liver sutures is depicted in the inset.
Additional sutures are placed, and additional parenchyma is divided
until the liver is completely divided and the lateral segment removed.
The remaining surface of the medial segment of the left lobe of the liver
should be dry and without bile leaks. Occasionally additional hemostasis is
required, using the electrocautery. Figure-of-eight sutures may also be used to
secure small bleeding points, or bile leaks. Some surgeons also feel that tacking
the omentum to the resected surface is helpful in containing bile leaks.
One may choose to reattach the falciform ligament (F) to increase the
stability of the remaining portion of the liver in the abdomen. This usually is
not necessary following removal of only the lateral segment of the left lobe. The
resected surface of the liver is drained with Penrose, closed suction, or sump
drains.
 Sagittal view

I
Overlapping
_______+ __ mattress
sutures

i
,

c,
Falciform
ligament

Spleen _ _--'-~

*1J-l,1,.,..,~- Resected surtace

of liver

~_ _ Gastrohepatic
ligament

Siomach
 R ection of Left Lobe of Liver

Operative Indications
f a benign or malignant lesion requiri ng re ection i confined toei!!1er

I medial segment or the medial and lateral segment of the left lobe of
liver, it is amenable to a left hepatic lobectomy. Large hemangiUill4!i,
hepatic adenomas, and fibronodular hyperplasia are the benign tes-ions
most commonly require left hepatic lobectomy. Solitary or multiple coIom:taJ
metastases to the left lobe of the liver or unifocal or multifocal hepatOllJaS
confined to the left lobe of the liver are the most common malignant lesiJ[);JS
require left hepatic lobectomy. Trauma is a rare indication for left hepatic
lobectomy.

Operative Technique
variety of incisions can be used for a left hepatic lobectomy. A -

A subcostal, an extended right subcostal, a bilateral subcostal, or an

upper midline incision are all acceptable incision .
In addition, the patient's chest should be prepped and clrataJ.
that if necessary the incision can be extended to include a median emotocy.
This will only rarely be necessary, but occasionally if the hepatic veins are
difficult to expose in a deep-chested individual with a narrow costal rnmgin, a
median sternotomy can be most helpful in obtaining adequate exposure.
In performing a left hepatic lobectomy, the left hepatic duct, the left bra:::JdJ
of the hepatic artery, and the left branch of the portal vein are all divided.
addition the left hepatic vein is divided (inset).
After the abdomen has been adequately explored to be certain that th£~ axJfy
lesions present are in the left lobe of the liver, one proceeds with the left ~mi:

j lobectomy. Exposure is markedly enhanced by the use of the upper hand

retractor. This allows constant retraction of both costal margin with ret:r2fm:s
suspended from a frame fixed to the operating room table.
The falciform and triangular ligaments are divided in the process of
mobilizing the left lobe of the liver (A).

ICV
 Une of resect.on _ _ _ _--I

"'-_ = >""-'----___+_ Hepatic a

"'~--- ____-+- Falciform ligament

~---_ _ _ _ _ _+Portal v.

-"'-- -- - - - - -- t- Biliary tree

_-=L - -- - - - - - - - + l n f erior vena cava

Coronary ligament

Falciform
ligament

L.lobe
of liver

Lesion
 he line of resection will pass through the bed of the gallbladder.

T Therefore, the gallbladder is mobilized after identifying the cystic

duct and ligating and dividing the cystic artery (B). It is not on ly
necessary to remove the gallbladder from the line of resection
between the right and left lobes of the liver, but removal of the gallbladder also
markedly improves exposure of the porta hepatis.
The bifurcation of the biliary tree is identified and dissected, and the left
hepatic duct mobilized (C). Several centimeters of the left hepatic duct generally
traverse the undersurface of the left lobe of the liver in the hilar plate before
entering liver parenchyma, and thus a long segment of left hepatic duct can be
mobilized.
The left hepatic duct is doubly ligated with 3-0 silk and divided. This
allows access to the left branch of the hepatic artery. The hepatic arterial
anatomy is variable, and not uncommonly the left hepatic artery arises from the
left gastric artery; in most instances, however, it arises from the common
hepatic artery and is located between the left hepatic duct and the left branch of
the portal vein.
The left branch of the hepatic artery is identified, mobilized, triply ligated,
and divided (D). This exposes the left branch of the portal vein. It is necessary
to dissect the bifurcation of the portal vein, so that one is certain when dividing
the left branch of the portal vein that the bifurcation is not encroached upon.
Once the left branch of the portal vein has been widely mobilized, it is
clamped proximally and distally with straight Cooley clamps. The left branch of
the portal vein is divided and oversewn with a continuous 4- 0 synthetic
non absorbable suture (E). That portion which extends beyond the Cooley
clamps is sutured, first with a continuous horizontal mattress stitch, and then
run back with an over·and-over suture.
If the distal end of the portal vein on the specimen side is long enough, it
may merely be ligated. If not, it is closed in a similar fashion with 4-0 synthetic
non absorbable suture.
 Hepatic duct
'----~'rr--- bifurcation

~---1I\S--- Portal v.

, of portal v.---~=-l
R. bran ch

Cystic duct
stump
Divided
I. hepatic Hepa 'c a
duct

L branch
of portal v.

L. hepatic a.

Divided
'- branch
of
portal v.
 t has been our practice to not only divide all hilar structures to the lobe to

I be resected prior to dividing hepatic parenchyma, but also to divide the

appropriate hepatic vein or veins. This is an optional step. Many surgeons
after dividing the hilar structures will divide hepatic parenchyma and only
control the hepatic vein or veins as the final step in removing the lobe.
Generally, however, we divide the hepatic vein prior to dividing hepatic
parenchyma.
With the aid of the upper hand retractor, the hepatic veins usually can be
adequately exposed at this point of the procedure. The liver is retracted
caudally, and the suprahepatic inferior vena cava is dissected to expose the
hepatic veins. The left hepatic vein is easily identified and easily dissected (F).
Additional length can be obtained on the left hepatic vein by dissecting down
into hepatic parenchyma. .
Once an adequate length has been obtained, the left hepatic vein is doubly
clamped with acutely curved Cooley clamps. The left hepatic vein is then
divided.
The ends of the left hepatic vein are oversewn in a fashion identical to the
control of the portal vein. Using 4-0 synthetic nonabsorbable suture, each end of
the hepatic vein within the Cooley clamp is oversewn, first with a running
horizontal mattress suture, and then back with an over·and·over suture (G).
The clamps are then removed.
 cava

v.

Diaphragm

~~__________ ~Ee"

L. lobe
of liver

l c.oP..INr.(E,
~","'i>ON<'

!'!L-~- Divided
L hepatic v.
 he left lobe is now devascularized. The hepatic arterial and portal

T venous inflow and the hepatic venous outflow have all been
interrupted. Generally there is an obvious demarcation between the
devascularized left lobe of the liver and the vascularized right lobe.
This line of demarcation will pass from the gallbladder fossa up to the region of
the suprahepatic inferior vena cava.
The hepatic parenchyma is then divided. This can be performed utilizing a
variety of techniques, with or without the ultrasonic dissector. In the following
sequence we demonstrate the technique utilizing liver sutures and the
electrocautery.
The proposed line of resection is first scored with the electrocautery (H).
Starting at the anterior lower liver edge, horizontal mattress sutures of #1
chromic are placed 1 em on either side of the line of resection (I). Placement is
facilitated if most of the curve is removed from the large liver needle.
Two or three sutures are placed, and then hepatic parenchyma is divided
(J). If the liver sutures have been secured properly, virtually no bleeding is
encountered. The sutures have to be snugged down to compress liver
parenchyma, but not to cut through capsule or crush parenchyma.
After liver parenchyma has been divided, two or three additional sutures
are placed, and more parenchyma is divided (K). These liver sutures are easily
placed until one approaches the dome of the liver. At this point sutures often
can only be placed anteriorly on the diaphragmatic surface of the liver and wil
not pass all the way through posteriorly.
Simple compression of hepatic parenchyma at the superior aspect of the
right lobe of the liver will adequately achieve any hemostasis that the liver
sutures do not achieve. Utilizing these sutures and the electrocautery, the rigl
and left lobes can be divided with virtually no blood loss.
 ,.I . . . . K)~
I of .e'

J
/

Overlapping
mattress
sutures

OJ /
 nce the hepatic parenchyma between the right and left lobes has

O been completely divided, the specimen is removed (L). Any additional

hemostasis that is required is achieved with the electrocautery or
with suture ligatures. Some surgeons feel that tacking the omentum
to the resected surface is helpful in containing bile leaks.
The specimen (M) is sent to pathology to check the adequacy of the gross
and microscopic margins.
The resected surface of the liver (L) is drained with Penrose, closed suction,
or sump drains.
 f#-- - Caudate
lobe

Stomach

Pes....ccted ---.!,~~-'
surface of
;va,

Resected left lobe

L. hepatic v. _ __ __ _ _

Resected surfa'oe _ __ _ __ _ -l~~~ L.L'- "'l~.'

of liver

Divodec
portal
strudu(es _ _ _ _ _ _ _ _ _L--L~
Resection of Right Lobe of Ii, er

Operative Indications
he right lobe of the liver comprises approximately 60 (brew: '

T parenchymal cell mass of the liver and thu i a frequent .

benign and malignant lesions that are amenable to lese ;ion •
most common benign lesions requiring right hepatic Iobect~:y
include large capillary hemangiomas, hepatic adenomas, and benign
fibronodular hyperplasia. The most common malignant lesions ind
or multiple colorectal metastases and solitary or multiple hepatullld:S,
confined to the right lobe. Trauma is rarely an indication for righ he;Ja .
lobectomy.

Operative Technique
he same variety of incisions available for left hepatic lobecmrr.

T also used for right hepatic lobectomy. Exposure i somewhat

critical for right hepatic lobectomy than for left hepatic lo~ •
We prefer an upper midline incision , prepping the anterior en
that the incision can be extended into a median sternotomy if necessary. .
rarely necessary, but in an occasional deep-chested individual with a n:n.,.....,..,
costal margin, exposure of the hepatic veins may require exten ion of the
InCISIon.
Other acceptable incisions are a right subcostal incision or an ~'UeIlded
right subcostal incision, with the possibility of extension in the midline up
the xiphoid. A bilateral subcostal incision can also be used. In addition, the
chest should be prepped so that a median sternotomy can be added if nere;.s:ary.
A lesion located in the right lobe of the liver will require dis ection of ....
porta hepatis with division of the right hepatic duct, right hepatic artery. an
right branch of the portal vein. In addition, the right hepatic vein will also be
divided (inset).
After the incision is made, the abdomen is explored to be certain there ·
other pathology that would preclude right hepatic lobectomy. Exposure is
markedly enhanced by use of the upper hand retractor. This allows for
optimum retraction of both costal margins with the aid of retractors us:peil
from a frame anchored to the operating room table.
The falciform ligamen t is taken down, leaving equal amount attached
the abdominal wall and liver , so that it can be easily reapproximated at
of the procedure (A).
Lme o;
resectIon

~-+t-----,=.L---+- Hepatic a

- -- - -- ----+- Falc· oon Iigamenl

!!L_ __ _ __ _ _ + _ Portal v.
__

~-----------I__ Biliary tree

~+------------__l- Inferior vena cava

Gallbladder

Falciform ligament

I
 he diaphragmatic and retroperitoneal attachments of the right lobe of

T the liver are divided, and the right lobe of the liver is rotated medially
(B). These attachments are often areolar in nature and relatively
bloodless. Occasionally the tumor is adherent to the posterior aspect
of the diaphragm, and it is necessary to include a segment of diaphragm with
the specimen.
 k - - - - -- R. lobe 0/

'--_ _ _ _ ____ Lesion

Bare area of liver

Triangular
ligament
 he line of division between the right and left lobes passes through the

T gallbladder fossa. Therefore it is necessary to remove the gallbladder.

In addition, this greatly aids in the exposure and dissection of the
porta hepatis.
The cystic artery is identified, doubly ligated, and divided (C). The cystic
duct is then identified, doubly ligated, and divided (D). If there is any question
concerning the anatomy in this region, the cystic duct should be merely looped
with a vessel loop and the gallbladder taken down from above.
Once the cystic artery and duct have been ligated and divided, the
gallbladder is mobilized out of the liver bed (D). This improves access to the
porta hepatis, which is dissected next.
The right hepatic duct is identified, triply ligated, and divided (E). Great
care must be taken at this point to ensure that the bifurcation of the biliary tree
is not encroached upon. Anatomy is extremely variable in this region , and
frequently the two segmental ducts to the right lobe of the liver come out
separately, actually creating a trifurcation. If that is the case, each segmental
duct has to be dissected, ligated, and divided separately.
Once the right hepatic duct is divided, this allows exposure of and access to
the right hepatic artery and right branch of the portal vein. Again, anatomy in
this area can be extremely variable and great caution should be used. In
approximately 20 percent of patients, the right hepatic artery arises from the
superior mesenteric artery. If this is determined preoperatively by angiography,
it is helpful information at the time of surgery and allows the surgeon to
proceed with ligation of the right hepatic artery without looking for the take-off
of the left hepatic artery.
Once the right hepatic artery is identified, it is triply ligated and divided (F).
The right branch of the portal vein is dissected next. Once an adequate
segment of right portal vein has been cleaned, it is doubly clamped with straight
Cooley clamps (G). The bifurcation and left branch of the portal vein have to be
identified before dividing the right portal vein, to be certain the bifurcation and
left branch of the portal vein are not encroached upon.
Once the portal vein is divided, it is oversewn with a continuous 4-0
synthetic nonabsorbable suture. The suture is run in one direction in a
horizontal mattress fashion and then back in an over-and·over stitch. If the
segment is sufficiently long, the end of the portal vein on the specimen side can
be merely ligated.
 Divided cystIc a.

__,.c"l.>l~---- R. hepatic a.

Cystic duct

~\

R. hepatic duct

Gallbladder_-f-_~
fossa

f ' - - - - Hepatic a.

Ii-T- - - Common duct

R. hepatic a.
Divided
r. hepatic duct

C-.._ _ _ Cystic duct

stump

Divided
r. branch of
portal v.

c.o,,-,.,.N £,
l.,s"'''l)of'l.So

--
, ,.
 fter the hilar structures have been dissected and divided, we prefer to

A control the hepatic veins before dividing hepatic parenchyma. Other

liver surgeons prefer to divide the hepatic parenchyma between the
right and left lobes first, controlling the major hepatic veins as the
last step before removing the specimen. We feel that better hemostasis is
achieved and a greater degree of safety ensured if the hepatic veins are
divided first.
The liver, which earlier had been mobilized out of the retroperitoneum and
away from the diaphragm, is once again rotated medially.
The entire length of the inferior vena cava posterior to the liver is
dissected. There are several small hepatic veins that pass directly from the vena
cava into liver parenchyma. These are carefully dissected, doubly ligated, and
divided (H).
The right hepatic vein is then identified and dissected. This dissection can
be somewhat tedious and should proceed very cautiously. An injury to the
hepatic vein at this point can result in significant blood loss. If the dissection
proceeds cautiously, however, the right hepatic vein ca n always be identified
and dissected. The hepatic vein should be mobilized down into hepatic
parenchyma for a great enough distance so that two acutely-curved Cooley
clamps can be applied.
The right hepatic vein is then divided, and each end is oversewn with a
continuous 4-0 synthetic non absorbable suture run in one direction in a
horizontal mattress fashion and then back in an over-and-over suture (inset). If
a sufficiently long segment has been dissected free, the hepatic vei n on the
specimen side can be merely ligated.
 R hepa!lc v

Infeoor vena cava _ _ _,

Bare area

~,------ Rlobed

~~~~------- ~

~ _ __ _ SmaJ""",*

Infenor vena cava _ _ _ __ -.:!-:-:p!-_ _ .....,...,

R. hepatic v. -------I-?---4t.;~
 nce the hilar vessels have been divided and the hepatic vein identified

O and divided, a clear demarcation is visible between the

devascularized right lobe and the vascularized left lobe. A variety of
means are available to divide the parenchyma between the right and
left lobes. In this instance the ultrasonic dissector is used.
Stay sutures are placed on either side of the proposed line of division, which
has been marked with the electrocautery (I). The stay sutures aid in retracting
and exposing parenchyma to be divided with the ultrasonic dissector (I).
Sizable vascular and biliary structures are easily identified. The structures
on the left lobe side are controlled with either ligatures or suture ligatures,
whereas on the specimen side ligaclips are applied (inset). As the dissection
proceeds toward the dome of the liver, sizable branches from the middle hepatic
vein may be encountered.
 Ultrason ic
dissector

Stay suture
 nce the parenchyma has been completely divided, the specimen is

O removed from the operative field. Additional hemostasis is achieved

with the electrocautery or with suture ligatures, as required. Some
surgeons feel it is helpful in containing bile leaks to tack the
omentum to the resected surface.
It is important following a right hepatic lobectomy to reconstitute the
previously divided falciform ligament, to insure stability of the liver mass left
behind (J). It is possible for the segment to torque and to impair vascular inflow
and/or outflow.
The specimen (K) is sent to pathology to check for the adequacy of gross
and microscopic margins. The resected surface of the liver is drained with
Penrose, closed suction, or Silas tic sump drains.
 R lei'

:lMded:

R branch of porta l v.

R hepatic duct and

Resected right lobe

~-_ R hepaIic w.

lJ~""f------ R ,.."
smacedila

Lesion _ _ _ "
Divided
/L--- - -- - portal sIrucIures

~_ _ __ ____ G al~~

189
 Kesec:Oon of Ri'g ht Lobe 0
I •

edial Segment of Left to oe

I

Trisegmentectomy)

Operative Indications
f one adds removal of the medial segment of the left lobe of the

I right hepatic lobectomy, approximately 75 percent of the pan:ocbymal

mass of the liver is removed. Hepatic reserve i uch that if one IeaiKS
to 20 percent of normal liver behind, patients can tolerate the opel2tive
procedure, and liver regeneration will proceed from the remnant with 00
difficulty. Thus removing the anterior and posterior segments of the -
along with the medial segment of the left lobe, or trisegmentectomy,
tolerated in most individuals in whom the liver remnant, the lateral sel]~:d: .ri
the left lobe, is normal.
T his procedure is performed for benign and malignant lesions thatoa:~~2
large part of the right lobe and extend into the medial segment of the left
or just as commonly for lesions that occur midway between the right and
lobes. Benign lesions include large capillary hemangiomas, hepatic aooJQ;:;:=.
and fibronodular hyperplasia. The most common malignant lesion wouJdbe
•
hepatoma or metastases from a colorectal tumor. A rare indication fm-ID<!SSiNe
liver resection is trauma.

Operative Technique
aximum exposure is required in performing a trisegm _

M We prefer an upper midline incision with the chest prepp9i

the incision can be extended into a median sternotomy if
necessary. Even though this is rarely necessary, occasinnanr- "-
deep-chested individual with a narrow costal margin , median sternoto;:ny
required to achieve adequate exposure of the hepatic veins.
:~

Other acceptable incisions are a right subcostal, a right sulxnstalex,1m:e:

over on to the left side, or a right subcostal extended in the midline up tol~
xiphoid. A bilateral subcostal incision can also be used. In these in..<:tanres-
chest should also be prepped so that if a median sternotomy i Deo'sSa" .-
be rapidly performed.
In performing a trisegmentectomy, the right hepatic duct, the righrooa:a:il
I of the hepatic artery, and the right branch of the portal vein are aD diY-idea..
I
I addition, the right, and often the middle hepatic veins are divided (imeJ)
I
I • After entering the peritoneal cavity, the abdomen is carefully extllmmlD<
I other evidence of disease that would preclude the performance of a
trisegmentectomy. The upper hand retractor is used. Thi allows ma!Xi::::;:a

/ '" retraction of both costal margins by retractors connected to a frame

to the operating room table.
The liver i mobilized by taking down the falciform and triaoguJar
ligaments (A). At this tage one would also mobilize the right lobe out .
retroperitoneum and away from the posterior a peet of the diapbtagm
certain that local tuJ.IIOC extension does not preclude the hepatic .em I jU;L

190
l esion _+--1-+'- hrt-"""':----~---I-- line 01 "",,:Ii:liIlD+'
rei

~K\;~.,,~--+- Hepatic a
p------------l- Falcilorm . . . . . .
~---------+- Portal v.
~~-------+-- Biliaty tree

~~~------~~~========================r-- Inf~venacava

Falciform ligament

Stomach

'/--;99'------ TI<l1iSVBSe
colon

Gallbladdef
 nce it has been determined that a trisegmentectomy is feasible, the

O portal structures are dissected. The cystic artery is identified, doubly

ligated, and divided. The cystic duct is identified, doubly ligated, and
divided (B).
It is not necessary to remove the gallbladder from the gallbladder fossa , as
one would do at this stage with a right hepatic lobectomy. With right hepatic
lobectomy the line of parenchymal resection passes through the gallbladder
fossa, and it is necessary to remove the gallbladder. With a trisegmentectomy
the line of resection passes medial to the gallbladder fossa, and it is sufficient to
merely divide the cystic artery and duct. Division of the cystic artery and duct
improves access to and identification of hilar structures.
The right hepatic duct is dissected free, triply ligated, and divided (C). One
has to be careful to dissect out the hepatic duct bifurcation to be certain that the
division of the right hepatic duct does not encroach upon the hepatic duct
bifurcation. Occasionally the anterior and posterior segmental ducts arise at the
bifurcation, creating a trifurcation. If this is the case, it is necessary to divide
the anterior and posterior segmental branches to the right lobe separately.
Once the right hepatic duct has been divided, the right hepatic artery is
identified, cleaned, triply ligated, and divided (D). Hepatic arterial anatomy is
extremely variable. Approximately 20 percent of the time the right hepatic
artery arises from the superior mesenteric artery. It is helpful to know this
preoperatively from angiography, because it allows the surgeon to go ahead and
ligate the artery without looking for the take-off of the left hepatic artery. The
right branch of the portal vein is then easily identified and cleaned.
It is important to dissect back to the bifurcation and clearly identify the left
branch of the portal vein before dividing the right branch of the portal vein.
Straight Cooley clamps are placed across the right portal vein, while being
careful not to encroach upon the bifurcation with the most proximal clamp (E).
The two ends of the divided portal vein are then oversewn with continuous
4-0 synthetic nonabsorbable material run in one direction in a horizontal
mattress fashion and then back in an over-and-over fashion. The divided end of
the portal vein on the bifurcation has already been oversewn (E).
The portal vein on the specimen side is now oversewn in a similar fas hion.
If this portion of the portal vein is long enough on the specimen side, it can
merely be ligated with a 2-0 silk.
Since the line of parenchymal division occurs between the medial and
lateral segments of the left lobe of the liver, it is necessary to take down the
hilar plate and to dissect the left hepatic duct, the left hepatic artery, and the
left branch of the portal vein away from the under surface of the medial
segment of the liver. These structures generally do not enter liver parenchyma
of the left lobe until the region of the falciform ligament, the division between
the medial and lateral segments. Cleaning this area allows one ready access to
divide liver parenchyma between the medial and lateral segments of the left lobe
of the liver (F)-
 Divided
cystic a.

R hepatic a

Cystic duct
Common
I
duct

Divided
cystic duct
J!.

Line of
resection

R. branch of
portal v.

I
D'\i ded r branch
of pona, v
 he hepatic veins are divided next. The right lobe of the liver is

T rotated medially out of the retroperitoneum and away from the

diaphragm. This requires division of peritoneum and soft areolar
tissue that generally contain few vessels. Small hepatic veins that
enter the inferior vena cava directly from liver parenchyma, below the three
major hepatic veins, are identified, cleaned, doubly ligated, and divided.
All three major hepatic veins are then identified and dissected free. This
anatomy is somewhat variable, but most commonly there are three distinct
major hepatic veins. The right hepatic vein is encountered most laterally in the
dissection, and generally can be identified quite easily, cleaned, and looped with
a vessel loop.
A sufficient length is cleaned so that two acutely-curved Cooley clamps can
be applied (G). The clamps are placed far enough apart so that once the vein has
been divided, enough vein extends beyond the clamp to be oversewn. Both ends
are oversewn with a continuous 4-0 synthetic nonabsorbable suture run in one
direction in a horizontal mattress fashion and then back in an over-and-over
stitch
The middle hepatic vein is also identified and can be cleaned and divided
between acutely-curved Cooley clamps; the ends are oversewn in a fashion
identical to that used for the right hepatic vein (H). More commonly, however,
the middle hepatic vein is not divided at this stage, but its branches are merely
divided as the parenchyma between the medial and lateral segments is divided
subsequently.
At this stage we always divide the right hepatic vein, but division of the
middle hepatic vein during a trisegmentectomy at this stage is optional.
 .-
Ji

19!
 he right lobe of the liver has now been completely devascularized.

T The right branch of the hepatic artery, the right branch of the portal
vein, and the right and middle hepatic veins have been divided. The
line of demarcation is between the right and left lobes of the liver and
passes generally from the gallbladder fossa up to the suprahepatic vena cava. In
this instance, since a trisegmentectomy is to be performed, the line of division of
hepatic parenchyma will not be along the line of demarcation, but will be
between the medial and lateral segments of the left lobe of the liver.
The proposed line of resection is scored with the electrocautery. Stay
sutures are placed on either side of the proposed line of resection. A variety of
techniques are available to divide the hepatic parenchyma. In this instance the
ultrasonic dissector is used. The line of division generally is close to or at the
falciform ligament (I).
The ultrasonic dissector is used to divide and separate parenchymal tissue
so that one can easily identify all substantial vascular and biliary structures.
The significant vascular and biliary structures are cleaned, and on the specimen
side are ligated with a ligaclip. On the side to be retained, the structures are
either ligated or suture ligated (inset).
 Stomach

Hepatic flexure
of colon
dissector
 he liver parenchyma between the medial and lateral segments

T of the left lobe of the liver has been completely divided and the
specimen removed from the operative field. The specimen (K)
is sent to pathology to check for the adequacy of the gross and
microscopic margins.
Additional hemostasis is achieved using the electrocautery or suture
ligatures. Some surgeons feel it is helpful in containing bile leaks to tack the
omentum to the resected surface.
It is very important to reconstitute the divided falciform ligament (J). The
lateral segment of the left lobe of the liver is extremely mobile, being attached
only by the portal structures and the left hepatic vein. This segment can easily
torque and interfere with blood flow. Reattaching the falciform ligament
stabilizes this segment.
The resected surface of the liver is drained with Penrose, closed suction, or
Silastic sump drains.
 R Jed
Wenar suface
Diapli ayah
vela cava 01_ FaIcibm 1i9aili"'~

Tnsegmentectomy
specimen
R. and
middle hepatic veins

Resected
surface of liver

Divided
/ -_ _ _ _ portal
structures

'---_ _ Gallbladder

199
Insertion of Infusaid Pump for
Hepatic Artery Infusion

Operative Indications
ver the past decade evidence has accumulated that infusion d

O chemotherapeutic agents directly into the hepatic artery can OJiIhd

colorectal metastases to the liver in a significant proportion of
patients, although prolongation of survival has not been dearly
demonstrated. Nevertheless, patients with multiple colorectal metastases to
both lobes of the liver, who are not candidates for hepatic resection, may be
managed effectively with hepatic artery infusion. Most oncologists feel that
" IIl2.l
patients with metastatic disease confined to the liver are candidates for n;gja]
perfusion. If there is evidence of other intra-abdominal or extra-abdominal
tumor dissemination, patients are not candidates for Infusaid pump insertion..
a patient is considered a candidate for Infusaid pump insertion, celiac axis and
superior mesenteric artery angiography is performed to determine hepatic
arterial anatomy.

Operative Technique
he patient is explored through an upper midline incision. The

T abdomen is carefully examined to be certain there is no evidence d

tumor outside the liver. If not, the hepatic arterial blood supply is
exposed to insert the perfusion catheter. The Infusaid pump is
inserted into a subcutaneous pocket created through a transverse incision in the
left mid abdomen (inset).
Hepatic arterial anatomy is quite variable. The anatomy will have been
determined prior to laparotomy, by angiography. In this instance classic hepatic
arterial anatomy is present, with a common hepatic artery arising from the
celiac axis, which gives off a right gastric artery and the gastroduodenal artery
prior to bifurcating into the right and left hepatic arteries (A).
The common hepatic artery, the gastroduodenal artery, and the hepatic
artery are all dissected and encircled with vessel loops.
It is important to divide all arterial branches arising from the common
hepatic and hepatic arteries that do not supply the liver to avoid any chance of
the chemotherapeutic agents entering vessels perfusing structures other than
the liver. If this is not successfully performed, significant gastritis and
duodenitis will result from exposure to the chemotherapeutic agents infused.
All branches arising from the common hepatic, hepatic, and gastroduooenal
artery, including the right gastric artery, have been identified, ligated, and
divided (B).
 Lgaslica
tiepaka

r
Rhepabc
Common hepabc dud
Cystic

Splenic a

00
Gallbladder Stomach

Gastroduodenal a. R. gastroepiploic a

Superior
pancreaticoduodenal a,

Gastrohepatic ligament
Lesions
Hepatic a.
Gallbladder
fossa
or- ..Ii

Stomach

Com mon duct

 nce the arterial anatomy has been identified, dissected, and made

O ready for catheter insertion, the subcutaneous pocket is created. A

transverse incision is made on the left side of the abdomen at
approximately the level of the umbilicus and deepened down through
subcutaneous tissue to fascia overlying the rectus muscle (C).
The pocket is then created with a combination of blunt and sharp
dissection, with liberal use of the electrocautery (inset 1). The Infusaid pump is
inserted for fitting on several occasions, so the pocket is created the exact size
required for the pump and is not too large or too small. Because the pump will
be accessed by percutaneous needle puncture to both the reservoir and the side
port, it is important to avoid any suture line traversing the device.
Once the pocket has been created, the Infusaid pump is inserted (D), and a
tonsil clamp is passed from within the peritoneal cavity through the rectus
muscle and fascia into the most superior aspect of the pouch (inset 2). The
Infusaid tubing is grasped with the clamp, and drawn into the peritoneal cavity.
The Infusaid pump is anchored to the rectus fascia with sutures of 3-0 silk,
utilizing the loops on the pump. The pocket is then closed with an interrupted
layer of 3-0 synthetic absorbable sutures in the subcutaneous layer and either
subcuticular or skin sutures (inset 3).
=tJiicus _ _

Anterior
_ _-"-_ __ superior iliac
spine

Subcutaneous
poe el_

Catheter

/ 2

Subcutaneous
pocket
Catheter

Pu mp

3
 he Infusaid pump tubing courses through the peritoneal cavity on top

T of the omentum, on top of transverse colon and stomach, and is

inserted into the gastroduodenal artery. The length of the tubing
allows a gentle loose curve, without kinks or sharp bends (G).
The gastroduodenal artery is ligated distally just above the stomach and
duodenum. The common and main hepatic arteries are then both occluded with
a DeBakey clamp (E).
The infusion catheter is inserted into the hepatic artery via an arteriotomy
in the ligated gastroduodenal artery. It is positioned such that the tip is just into
the hepatic artery. The catheter is then secured with two ties of 3- 0 silk (F).
The catheter is further secured to the more distal aspect of the ligated
gastroduodenal artery with ties that pass around both the catheter and the
gastroduodenal artery (F).
Replaced right hepatic arteries, arising from the superior mesenteric artery,
are present in approximately 20 percent of all individuals. If this has been
identified prior to surgery, the surgeon should be prepared to insert a catheter
into the hepatic artery, from which the left hepatic artery arises, through the
usual access via the gastroduodenal artery (H). In addition, a second catheter is
inserted into the replaced right hepatic artery through a purse string that does
not occlude the right hepatic artery (H). There are many anatomical variations,
and the surgeon must learn to be innovative in inserting catheters into all
arteries that are perfusing the liver, while being certain that all branches distal
to the infusion catheters that pass to other organs other than the liver are
carefully ligated.
 Catheter

I
Gastroduodenal a. F

L. hepatic a.
A hepatic a.

- ->"'""",--j_ Celi ac
Gastroduodenal a. axi s

~....,..-:+;t----j--I~ . hepatic a.
arising from
- -"-- -cf- Superior
mesenteric a.

-'I;:-'[-'r - Second catheter for

van able anatomy Pump

Rectus m.

IngUinal ligament
1& ection of Simple C s of

Operative Indications
imple cy [ of the liver are common. Many are small (1 an -

S diameter), are asymptomatic, and pose no health risks. Others

larger, may be palpable on abdominal exam, or even visiblem
inspecting the anterior abdominal wall, and may be sympt'NIGtlic
Respiratory compromise and vena caval compression have both been IeIIuted
With minimal trauma large cysts may rupture, or be the site of sign;'" ad
hemorrhage. In addition, considerable pressure atrophy may occur in Irnlr
parenchyma surrounding the cyst.
Generally lesions 10 cm or greater in diameter are thought to It11uite
surgical removal. Some reports have suggested percutaneou needle 3SIm:lio:;.
with introduction of sclerosants, as effective therapy. Secondary infections
occurred following aspiration and recurrences have been common, and
term efficacy is as yet unproven.
Patients with simple hepatic cysts, particularly massive ones where
abdominal fullness and early satiety are present, receive excellent relief
surgical intervention. Patients with polycystic liver disease may also
occasionally be candidates for cyst excision and/ or marsupialization. Poly(;) ta:
liver disease is rare and only infrequently results in liver fa ilure. However.
occasionally cysts in polycystic livers become so large that they fill most of thf
abdominal cavity and patients are unable to eat. Such patients are candi~
for resection, fenestration, and marsupialization of their cysts with techni~
that are identical to those used to manage simple hepatic cysts.

Operative Technique
atients are generally explored through a right subcostal incision,

P although a midline incision is satisfactory.

Once the peritoneal cavity has been entered, the abdomen is
explored. The size, number, and configuration of liver cysts are
identified. With CT scanning, generally the exact location and number of simple
cysts are known prior to laparotomy. In this instance there is a single giant qst
arising from the under surfaces of the right and left lobes of the liver (A).
Many surgeons prefer to aspirate the cyst before it is opened to look for die
presence of bile or secondary infection. The cyst wall is then opened (B). and
contents are aspirated (C).
It there is the slightest suspicion that echinococchal cyst disease might be
present, prior to opening the cyst the area is fastidiously packed with Mikulicz
pads soaked in 20 percent saline. Fluid is then sent to pathology to look for the
presence of scoleces. In most instances, however, the solitary thin·walled simple
cyst containing clear serous fluid will not be confused with a hydatid cyst.
 A

A lobe - ----:.1, --;

0/ liver

~-j~--'P:f1.r--
Site of cyst
incision
~adder __~~~

'--,..-jt-____ Cyst

#hrt--- - Stomach

B c

-'=-_ _ _ _ Cy st _ _ _ _ -;;;-;-_
 ith the cyst wall opened, as much of it as possible is excised

W sharply with scissors or with the electrocautery, leaving a I/2-cm

rim attached to the liver (D). An attempt can be made to excise
the remaining cyst wall from liver parenchyma. Usually,
however, this is time consuming. In addition, vascular and biliary structures
often run in hepatic parenchyma immediately underneath cyst wall.
The cyst wall should be sent for frozen section to rule out
cystadenocarcinoma. T hese lesions are rare, but simple excision would not be
adequate if one were present.
For a simple cyst, it is unnecessary to excise all of the cyst wall as long as
most of the cyst is removed and the remaining wall is in wide contact with the
peritoneal cavity. T he remaining edge of cyst wall on the liver is sutured with a
continuous over-and-over locking suture of 3-0 synthetic absorbable material.
This is to achieve adequate hemostasis and to control any small bile ductules
that might be present in unrecognized liver parenchyma extending out on to the
base of the cyst wall (E).
The abdomen is then closed without drainage of the residual cyst wall.
This cyst wall will continue to secrete serous fluid, which will be rapidly and
readily absorbed by the peritoneal surfaces. Only if redundant cyst wall is left
that can loculate off will there be a risk of recurrence of the cyst. Recurrences
are rare.
 Liver Residual cyst wall

Gallbladder
 anagement of Hydatid Cyst
Disease of Liver

Operative Indications
nfestation with Echinococcus granulosa in the Uni ted tates is --

I However, with frequent travel abroad and with immigrants to thl-SOIElItIJ

from the Middle East and South America, hydatid cy t diseaseoftbe
is occasionally encountered. The combination of history, clinical
presentation, and CT scan findings of a solitary or loculated cyst with a
calcified wall can make the surgeon suspicious that hydatid cyst dj,;pase -
present. Serologic tests can also be of value. Untreated hydatid cyst rliseare
result in disaster. Rupture into the biliary tree, into adjacent abdominalOI;S~
or through the diaphragm and into the chest may all result from an
undiagnosed or unrrea[ea nyu-a"v· ,.;)~< .

Surgical Technique
atients can be explored through a right subcostal, an el<.i ended -

P subcostal, or a bilateral subcostal incision. Midline inci ion . may

provide adequate exposure.
In the patient being demonstrated, four hydatid cysts were Pll~::':
(A). A large cyst occupied a significant portion of the lateral segment of the
lobe of the liver and was found to communicate with the biliary tree. A sa olld
hydatid cyst was present in the dome of the right lobe of the liver; it bad
perforated through the diaphragm, into the right pleural cavity, and
communicated with one of the basilar segmental bronchi of the right Iov;a-
A third large, thick-walled calcified hydatid cyst was located in the anterio£
segment of the right lobe of the liver. Finally, a fourth small hydatid cyst
present along the liver edge of the lateral segment of the left lobe.
 •
• ., .
...
• • ~!/:
•

,'
Basilar
pulmonary
bronchus
/
I

Hydatid cyst Biliary communication

,, with hydatid cyst
with pulmonary
,ro OJ. IN r{
\ t ... I"If.J0,
"

Small
hydatid
cyst

" ."-_ __ _ Bil iary tree

Gallbladder

Calcified
wa ll of cyst

211
 variety of scolecidal agents have been employed. In the past

A formaldehyde was perhaps most frequently used. Today 20 percent

hypertonic saline is thought to be effective and less likely to cause
injury if it comes into contact with the biliary tree. However, one has
to be careful that large volumes are not in contact for prolonged periods with
serosal surfaces, or hypernatremia can result from sodium absorption.
The large cyst in the lateral segment of the left lobe of the liver was
managed first. Hypertonic saline was injected into the cyst in an effort to expose
the daughter cysts and scoleces to a scolecidal agent (B). On aspirating some of
the saline, bile was identified, indicating a communication with the biliary tree.
Once the saline was injected , the area was packed with Mikulicz pads soaked in
20 percent hypertonic saline.
Using the electrocautery the exposed surface of the cyst was incised (e).
The cyst contents, including the en tire germinal layer, the endolining, were
removed utilizing the suction and forceps (D).
It is extremely important to be absolutely fastidious about avoiding
contamination of the peritoneal cavity when dealing with hydatid cysts. If
scoleces are disseminated throughout the peritoneal cavity, subsequently
hydatid cysts well develop throughout the peritoneal cavity and prove lethal.
 8

Inner
germinal layer

Outer
laminated layer

Daughter cysts
Hydatid
fluid

I
a..IaIy communic ation

t
~u ~ I f~,'j f'" I
I IIM1 liE

Germinal layer
 nce the endolining has been removed and the cyst irrigated copiously

O . with hypertonic saline, nothing further need be done. However,

ideally the outer laminated, and often calcified, wall of the hydatid
cyst is removed. This often is difficult, if not impossible. Frequently
when one tries to remove this outer lining, injuries occur to the biliary tree and
vascular structures. In this instance the calcified wall could be dissected free
from hepatic parenchyma (E).
Once the outer layer of the hydatid cyst was removed, the bilious
communication of the hydatid cyst with the biliary tree could be identified and
was oversewn with a synthetic absorbable suture (F).
A Silastic sump was then placed into the bed, and the concavity remaining
was closed around the catheter with large chromic catgut liver sutures (G).
 Calcified
layer of
hydatid cyst

Biliary .
communicatIon
 he large hydatid cyst in the dome of the right lobe was managed

T next. The inflammatory attachments of the dome of the right lobe of

the liver were divided from the under surface of the diaphragm. In
the process a fi stulous communication between the hydatid cyst and
the pleural cavity was identified and dissected free (H).
The cyst was injected with hypertonic saline, and the entire area was
packed off from the peritoneal cavity with Mikulicz pads soaked in 20 percent
saline (I).
Using the electrocautery the overlying hepatic parenchyma was opened
down to the hepatic cyst (J).
 OIapIlagm

Hyper10nic
saline
solution

Fistula through diaphragm

Daughter cyst _ __ __ _

211
 he cyst contents, including the entire germinal layer, were then

T removed (K). Many recommend a thoracotomy at the same time as a

laparotomy when there is communication from a hydatid cyst to the
bronchopulmonary tree. However, we have found that in many
instances, when there is minimal disease above the diaphragm, it is not
necessary.
In this instance the rent in the diaphragm was closed with 2-0 synthetic
absorbable suture material (L). The outer layer of the hydatid cyst was not
calcified, was fairly malleable, and was not removed.
A Silastic sump drain was placed into the outer lining of the hydatid cyst
cavity, and parenchyma was loosely closed around it with #1 chromic catgut
sutures on liver needles (M).
r;+.,-:.E::.~--!"--~--- Daughter cysts

."..,r - - Germinal layer

Diaphragm

Cyst cavity

Silasbc~
sump
dra'f1
 he third hydatid cyst, in the anterior segment.of the right lobe of the

T liver, was managed by first packing the area off fastidiously with
hypertonic saline·soaked sponges and then by injecting hypertonic
saline into the cyst itself.
This cyst was approached from the under surface of the anterior segment
of the right lobe of the liver (N).
The outer lining of the cyst was opened, and the cyst contents and
germinal layer were removed (0). Not all of the germinal layer was removed
intact in this instance. Often the entire germinal layer will lift out totally intact.
It usually is not adherent to the outer fibrous layer. In this instance, however,
the germinal layer was adherent and remaining portions of the endolining had
to be removed sharply (P). The outer layer was heavily calcified and could not
be easily removed from the liver.
The concavity was packed with omentum (Q).
 Iypet .....

N
!I./"T-~~--- Gallbladder
Genmnal
layer and
Calcified
__k-J~---- hydalld cysl daughler
cysls

Hypertonic
saline- soaked
pads

Germinal
ayer

Omentum
HepatIC Fe"""
of COlO"
 he fourth hydatid cyst, a small lesion along the anterior edge of the

T left lobe of the liver, was managed last. This was merely excised in
toto using the ultrasonic dissector and removing a small amount of
normal hepatic parenchyma (R).
An additional Silas tic sump drainage catheter was left in the region of the
dome of the liver where the hydatid cyst had communicated through the
diaphragm with the pleural cavity (S). Penrose drains were left to drain the
areas of the third and fourth hydatid cyst sites.
 /

Ultrasonic
dissector

Stomach

Liver

Diaphragm

Stomach

Gallbladder
Drainage of Liver bscesses

Operative Indications
he diagnosis of liver abscess in any patient with fever i now readily

T made by sonography and CT scanning, despite the fact that there

may be very little in the way of physical findings. Liver abscesses
may be solitary or multiple and may reside in one or both lobes d the
liver. If they are unilocular, they may be managed by percutaneous a piratioo ()['
by percutaneous aspiration and drainage with a percutaneously-placed catheter-_
Many liver abscesses, however, are multilocular, and do not respond well to
percutaneous management. In addition, other abscesses that initially appear to
respond to percutaneous drainage subsequently require operative intervention
because of the inadequacy of the drainage established. Thus most liver
abscesses currently require laparotomy and open drainage.
Liver abscesses are most commonly associated with biliary tract pathology_
Occasionally the biliary tract pathology, such as an empyema of the gallbladder
or a common duct stone resulting in cholangitis will require management at the
same time as open drainage of the abscess. Generally, however, this is not the
case and merely open drainage is performed. Colonic diverticular disease and
other intra- abdominal septic processes may also produce liver abscesses_ A
significant number of liver abscesses are idiopathic.

Operative Technique
atients are generally explored through a right subcostal incision. If the

P pathology is in the left lobe of the liver, the incision can be extended
across the midline. Exposure can be maximized by the use of upper
hand retractors. This provides constan t retraction of both costal
margins by retractors attached to a frame anchored to the operating room table.
In this instance both lobes of the liver are involved. There is a large
unilocular abscess occupying a large part of the lateral segment of the left lobe
of the liver and a second deeply-situated multiloculated abscess involving the
right lobe of the liver (A).
 Gallbladder

Hepatic
flexure
of colon
 he abscess in the left lobe of the liver presenting at the capsular

T surface is managed first. The area is packed with antibiotic-soaked

Mikulicz pads _Several milliliters of abscess content are aspirated in
a syringe, to be sent for anaerobic culture (B).
The abscess cavity is then opened with the electrocautery (C).
Additional cultures are taken for aerobic organisms (D).
~
/
/
Anaerobic
culture

Aerobic
culture
 he abscess cavity is then retracted open and the contents completely

T suctioned free (E).

The abscess cavity is explored manually to be certain that there
are no loculations that need to be broken up (F).
The abscess cavity is then copiously irrigated with an antibiotic-containing
saline solution (G).
 to

Liver _ _ _ __

Abscess cavity

Antibiotic
containing
saline
solution
 he abscess in the right lobe of the liver, which is not visible on the

T anterior surface, had been identified preoperatively by CT scan. It

appeared on CT scan to be multilocular. Intraoperative sonography is
used to identify the extent of the loculated abscess and the site where
it most closely approaches the anterior surface (H).
Once the abscess is located sonographically, a small amount of pus is
aspirated for anaerobic culture and to further locate the site of the abscess (I).
A centimeter or two of normal liver parenchyma has to be divided with the
electrocautery to reach to abscess cavity (J).
 unilocular abscess

II

Liver

,
i

Normal liver parenchyma

Abscess

231
 nce the abscess cavity is opened, further cultures are taken for

O aerobic organisms (K).

Using one's fingers, the multiple loculations are carefully broken
up (L). One has to be very cautious while doing this, so that normal
parenchyma is not injured, initiating bleeding that can be very difficult to
control. If mild bleeding occurs, it can usually be controlled by packing the
cavity tightly for 10 or 15 minutes.
Once allloculations have been broken, the cavity is copiously irrigated with
antibiotic-containing saline solution (M).

I
t
I
I
I

I
 K

,
l

T-extension

Loculations
_ _ _ _ within
abscess

<

!~

Antib iotic
containing
saline
solution
 he unilocular abscess in the left lobe of the liver is drained with

T Penrose drains (N). A Silastic Foley catheter is also left alongside tl

Penrose drains for irrigation, if desired; it can also act as a vehicle I
perform sinography several days following surgery, to be certain tl:
the abscess cavity has contracted.
The larger multiloculated abscess cavity in the right lobe of the liver has
been drained with Penrose drains , and a Silastic sump catheter (N).

,
It
•

Siomach

Liver

Gallbladder
Management of Massive Liver
Trauma

Operative Indications
n rare instance isolated liver trauma identified by CT scan, in a stable

I patient, may be treated nonoperati vely. For most patients with li ver
trauma, however, laparotomy will be required.

Operative Technique
ll patients with abdom inal trauma are explored through a midline

A incision. If significant liver trauma is suspected and the clinical

situation allows, the chest should be prepped and draped and a temal
saw available for median sternotom y if required.
Once the abdomen is opened, blood is quickly removed by suction, and the
abdomen is explored. If nothing other than liver trau ma is identified, all
attention is paid to the li ver. Maximum exposure is obtained with the use of the
upper hand retractor, anchored to a frame that is attached to the operating
room table.
The falciform and triangular ligaments are quickly taken down to lnoli .
the li ver for adequate examination . Often the liver injury consists of a
laceration or a missile tract, with no bleeding and no evidence of a major bi iar
tract injury. Treatment in that instance will be minimal , and will perhaps jus'
consist of drainage.
In this instance (A), a large stellate injury involving most of the ant .
surface of the right lobe of the li ver and extending up on to the dome i found
 FaIcIIorm IigamenI

Stomach
Stett ate wound

Gallbladder
 emporary hemostasis has been obtained by packing the stellate

T injury with Mikulicz pads and by providing hand pressure (B). The
right lobe of the liver is mobilized by dividing the peritoneal and
areolar attachments to the retroperitoneum and the under surface of
the diaphragm. If a large stellate injury of the right lobe of the liver is to be
adequately examined and explored, particularly when it extends up towards the
hepatic veins, it is important that the liver be fully mobilized so that it can be
delivered out of the retroperitoneum. Occasionally an injury involves the
inferior vena cava posterior to the liver, and only by completely mobilizing the
right lobe and retracting it medially, will adequate access for control be
obtained.
 ' --=-"' - - - - - - - - - - Packing
- - "..:;= - - - - - - - _ Stellate wound

'--_ __ _ _ _ _ _ _ _ _ _ _ R. lobe 01 M!r

 he deep stellate injury of the liver is retracted open and its depth

T explored in an attempt to provide hemostasis with suture ligatures

and electrocautery. Any obvious biliary tract injuries should also be
controlled with suture ligatures (C).
At the same time that hemostasis is achieved, it is important to debride and
remove any and all devascularized liver parenchyma (D).
nce hemostasis has been achieved, the large stellate wound is drained

O
widely with multiple Penrose drains and Silas tic sump catheters (E).
 ~__~~~~~~ FakSoom
ligament

k
 ccasionally rhe surgeon will be unable to obtain adequate hemostasis,

O despite spending a grear deal of time and effort exposing the depth of
a stellate injury and fastidiou ly suture-ligating significant bleeding
points. A variety of options are available in this situation.
One can perform a Pringle maneuver (F) by clamping the porta hepati to
occlude the portal venous and hepatic arterial inflow. A noncrushing clamp can .
be used, or it can be done manually. Once the Pringle maneuver has been
performed, new attempts can be made to adequately expose and obtain
hemostasis in the depth of the wound, without the significant bleeding that may
persist without the Pringle maneuver. The Pringle maneuver, along with
renewed efforts at hemostasis, may be successful.
If occl usion of the portal structures provides adequate hemostasis during
the occlusion, but hemostasis can still not be obtained in the depth of the liver
wound, another option that may rarely be necessary is ligation of the right
hepatic artery. The right hepatic artery is identified, dissected free, and the
Pringle maneuver terminated. If occlusion of the right hepatic artery provides
hemostasis, the surgeon may choose to ligate or to ligate and divide the vessel
(G). If this is carried out , cholecystectomy should be performed because of the
likelihood that the gallbladder has been devascularized. Branches of the hepatic
artery can be divided with relative safety. In the past this procedure was widely
carried out in several institutions, and its safety and efficacy were
demonstrated. Today it is only rarely resorted to, but when needed, it can be
lifesaving.
 II]
. , - - -- - Gastrohepatic ligament

L _ _ __ _ _ _ Portal v.

L ______ _ _ Hepatic a.

~_ _ _ _ _ _-'-'---_ _ Common bile duct

~
\..
•
.'
t

2-
lSarge-y

nother option that is available when hemostasis cannot be obtained

A directly is to pack the depth of the wound tightly with Mikulicz pads
or Kling (H) to obtain immediate hemostasis.
Once hemostasis has been achieved, the patient is closed, taken
to an intensive care unit and supported for 24 to 48 hours , and then returned to
the operating room for removal of the pack when the patient is stable and
coagulopathies have been corrected. In the past, packing of liver wounds often
resulted in catastrophe because of injudicious use. Today, in extremely selected
circumstances, it can be lifesaving.
Once the depths of the wound are packed, additional Kling is piled on top so
that the abdominal wall will provide additional pressure (I).
The abdomen is then closed with a series of stay sutures of #1 nylon,
utilizing bumpers made from a #16 French catheter. The sutures pass through
and through skin, subcutaneous tissue, and rectus, but not through parietal
peritoneum (inset).
The patient is then returned to the operating room in 24 to 48 hours, the
stay sutures are removed, exposure is ,_,btained, and the pack is carefully
removed. Often with only minimal efforts at this time total hemostasis can be
obtained.
SL~e
wound

,..,.
,
\
. ~3!tJ
Stay suture

Packing Liver

~~~~::::=~ Portal v.
«-'~=iI----- Bile duct

-It--- - Inferior vena cava

L-_ _ Aorta
 he most difficult of stellate liver injm it:; to manage surgically are

T those that extend up towards the dome of the liver and involve the
hepatic veins or one of their major branches 0). Bleeding i often so
profuse that the surgeon cannot even attempt to achieve hernosta .
in the depth of the wound. The Pri ngle maneuver usually will not decrease the
bleeding, and this provides a clue that a major hepatic vein injury is present. A
variety of options are available and should be attempted as soon as the surgeolf
suspects that the massive bleeding is hepatic venous in origin.
The abdominal aorta can be occluded with a large aneurysm clamp by
placing the clamp vertically down against the spine just below the diaphragm.
The portal and hepatic arterial inflow into the liver can be controlled with a
noncrushing clamp by occluding the porta hepatis (pringle maneuver). Finally
the segment of vena cava including the hepatic veins can be isolated by placing
"keepers" around the inferior vena cava below the liver, but above the renal
veins, and around the suprahepatic vena cava within the pericardium.
A median sternotomy should be performed rapidly, the pericardium opened,
and the inferior vena cava encircled just below the right atrium. "Keepers"
consist of umbilical tape, both ends of which are threaded through a segment of
18 French catheter and clamped with a Kelly clamp. The nooses can be quickly
tightened to occlude and isolate the vena caval segment into which the hepatic
veins empty by pulling the umbilical tape ends up taut through the segment of.
catheter. This technique allows one to effectively render the stellate wound in
the liver relatively bloodless for a short period of time. This may be enough
to allow for control of a major hepatic venous injury. Obviously,
hemodynamically the patient will not tolerate this situation for longer than
brief intervals of time.
Another alternative, perhaps preferable, is to place a shunt immediately,
once it is recognized that a major hepatic venous injury is present. A median
sternotomy is quickly performed and the pericardium opened. A keeper is
passed around the suprahepatic vena cava within the pericardium, just below
the right atrium. A second keeper is passed around the inferior vena cava below
the liver, just above the renal veins. A shunt is constructed from a pIa tic chest
tube. Additional holes are required in the positioned chest tube so that they wiD
reside in the right atrium, but above the suprahepatic vena cava, which will be
occluded with the keeper.
A purse string of 0 synthetic nonabsorbable suture is placed in the right
atrium and threaded through a short segment of French catheter. An atriotomy
is made within the purse string, and the shunt is passed rapidly into the right
atrium and down into the inferior vena cava. Hemostasis at the atriotomy i
achieved with the purse string keeper. The end of the chest tube is clamped.
When it is determined by palpation that the last hole in the chest tube i distal
to the keeper placed just above the renal veins, the distal keeper is occluded.
The proximal keeper around the suprahepatic vena cava is also cinched down..
T he shunt has to be positioned perfectly so that there are only holes below the
distal keeper and within the right atrium . T his will allow venous retum from
the subhepatic inferior vena cava back to the right atrium while isolating the
middle segment of inferior vena cava into which the hepatic vein drain. This,
along with the Pringle maneuver, will render the liver wound relatively
bloodl and allow for repair of. the venous injury.
 )

Temporary
occlusion of:
,..-- - - - - - - - - - - - - Suprahepatic inferior vena cava
= =----- -- - -- Aorta

6~---- Hepatic a.
-=~ _ _ __ Portal v.
Caval-atrial shunt
. 2~-- Common bile duct

_ _ _ _ _ Inferior vena cava

" Keeper"
-,."--;--~~r-- Right abium

Suprahepa!ic DeriDr
"Keeper" _ _ _ _ _ _-:;:-'--:;
~-----~~~-~~- venacava

R. hepatic v. _ _ _ _ _ _ _'----_--;: ~~=:...~

wound

,...,.'--_ __ " Keeper" infeOOr

vena cava
Portasystemic Shunts
Interposition Mesocaval Shunt

Operative Indications
any patients with liver disease, portal hypertension, and bleeding

M esophageal varices are managed with sclerotherapy. Others, with

advanced liver disease, are managed by hepatic transplantation.
There remains a group of patients, however, with portal
hypertension and bleeding varices, that cannot be controlled adequately with
sclerotherapy, but who still have enough hepatic reserve that they are not yet
candidates for hepatic transplantation. These patients are candidates for a
mesenteric-systemic venous shun t.
The mesocaval shunt is a total shunt utilized to decompress the portal
venous system in the face of portal hypertension and bleeding varices. It has
been used extensively in patients with portal hypertension secondary to
ci rrhosis. When initially proposed, it was suggested that this shunt allowed
continued prograde flow through the portal system into the liver, while at the
same time achieving an adequate decrease in porta l pressure. This contention
has been debated over the past 20 years and is sti ll not resolved to everyone'
satisfaction. Although in some patients prograde flow to the liver may continue.
in most instances the shunt is total, and all portal flow passes into the systemic
venous system, bypassing the liver. Retrograde flow in the portal vein from the
liver also occurs_
The interposition mesocaval shunt is the easiest, quickest, and safest of all
the mesenteric-systemic decompression procedures. For this reason many
surgeons have adopted it as the shunt procedure of choice in the emergent or
semi-emergent situation. In addition , many have used it in the elective ituation.
in those instances when mesenteric-systemic decompression is chosen as the
means of management. Because it is a total shunt, many feel the risk of
encephalopathy post-shunt is high_However, many series have shown a low
incidence of encephalopathy, and thus some continue to support use of thi
shunt in the elective situation when a portasystemic decompression procedure
is required_ This is particularly true when intractable ascites is present.
Construction of a functional side-to-side total shunt such as the mesocaval
interposition shunt is an effective treatment for ascites, whereas a selective
sh unt is not.
The mesocaval interposition shunt is the procedure of choice for the
unusual form of portal hypertension that is secondary to hepatic vein
thrombosis, the Budd-Chiari syndrome_In the Budd-Chiari syndrome there is
no route of egress for the portal venous and hepatic arterial inflow. The liver
becomes markedly congested, central lobular necrosis occurs because of the
marked congestion, and patients present with massive ascites. Successful
management requires conversion of the portal \-ein into an outflow tract.
Although some have utilized the side-to-side portaca\-al shunt, the markedly
congested liver and the often h\-perrrophied caudate lobe frequently make a ide-
to-side porraca\-al shunt diliicult. and in some instances impossible_ For that
reason the mesocaval shunt. \1,-hich is performed well below the li\-er and well
away from the hyperrrophitrl ca:JCate lobe_ has been adopted by many a the
shunt of preference :oc pci.::Ja::'; "1:h :be B:xid-Chiari syndrome. prm;ded there
is no inferior vena ca..-al ~ CI" ob5trucrioo_
- rarsverse
color

Omentum

- ta.;S.erse _ _ _ __
~ f Transverse colon

Superior
mesenleric v.

?,53
 In all patients with portal hypenension who are considered candidates for l
mesenteric-systemic shun t, hepatic vein catheterization and mesenteric
angiography should be performed. Mea uring the wedged hepatic vein pressure
confirms the diagnosis of portal hypertension in patients with parenchymal
liver disease. Demonstrating clotted hepatic vein confirms the diagnosis of the
Budd·Chiari syndrome in patients with hepatic vein thrombosis. The venous
phase of mesenteric angiography demonstrates patency of the superior
mesenteric and portal veins. In patients with the Budd·Chiari syndrome;
inferior vena cavography and pressure measu rements also have to be carried
out. Patients with cirrhosis should also have an MRI or CT scan to rule out a
hepatoma.
Some surgeons have felt the long-term patency rate of the mesocaval
interposition shunt to be unacceptably low. To improve long-term patency, a
modification of the "H" shunt was developed at this institution. We have had
excellent long-term patency rates, and it is this modification that will be
demonstrated.

Operative Technique
mesocaval interposition shunt can be done through either a bilateral

A subcostal or a midline incision. We prefer the midline incision_Once

the peritoneal cavity is entered and any ascites suctioned free, the
abdomen is thoroughly explored. If a liver biopsy has not been
performed preoperatively, one is performed at the beginning of the operative
procedure. If the mesocaval shunt is being performed for portal hypertensim
secondary to cirrhosis, the liver should be carefully examined for evidence of a
hepatoma. Suspicious areas should be biopsied.
The transverse colon and omentum are reflected in a cephalad directoo
A transverse incision is made in the peritoneum at the root of the
transverse mesocolon to initiate dissection of the superior mesenteric vein (8).
There are no landmarks to lead one to the s uperior mesenteric vein. It gener.illr
is a midline structure, but the transverse mesocolon has to be opened widely
and the dissection deepened in an effort to identify the vein. The superior
mesenteric artery is generally to the left of the superior mesenteric vein and
posterior in location. The anatomic relationships of the superior mesenteric vein
and superior mesenteric artery, however, are inconstant, and palpating for th
superior mesenteric artery rarely is of help in identifying the superior
mesenteric vein. As the dissection in the root of the transverse mesocoloo is
deepened, however, the superior mesenteric vein is always readily identified.
In dissecting the s uperior mesenteric vein often one encounters large Iym
nodes and hypertrophied lymphatic channels. The larger lymphatic channels
should be ligated prior to division . Lymph flow through these enlarged
lymphatic channels is brisk and , unless controlled, will keep the operative field
surrounding the superior mesenteric vein flooded with lymph and will
contri bute s ignificantl y postoperatively to ascites formation.
Pancreas --------r,~

large
poslerior _ __ __ _--7.;.:.::...-2.~_:_;;~
oranch
o
Superior mesenteric V' ---'T:==t~~~iI--

Pancreas

Superior mesenteric v. - - -- - ----:.f:-:r - -.4

Duodenum _ _ _ _ __ - '-::-'--:

Inferior
vena cava
 nce the anterior surface of the superior mesenteric vein is identified,

O it is completely mobilized and cleaned for a length of at least 6 em

(C). Small branches are ligated and divided and large branches are
controlled with vessel loops. The vein should be completely mobilized
circumferentially in a cephalad direction up to the point where it passes
posterior to the neck of the pancreas. Distally the vein should be mobilized until
it starts its major branching, generally at the inferior border of the third portion
of the duodenum. In a significant percentage of patients, the inferior mesenteric
vein joins the left lateral aspect of the superior mesenteric vein and does not
enter the splenic vein directly. Although it can be safely ligated and divided, the
inferior mesenteric vein can also easily be preserved. It shou ld be mobilized and
then doubly looped with a vessel loop for control prior to opening the superior
mesenteric vein.
It is always possible to clean a 6· or 7-cm length of large-diameter superior
mesenteric vein, beginning at the inferior border of the pancreas and extending
caudally, prior to major branching. As one dissects the superior mesenteric vein
in a cephalad direction, there are often sizable branches from the uncinate
process and head of the pancreas that enter the vein posteriorly and into its
right lateral border. These should be carefu lly ligated and divided. There also
often is a major mesenteric branch that enters directly posteriorly. This is a
constant branch with a very wide diameter that is difficult to ligate and divide
because of its posterior location. It is nearly always present and should be
controlled by double looping with a vessel loop.
Once an adequate length of superior mesenteric vein has been mobilized,
the inferior vena cava is identified. The bare area over the junction of the
second and third portions of the duodenum is identified through the right colon
mesentery, and the dissection is initiated by mobilizing this portion of the
duodenum (D). The retroperitoneu m is often filled with large hypertrophied
lymphatic channels and lymph nodes. It is preferable to clamp and ligate this
tissue , rather than dividing it directly with scissors or the electrocautery.
A 6- or 7-cm length segment of inferior vena cava should be cleaned along
its anterior and lateral borders. It is not necessary to mobilize the inferior vena
cava circumferentially. Occasionally a lumbar vein will enter so far anteriorly
on the inferior vena cava that ligation and division is required. Often, however,
no branches require control (E). The portion of the inferior vena cava that is
cleaned actually extends up under the duodenum for 2 or 3 cm.
Once adequate lengths of superior mesenteric vein and inferior vena cava
ha\-e been cleaned, all of the soft tissue between these two structures s hould be
di\-ided (F). T his may at times require dividing arterial branches of substantial
size to either the right or the transverse colon. If the artery is so large that the
surgeon is reluctant to diyide it, it can be clamped with a bulldog clamp for
se\-eral minutes and adequate pulsations palpated for in the colonic marginal
vessel . We ha\-e not encountered a situation in \\-hich the patient did not
w era e ha\ing such \-essels ligated and di\·ided.
 E

p '&nO< ---~~'?'T.-'-­
vena
CC:Y2

~~~~------------~
mes.. ·--=,

~~~~=------ Supenor
meserc:enc y

Duodenum

Small
bowe l
mesentery
 he caval anastomosis is performed first. The inferior vena cava is

T partially occluded with a Satinsky clamp. A lock ma y be placed on

the vascular clamp handle to prevent dislodgement during the
anastomosis.
An ellipse of inferior vena cava is removed from its an terior surface (G).
The length of this ellipse is important. Depending upon the size of the inferior
vena cava and the superior mesenteric vei n, a kni tted Dacron prosthesis is
chosen that ranges from 14 mm to 20 mm in diameter. The prosthesis diameter
should be chosen prior to removing the ellipse. If the length of the ellipse is too
long, this will tend to prevent the prosthesis from assuming a circular
configuration at the anastomosis and will make it slit-like and narrow
its lumen.
Once an appropriate sized ellipse is removed, an end-to-side anastomosis is
performed between the knitted prosthesis and the inferior vena cava. Mattress
sutures of 5- 0 synthetic non absorbable suture material are placed at each end of
the venotomy. The suture passes outside in on the vein, inside out on the
prosthesis, then outside in , and finally inside out on the inferior vena cava.
These mattress sutures tend to evert the anastomosis (H). A stay suture is also
placed midway along the venotomy on the right lateral wall for gentle traction.
The left side of the anastomosis is completed first. The mattress suture at
the superior end of the anastomosis is secured, and then one arm is run down in
an over-and-over fashion to the inferiorly placed mattress suture. With the
previously placed stay suture in the right lateral wall of the venotomy, the right
lateral wall of the inferior vena cava can be gently retracted to prevent a suture
in the left lateral suture line from securing both walls of the vein (I). The
inferiorly placed mattress suture is then secured and the suture run down from
above secured to it.
The right lateral wall of the anastomosis is then completed, running a
suture both from above downward and from downward upward, meeting at the
pcint where the stay suture has previously been placed. One should maintain
steady gentle traction on the stay suture again to prevent incorporating the
oppcsite wall in the suture line (J).
The stay suture is then removed, and the two ends are tied midway along
the right lateral anastomotic line (K).
A second vascular clamp is placed on the prosthesis just above the
anastomosis and the Satinsky clamp released to be certain the anastomosis
is secure (L).
When one has determined that the anastomosis is satisfactory, the
atinsky is reapplied to the inferior vena cava, the vascular clamp removed
from the prosthesis, and the blood suctioned out of the prosthesis.
 rl

~-'-----,--- ~ Inferior vena cava

I

"Kl~~~--- cava
InJerJ()( vena

l\
.: =-:-., \
! I(,.:r "-
1-". !'\, .,.
-'

Vascular clamp

~ .'

r,

- I'
IS..

,I
--'
J

259
 eciding upon the length of the prosthesis is extremely important. The

D prosthesis will pass from the inferior vena cava anteriorly and
somewhat inferiorly around the lower border of the third portion of
the duodenum. It will then pass anterior to the third portion of the
duodenum, on top of the uncinate process, to be anastomosed obliquely to the
anterior surface of the superior mesenteric vein. The prosthesis will thus
assume a "C " configuration. If the prosthesis is cut too short, the superior
mesenteric vein will be retracted and distorted. If the prosthesis is fashioned too
long, it will bow out in an exaggerated fashion after the clamps are removed. It
is helpfu l to use a prosthesis that is marked (M), so that one can maintain
orientation of the graft.
Once the appropriate length has been decided, the prosthesis is cut in an
oblique fash ion, duplicating the angle with which it will meet the superior
mesenteric vein (M). In addition, the orientation of the prosthesis shou ld be
such that the portion of the prosthesis that has been anastomosed to the inferior
aspect of the inferior vena cava will actually be the mid portion of the right
lateral anastomosis on the superior mesenteric vein (M).
The superior mesenteric vein is controlled with an acutely curved Cooley
clamp placed across its most cephalad aspect, at the point where the vein passes
posterior to the neck of the pancreas. A straight Cooley clamp is often used
inferiorly. Any major branches that have been doubly looped with vessel loops
are then controlled by retracting the vessel loops.
A small ellipse is removed from the anterior aspect of the superior
mesenteric vein (N). It will be a long venotomy to match the length of the
obliquely divided prosthesis. The ellipse, however, should not be wide. If too
wide an ellipse is removed, once the vascular clamps have been removed and the
prosthesis allowed to assume its normal diameter, the rest of the superior
mesenteric vein may be stretched over the opening of the prosthesis like a
drum , without adequate diameter of vein for good flow.
The prosthesis is anastomosed to the superior mesenteric vein with 5-0
synthetic non absorbable suture material. Sutures are placed at each end of the
anastomosis, passing from outside in on the superior mesenteric vein and from
inside out on the prosthesis.
The right lateral suture line is run first; it is run from with in the
prosthesis and vein (0). The superior suture is tied and then passed from
outside the prosthesis to within before being run. This suture line should
incorporate very small bites of superior mesenteric vein and prosthesis, in order
not to inwrt a significant suture line that will subseq uently interfere with flow.
The suture line is run down to the inferior limit of the venotomy.
The inferior stay suture is then secured, and the suture that has been run
down from abo\·e is passed from \\·ithin to without the prosthesis and then
secured to the inferior suture. The left lateral anastomotic line is then run fro m
abo\·e down and do\\·n upwards to meet at the mid portion of the suture line (Pl.
 ::>acron
gran

Pancreas

Supenor
mesemen:;: v

Inferior
vena cava

i.

, f

,/

.~
.,
-1
"
Q
::::c
:L
~
,
~1
...:.:j ~
 large bore needle is passed into the most anterior portion of the

A prosthesis and the clamps removed slowly from the superior

mesenteric vein (Q). The clamp on the inferior vena cava is left in
place. This allows the prosthesis to fi ll with blood, with the needle
acting as a vent for the release of air.
Once the prosthesis has completely filled with blood, the clamp is removed
from the inferior vena cava and flow through the prosthesis established (R).
T he course of the prosthesis assumes a "C" configuration. The
anastomosis between the prosthesis and inferior vena cava is actually partially
underneath the third portion of the duodenum. The prosthesis has to pass
inferiorly as well as anteriorly to pass below the third portion of the duodenum.
It then passes on top of the third portion of the duodenum, on top of the
uncinate process, to be anastomosed obliquely to the anterior surface of the
superior mesenteric vein.
This "C" configuration allows the prosthesis to be anastomosed to the
anterior aspect of the superior mesenteric vein well above where the superior
mesenteric vein branching occurs (S). Thus one is always assured of superior
mesenteric vein with a large diameter. Furthermore, since the anastomosis is
oblique, it tends to be very large. In addition, since the anastomosis is to the
anterior aspect of the superior mesenteric vein, it technically is easy to perform.
This is in contrast to the old "R" shunt, which runs directly anteriorly from the
inferior vena cava, below the lower border of the third portion of the duodenum,
and joins the posterior aspect of the s uperior mesenteric vein. T he "R" shunt
anastomosis is much harder to perform and often is performed to a segment of
the superior mesenteric vein that has already branched.
 Q

Duodenum _____-;_
Superior
i-:r-- - - - - mesenteric v.

---i!;......-- - - - - .. c .. graft

Inferior vena cava - - - -- -t

Lateral view

_,.~m'n'"r ' ), .. c .. graft

/ 1':>,:
/ 1.-
./·~~~~i~----_superior mesenteri c v.
 he prosthesis is punctured with a 19-9auge needle connected to

T intravenous extension tubing. This can either be passed off the head
of the table so that pressures may be recorded on electronic
equipment by the anesthesiologist. or it can be connected to a
manometer by the surgeon and measured directly (T).
The first measurement is taken with the prosthesis open and mesenteric
systemic flow intact (U). This figure is taken as the decompressed portal
pressure.
The prosthesis is then clamped on the inferior vena cava side of the
manometer M. and this elevated pressure is taken as the undecompressed
portal pressure.
Finally. the prosthesis is clamped on the superior mesenteric venous side
(JI). and this pressure should represen t the pressure in the inferior vena cava.
It is also important for the anesthesiologist to record right atrial or superior
yena caval pressure. to be certain that the portal pressure drop can be corrected
for any gradient that exists between the inferior vena cava at the level of the
anastomosis and the right atrium. Taking these pressure measurements at the
end of the operative procedure allows the surgeon to proceed with the shunt
without the initial delay required for measuring undecompressed portal
pressure.
 T

- - - - - - - Transverse
mesocolon

---'lI_-i!~~+--- Dacron graft

Superior
~....._~~-"~_ mesenteric
vein

Duodenum

Inferior
vena cava

Superior Superior
mesenteric mesenteric

(~~<ein
~
t -:":.

~ ., ,
l "'-
:J
.
<-' (\ \

In eoor vena Inferior vena

Inferior vena
cava cava
cava
w

265
Distal

Operative Indications
he di tal splenorenal shunt is a selective shunt, in contra t to the

T mesocaval and portacaval shunts, which are total shunt . The distal
splenorenal shunt is constructed so that mesenteric blood continues
to fl ow antegrade into the li ver, while gastroesophageal varices are
decompressed retrograde, through the short gastric and left gastroepiploic
vessels, into the spleen, and out the splenic vein into the systemic venous ·
system. This sh un t was introduced in an attempt to eliminate the
portasystemic encephalopathy that some patients develop after a total shunt.
With the acceptance of sclerotherapy as the first line of management for
gastroesophageal variceal bleeding secondary to portal hypertension, the need
for elective portasystemic decompression has decreased. Nevertheless there are
situations in which an elective portasystemic shunt is indicated. Many SUrgeJCffiS
have accepted the selective distal splenorenal shunt as the procedure of choice
in the elective situation. Patients with intractable ascites are not candidates fo£
the distal splenorenal shunt. Since sinusoidal pressure is not decreased by the
distal splenorenal shunt, massive ascites is not treated effectively by thi
procedure. Technically, the distal·splenorenal shun t is a difficult operative
procedure and thus should not be attempted in the emergency setting. However.
patients with liver disease, portal hypertension, and a history of bleeding
esophageal varices, who are considered candidates for an elective shunt, are
good candidates for the distal splenorenal shunt.
Candidates for the distal splenorenal shunt should be worked up
angiographicaUy prior to surgery. Celiac axis and superior mesenteric
angiography will demonstrate on the venous phase whether or not there
continues to be prograde mesenteric flow to the liver. If there is not prograde
flow, the potential theoretical benefits of the distal splenorenal shunt are
obviated, and the patient should be considered for a total shunt. If, however,
prograde flow to the liver is demonstrated, and the mesenteric venous sy tem is
patent, the patient is an appropriate candidate for a selective shunt. The
position of the left renal vein should also be determined angiographically, so
that its relationship to the splenic vein is delineated prior to surgery. If the
distal splenorenal shunt is performed correctly, one can expect a high incidence
of shunt patency, excellent control of bleeding from gastroesophageal varices,
and perhaps a reduction of both the incidence and severity of portasy ternic
encephalopathy when compared to a total shunt.

Operative Technique
ither a long upper midline incision or a long left subcostal incision

E with extension across the right rectus muscle can be used for this
operative procedure.
After the peritoneal cavity is opened , the abdomen i explored
evidence of additional pathology. If none is found , a liver biopsy is obtained if
one has not been performed preoperatively.
 Stomach

\
'-
(
.f!
it

Transverse colon
Retroperrtoneum
 Pon entering the abdomen, great care should be taken to divide all

U vascular attachments to the spleen, so that the splenic capsule is not

torn. Obviously, preservation of the spleen is essential in this
operative procedure, and care should be taken immediately upon
entering the abdomen to be certain that the spleen is not injured.
The lesser sac is entered by dividing the gastrocolic omentum along the
greater curvature, while preserving the gastroepiploic blood supply to the
stomach. The right gastroepiploic vein is divided at the level of the pylorus, but
the artery is preserved. Care should be taken to preserve the left gastroepiploic
vein, with its gastric branches, draining toward the splenic hilum. In addition
one has to be certain, wh ile extending the opening in the lesser sac towards the
spleen, not to divide any of the short gastric vessels.
The retroperitoneum is entered along the inferior border of the pancreas
(A). This border is usually visible and can be identified quickly by palpation.
This plane in the retroperitoneum along the inferior border of the pancreas is
often relatively bloodless, even in the cirrhotic. However , large lymphatic
channels are often encountered, and these should be controlled by clamping,
division, and ligation to prevent the subsequent accumulation of ascites.
Once this space along the inferior border of the pancreas is opened, the
pancreas is mobilized out of the retroperitoneum. Often the first structure that
is encountered is the inferior mesenteric vein. This structure is often an
excellent guide to the splenic vein and, if it enters the splenic vein, it should be
ligated and divided at that junction (B). The inferior border of the pancreas is
reflected in a cephalad direction and the splenic vein identified and cleaned on
its posterior surface. The splenic vein usually traverses the pancreas posteriorly
approximately at its mid portion, but may on occasion actually be closer to its
su perior border.
Once the splenic vein is identified, it is carefully mobilized
circumferentially for a 6· or 7·cm distance from its junction with the superior
mesenteric vein out towards the tail of the pancreas. This requires meticulous,
low, fastidious dissection. After its posterior and inferior surfaces are cleaned
of all surrounding areolar tissue, its anterior surface is mobilized, carefully
identifying the small branches passing anteriorly into the posterior aspect of the
pancreas. These small branches should be doubly ligated in continuity, prior to
division. Some have suggested ligating the splenic vein side of the branches and
usi ng smallligaclips on the pancreatic side. In our experience the small Jigaclips
often are displaced on the pancreatic side, and further hemostasis is required.
With carefu l fast idious dissection, the splenic vein can be completely
mobilized from the posterior aspect of the pancreas. This dissection is
particularly difficult in the patient with chronic pancreatitis, but it is always
possible. The junction of the splenic vein with the superior mesenteric vein
hould be identified early since a \'essel loop passed around the splenic vein at
thi point facilitates further distal dissection.
The dissection hould also proceed further along the superior a peet of the
portal "ein, in an effon to identify the coronary ,"ein" If found in thi location,
~rnan:" ""ar " doubly ligated and di\-ided C"
 Splenic v.

h;Z:::'~-------- Divided inferior

mesenteric v.

Coronary v.

Portal v.
IJ \

Pancreas ___ _ _ _ _-.r-

' Spl,enic v.

Superior mesenteric Y.
 nee an acequate length 0: splenic "-ein has D.:t:n mobilized

O circumierentially. the left renal vein is identified and dissected_ In

obese patients this mav be diificult. and localization oi the left renal
\-ein is facilitated by elevating the trans\-erse mesocolon. di\-iding the
ligament of Trei tz , and exposing the vein as it crosses the aona. as is done in
aortIc surgerv.
\Vhile deepening the dissection in the retroperi toneum towards the left
renal vein, once again enlarged lymphatic channels are encountered, and these
should be clamped and ligated to decrease subsequent ascites formation , The
left renal vein is identified and cleaned for a length of approxim2.~ely 6 em, The
gonadal and left adrenal veins are easily identified, They should both be li~ated
and divided. Care has to be taken in dissecting and en6rcllng tnese nyo yeins
\\-ith a right-angle clamp, because often additional branches join these \-enous
structures posteriorly close to their junction with the renal vein (0 ).
Once an adequate length of left renal vein is mobilized, the splenic \'ein is
di vided close to its junction with the superior mesenteric vein (E). The splenic
vein is clamped just before its junctior, with the superior mesen teric win with
two straight Cooley clamps. The vein is then divided, and the splenic \'ein end
adjacent to the superior mesenteric vein is oversewn with a continuous 5-0
synthetic nonabsorbable suture.
In the past, the splenic vein end adjacent to the superior mesenteric vein
was merely ligated, if length permitted. This often left a small cul·de-sac. which
in a large diameter, low-flow venous system resulted in thrombosis that on
occasion extended up into the portal vein. Thus, one should overse\\- the splaric
vein end at its junction with the superior mesenteric vein as close as possible in
order to avoid leaving a cul-de-sac behind_
Before dividing the splenic vein , it is helpful to mark its superior and
inferior borders with fine traction sutures, so that orientation is maintained
during the subsequent performance of the splenorenal anastomosis_
In determining the length of splenic vein that one needs to perform a
tension-free anastomosis, one should be certain to release the retraction on the
inferior border of the pancreas. If one continues to retract the pancreas in a
cephalad direction, this can result in a segment of splenic vein that proves too
long once the anastomosis has been completed, and the pancreas is allowed to
return to its normal position_
A l.5- to 2.0-cm long, but narrow ellipse of renal vein is removed along its
superior border. This ellipse occasionally includes the ligated stump of the
adrenal vein. Prior to performing the anastomosis the splenic vein is occl uded
toward its splenic end with a OeBakey bulldog clamp, and the straight Cooley
clamp is removed_The renal vein , which has been mobilized circumferentially.
is occluded proximally and distally with straight Cooley clamps.
The posterior layer of the splenoren?! anastomosis is performed first. \\-ith
a continuous 5-0 synthetic nonabsorable suture_ The su ture line is placed from
wi thin the vessels (F).
Although the anterior suture line can also be placed in a continuous
fashion, \\-e usuall\' place a series of interrupted ::i- Os\-nthetic nonabsorbable
sut ures' G, to a\-oid ;Ju~se5tringing_
Before the ii:-,a: S'~:'~~e is secured in :he anterior ro\\- of the anastomosis.
the OeBai-:e-.- b'JilC,:r,; ::2---:":;J :5 :-~:u...-cC irom the splenic \-tin. \\ith the Cooley
c1ar::ps s:ill ::-_ ;Jic'cc::-_ ::-_e :-e:-'- -.-ei:-:. ::' :iJl :i:e anastomosis \\irh blood and ro
 Ltga2ad coronary Y
Paoeas

SplenIC v

Adrenal v.

Superior Renal v.
mesenteric v.

Gonadal v. SplenIC v

'- Flen<3J Y.

Superior
mesenteric v.
Splen ic v.
oversewn

v.
\

Paoeas

----_ ::.plenlic v.
~=----_ Splerlic v.

Renal v.
Renal v.

27I
 modification of the distal splenorenal shunt can be performed

A whereby the body and tail of the pancreas are completely mobilized off
the splenic vein all the way to the splenic hilum. This modification
has been introduced in an attempt to prevent the development of
vascular collaterals between the mesenteric venous system providing prograde
flow to the liver and venous channels leading to the spleen that are
decompressed through the distal splenorenal shunt. The development of such
collaterals through the pancreas can obviate the selectiveness of this shunt and
result in mesenteric blood entering the systemic venous system and bypassing
the liver.
If performing this modification, the mobilization and cleaning of the splenic
vein circumferentially proceeds toward the splenic hilum until the body and tail
of the pancreas are actually completely freed all the way to the hilum. This
prolongs the operative procedure, but is felt by some to be necessary to insure
long-term success of the distal splenorenal shunt (H).
When one successfully constructs a selective distal splenorenal shunt (D,
portal hypertension persists in the mesenteric system and prograde flow
continues through the portal vein into the liver. In contrast, the pressure in the
gastroesophageal varices has been lowered by decompression through the short
gastric and left gastroepiploic vessels into the spleen, out the splenic vein, and
into the left renal vein. These two portal beds are further disconnected by
ligating the right gastroepiploic, the coronary, and the right and left gastric
veins (H).
If the coronary vein has not been ligated at its j unction with the portal
vein, it should be interrupted at the superior border of the pancreas. The
umbilical vein is also ligated at the point where the abdominal incision crosses
the ligamentum teres.
 .!i
Enure length
0/ splentc v.

Pa ..... eas ---c; -- - -- Spleen

Short
gastric
vv.

Ligated inferior
mesenteric v.

Paraesophageal vv.
Inferior
vena
cava

Splenic v.
Coronary v.

Portal v. _ _ _ _ __ _ _ _----:
" . l. gastroepiploic Y.

Pancreas _ _ _ __ _ _-;-

Divided
r. gastroepi ploic v. _ _ __ __ , ' ; .

1<~!lhE
,Mj~,, ' (r I

I u a:h" v
Portacaval Shunt

Operative Indications
oday most patients with liver disease, portal hypertension, and

T bleeding esophageal varices are managed nonoperatively with

sclerotherapy. Others with advanced liver disease and no hepatic
reserve are managed by hepatic transplantation. T here remains a
group of patients, however, with portal hypertension and bleeding varices that
cannot be controlled with sclerotherapy, but with enough hepatic reserve tha
they are not yet candidates for hepatic transplantation. These patient are
candidates for a mesenteric-system ic venous shunt.
Which shunt to use remains controversial despite decades of data coIled:im
and debate. The first shunts to be used successfully were the end-to- ide and
side-to-side direct portacaval anastomoses. Although used infrequently today,
these shunts still have their advocates. The end-to-side portacaval hunt can be
performed with moderate speed and only moderate blood loss. T hi bunt is
contraindicated in patients with intractable ascites , since sinusoidal pn:ssme-
not reduced with this procedure. Some surgeons continue to use this -
for emergency portacaval shunting, and some use it in the elective simatjra
The incidence of encephalopathy following end-to-side portacaval hunt-
significant, but its incidence compared to the side-to-side portacaval sh
remains unclear. Even though all prograde flow to the liver through the pala'J
venous system is obviously interrupted following an end-to-side hunt,
retrograde flow out the portal vein does not occu r, and many feel that endto-
side portacaval shunting carries with it a lower incidence of encephalopaID'
than the side-to-side sh unt.
The side-to-side portacaval shunt can be used in the presence of infractible.
ascites. Mesenteric pressure is not only reduced, but the portal vein i convata:
in to an outflow tract and sinusoidal pressure is lowered , thus effectively
eliminating ascites formation. It technically is a more difficult shunt to per f.......
and partial resection of the caudate lobe is often necessary to approximate the
portal vein and inferior vena cava. The shunt continues, however, to have its
advocates.
The newest of the portacaval shunts is the interposition "H" graft_This
involves interposing a prosthesis between the portal vein and inferior vena ca'r.L
If these prostheses are of sufficiently small diameter, advocates of thi
procedure claim that the shunt is selecti vc and that prograde flow through the
portal vein into the liver continues . Drops in portal pressure are more modesr
when small diameter interposition " H" grafts are used, b"J t in most in ra!lCfS
the drop in portal pressure is sufficient to eliminate subsequent esophageal
bleed ing.
It is im portant to note that he presence of any type of portacaval shunt
will significantly increase the technical difficulry of hepatic tran planratioo.
Accordin ly, none of these shun houId be employed in a patient who mil-p
e\-er be a transplant candidare In such an instance_ a mesocaval shunt is
preferable.
Small
bowel

Mesenteric v.
 Whiche\'er type of portacayal shunt is antripated all patients should
undergo angiography preoperati\·ely. This should include catheterization of tlv:
hepatic veins, with estimation of portal pressure by obtaining wedged hepatic
venous pressu res. In addition, mesen teric arteriography should be performed SII
that patency of the mesenteric venous system can be confirmed on the venous
phase.

Operative Technique
End-to-Side

hese portacaval shunt procedures are best performed through a long

'-
T right subcostal incision, often extended over to the left costal margin
The patient should be rotated 15 degrees to the left by placing a pack
under the right flank.
Upon entering the abdomen any ascitic fluid is suctioned free and the
abdomen is carefully examined for evidence of other pathology. If the liver has
not been biopsied preoperatively, a biopsy is performed. The diseased liver is
carefully examined for any evidence of suspicious nodules that could indicate a
hepatoma.
Portal pressure is often measured prior to performing the shunt (A). T his is
accomplished by threading a soft Silastic catheter through a small venotomy in
a mesenteric vein. A vein guide often aids in inserting the catheter into the vein.
The catheter length should be measured and inserted to the length determined
to place it in the superior mesenteric or portal vein. Utilizing a water
manometer, portal pressure is measured using the inferior vena cava as the zero
point.
The portal vein is exposed by opening the hepatoduodenalligament
laterally and well posteriorly. The biliary tree, which resides anterior and
slightly lateral to the portal vein, is gently retracted medially (B).
The gallbladder is often thickened, and somewhat tense, because of the
lymphatic hypertension. One should not confuse this with acute cholecystitis.
because removing the gallbladder unnecessarily will add greatly to the
morbidity and mortality of the procedure.
The hepatoduodenalligament should be opened widely from the duodenum
to the hepatic hilum. The portal vein should be mobilized and cleaned
circumferentially from the duodenum to the portal vein bifurca tion . Amazingly
few branches will require division. There is often a small branch from the right
branch of the portal vein into the posterior segment of the righ t lobe of the li\'er
that should be divided early to avoid injury (C ). In addition the coronary vein
may be encountered if the dissection proceeds far enough under the first portion
of the duodenum and head of the pancreas. This vein should be presen·ed.
 Common
-tI~!;-r------bileduel

Duodenum

Iv.

Pancreas

Duodenum
 nce an adequate length of portal vein has been mobilized, the inferior

O vena cava is exposed. The duodenum is kocherized. The overlying

serosa and areolar tissue should be clamped and ligated before
division. The retroperitoneum is rich with enlarged lymphatic and
venous channels. The electrocautery is usually not adeq uate to control bleeding
and the escape of lymph (D).
The duodenum is extensively mobilized to expose the inferior vena cava
from the level of the renal veins up to the point where is passes posterior to the
caudate lobe (E). It is not necessary to completely mobilize the inferior vena cava
circumferentially or to surround it with a vessel loop. The inferior vena cava
will be partially occluded with a Satinsky clamp along its anterior and lateral
surfaces, and circumferential mobilization is not necessary.
 ?ona: v

Duodenum

I
eR IN II
AtL t

\
Transverse colon

Y•

..... -cava

279
 ollowing circumferential mobilization of the portal vein and cleaning of

F the anterior and lateral surfaces of the inferior vena cava, one is
prepared to perform the end-to-side portacaval shunt As much length
as possible is obtained on the portal vein . This is accomplished best if
the right and left branches of the portal vein are identified, cleaned, and ligated
with 2-0 silk. The portal vein can then be occluded wit h a straight Cooley
clamp at the point where it arises from behind the pancreas.
The portal vein is divided just prior to its bifurcation into right and left
branches (F)- It is helpful for subsequent orientation to mark the inferior and
superior borders of the portal vein with fine traction sutures.
The portal vein is trimmed to the appropriate length (G). This is an
important step as one does not want redundancy or a portal vein that is too
short and results in tension. Often a slight bevel is required on the end of the
portal vein, but this varies and is determined by the anatomic relationships
between the portal vein and inferior vena cava.
The inferior vena cava is partially occluded with a Satinsky clamp (H). An
ellipse is removed from the anterior wall of the inferior vena cava. It is
important not to make this venotomy too long, otherwise the portal vein will be
stretched into a slit-like orifice.
The anastomosis is performed with continuous 5-0 synthetic
non absorbable suture material. Stay sutures are placed from outside portal vein
to within and from inside inferior vena cava to without, on both the superior
and inferior ends of the anastomosis. The superior suture is secured and then
passed to within the inferior vena cava. The left lateral suture line is run from
within the anastomosis. It is then passed back outside at the inferior limit of the
suture line and secured to the inferiorly placed stay suture.
The right lateral anastomosis is performed suturing from above downward
and then from below upward, meeting midway (I). Before these two sutures are
secured, the Cooley clamp on the portal vein is slowly opened to allow the
anastomosis to fi ll with blood and air to be excluded (I).
The completed shunt is a total portasystemic shunt, completely diverting
all mesenteric flow into the inferior vena cava (J).
 F

Caudate lobe

J:i

In ferior
venacava __________~~~.

)
./~
)
Superior
)
mesenteric v.

vena

Gaslroepiploic arcade

i
l \.

f
Side-to-Side

ome surgeons prefer a side·to-side portacaval shunt over an end·to-side

S shunt. This may be driven by personal preference or by massive

intractable ascites that would not be helped by an end·to·side
portacaval shun t. In addition, long·term patency rates are probably
highest for this shunt.
The initial steps in performing a side·to·side portacaval shunt are identical
to those in performing an end· to· side portacaval shunt. However, the portal vein
should be mobilized for a greater length under the first portion of the duodenum
and under the head of the pancreas to allow more mobili ty (K). This usually
involves ligating and dividing several branches that pass from the portal vein
along its anteromedial surface into the duodenum and the head of the pa ncreas.
In addition, more mobilization of the inferior vena cava is required, and this
often means circumferential mobilization with the passage of vessel loops.
The caudate lobe is usually interposed between the most cephalad portion
of the portal vein and the inferior vena cava. To insure tension·free
approximation of these two venous structures , it is often necessary to divide or
even to resect a portion of the caudate lobe. In the instance illustrated the
caudate lobe is small and is merely elevated out of the way by dividing several
small branches that pass directly from the parenchyma of the caudate lobe into
the inferior vena cava (L). Great care has to be taken in determining the areas of
approximation of the portal vein and inferior vena cava.
The inferior vena cava is partially occluded with a Satinsky clamp in the
direction of the portal vein (M). An ellipse is then removed obliquely from the
anterior surface of the inferior vena cava.
Straight Cooley clamps are placed proximally and distally to occlude the
portal vein and are then rotated so the inferior surface of the portal vein is
rotated into view. An ellipse of portal vein is then removed, corresponding to the
position of the ellipse removed from the anterior surface of the inferior vena
cava.
The side·to·side anastomosis is performed with a continuous 5-0 synthetic
nonabsorbable suture. Stay sutures are placed at each end of the anastomosis
by passing the suture material from outside in on the portal vein and inside out
on the inferior vena cava. The most cephalad suture is then secured, and one
needle is passed inside on the inferior vena cava. The anastomosis is run in a
continuous fashion, taking small bites so as not to invert a large cuff. At the
inferior end the suture is then passed outside on the inferior vena cava and
secured to [he second stay su ture (N).
 Conwnonbie
5

..
he ID
~

/,
;J

lobe

Infenor
vena cava
\Duodenum
Inferior vena
cava

Portal .

283
 he anterior suture line is completed by running sutures superiorly

T and inferiorly to meet midway. Before the sutures are secured, one of
the portal vein clamps is removed to allow the anastomosis to fill
with blood and air to be exuded (0).
The completed anastomosis should rest in a comfortable tension-free
fashion (P) obliquely on the inferior vena cava and in the direction of
the portal vein.
The completed side-to-side portacaval shunt is a total shunt that not only
shunts all mesenteric venous blood into the inferior vena cava but also in most
instances probably results in retrograde flow out of the liver (Q).
 PonaJ v
. Commonbdeu"'"-_ __
/

_ ---'-_ _ _ Duodenum

lobe

Side-la-side
portacaval
anastomosis

Spleen

Portal v. ---~

Splenic v.

Superior
Inferior vena - - --if-
mesenteric v.
cava

285
•
 Q:C:-:': ::: a :lc-,\' ::"-;>C 'j: ~1:-: 2.('a·.-~ ~:::.:.:--~ ·.;:c~ ::1::-I:C1;('K. ::-It:

R intcrpo,i:ion "H" grait. I: fia , brr:: "~ggc-,;ce :i:at i: this shunt is

;JCr:'ormed \\'ith a prosthesis oi an 2.pp~opriattl :: smail diameter. the
shunt is a selecti\'e shunt and does nOt result in IOtal d.i\·ersion oi
mesenteric flo\\' inlO the systemic yenous system. Ii a large prosthesis is used. a
marked fall in portal pressure resul ts, and IOta I diyersion of mesenteric blood
t10\\ into the inferior vena cava is produced. However, it is thought that if a
small prosthesis is used, portal pressure fall is less marked, and shunting of
mesenteric blood flow is not total. Angiographic data suggest that with a
successful small interposition graft, antegrade flow into the liver still occurs.
This has the theoretical advantage of lowering the incidence of portasystemic
encephalopathy that follows the traditional portacaval shunts.
The initial steps in performing a portacaval interposition "H" graft are the
same as if one is performing a standard portacaval shunt. The portal vein is
exposed by opening the hepatoduodenalligament latera ll y and posteriorly and
retracting the biliary tree in a medial direction. The inferior vena cava is
exposed by kocherizing the duodenum. It is not necessary to circumferentially
mobilize the inferior vena cava. Both the inferior vena cava and the portal yein
are partially occluded with Satinsky clamps (R).
The prosthesis is an 8· or lO·mm polytetrafluoroethylene graft. The
prosthesis is reinforced with external support rings. Since the gap between the
inferior vena cava and portal vein is short, these prostheses are only 3 or 4 cm
in length. Both ends are cut on a bevel to approximate the angle with which the
prosthesis will meet the venous structure and also to increase the size of the
anastomosis. The bevels are cut at gO·degree angles to each other. The
originator of the procedure feel s that it is important to soak the prosthesis in
heparin.
Following application of the partial occlusion clamp to the inferior vena
cava, a small ellipse is removed from its anterior surface. The originator of the
procedure feels that it is important to perform the anastomosis with a
continuous horizontal mattress everting suture. Both the right and left lateral
rows of the anastomosis can be placed from the outside.
When the caval anastomosis is completed, a small ellipse is removed from
the lateral wall of the portal vein, and an oblique anastomosis performed with
the prosthesis. The posterior row is placed from within the anastomosis.
However, it is placed again in a continuous horizontal fashion so that once it is
completely placed and drawn taut, the graft and vein are everted. The anterior
row is completed in a similar fashion (S).
Following construction of the shunt, major venous collaterals are diyidce.
The umbilical vein in the falciform ligament is clamped, divided, and ligated.
The gastroepiploic veins along the greater curvature of the stomach are ligatce.
The coronary vein is exposed, ligated, and divided from within the lesser sac.
along the superior border of the pancreas. The inferior mesenteric vein is
interrupted at the ligament of Treitz. The large paraesophageal veins
surrounding the esophagus are suture ligated and divided. The originator of this
operatiye procedure Ieels :hat di\'ision of collateral fl ow is important in directing
all portal flo\\' to'.':arcs ::-.c ::':cc anc shunt IT I.
Follo·,':i ~,g eli :::..,:: ':2.:-.::::", :,: }<~r: c.ca\·al shunt. the final step is often
,er.. ea S ".l,e::-:e~.: ,: :;< :-:~ : ;,::,,·~,e . :,. :: :2':~ : ':':: iC:en:ical to that ;>erformed at
:::c ':-c-f:-::--'::-.,; == ::-.:- ;:-:'::-:_:": -.' _~. ~:-:-.=-:: :-::-:~-::-_: e ri ..: ',-ei:1 i:. c2.n:1~:c:cC. -...itl: c
 Common bil e duct

Portal v.

+~cr, Portal v.

Inferior
vena
graft
cava - - - ,

JL..odenum

Short gastric vv.

-" =-=-=
~?~
Splenic v

--0::-- _

Superior .
mesenteric v. Small bowel

Mesenteric v.

J
:!as of Surgery

Direct Mesocaval Shunt

Operative Indications
he direct mesocaval shunt was introduced three decades ago for the

T management of esophageal variceal bleeding secondary to portal

hypertension in the pediatric age group. This procedure requires
division of the inferior vena cava and its use as a receptacle for
mesenteric blood. This is well tolerated in children. An attempt was made to
extend the use of this procedure to the adult. Edema and venous disease in the
lower extremities obviated its extension to adults. There currently is only
infrequent indication for portasystemic decompression for portal hypertension
and bleeding esophageal varices in the pediatric age group. Portal hypertension
in children is most often secondary to portal vein occlusion.
Mesenteric angiography is performed preoperatively to determine the
anatomy of the mesenteric venous system. The portal vein is usually
thrombosed, with significant cavernous transformation of the portal vein or
recollateralization. For the direct mesocaval shunt to be effective, it is es entia!
that the superior mesenteric vein be patent and in communication with the
major venous collaterals. This total shunt has demonstrated excellent long-term
patency in the pediatric age group and has been very effective in controlling
variceal hemorrhage.

Operative Technique
he operative procedure is performed through a midline incision. Upoo

T entering the abdomen the peritoneal cavity is explored for evidence Ii

other pathology. The liver usually is grossly normal. If it has not
been biopsied preoperatively, a liver biopsy is obtained.
The omentum and transverse colon are reflected in a cephalad direction (A).
A transverse incision is made in the root of the transverse mesocolon.
The dissection is deepened until the superior mesenteric vein is identified.
There are no clear landmarks to identify the superior mesenteric vein. The
superior mesenteric artery is usually to the left and often posterior to the
superior mesenteric vein. The relationships of these two vessels are inconstant,
however, and palpating for the superior mesenteric artery pul e i generally Ii
li ttle help in identifying the superior mesenteric vein . A the dissection is
deepened in the mesocolon, however, the superior mesenteric vein i always
easily identified.
 Transverse
cokln

!
Transverse ___...;-_ _ _ _ L_-'-
mesocolon

Superior
mesenteric v.
 here are many large lymphatic channels in the retroperitoneum, and

T these should all be clamped and ligated before division.

Once the superior mesenteric vein has been identified, it is
looped with vessel loops and mobilized for a length of several
centimeters (B). The superior mesenteric vein diameter is always greatest in its
most cephalad portion. Therefore, it is cleaned in a cephalad direction to the
point where it passes posterior to the neck of the pancreas. At this level major
branching has not occurred in the superior mesenteric vein, and the diameter is
generally quite large.
Large branches between the posterior and right lateral aspect of the
superior mesenteric vein and the uncinate process and head of the pancreas are
identified, ligated, and divided. The inferior mesenteric vein occasionally enters
the left lateral aspect of the superior mesenteric vein, and it is doubly looped
with a vessel loop for control. There frequently is a large branch emanating
from the posterior aspect of the superior mesenteric vein, passing directly
posteriorly (B). This vein is difficult to isolate, ligate, and divide and is best
controlled by double looping with a vessel loop.
Once a 5- or 6-cm segment of superior mesenteric vein is completely
mobilized, one is ready to expose and mobilize the inferior vena cava.
 Portasystemic Shu nts

/
 he right colon is completely mobilized out of the retroperitoneum

T towards the midline (C). The inferior vena cava is identified, cleaned,
and mobilized circumferentially along its entire length extending
from the inferior border of the kidney, down to and including its
bifurcation. Lumbar vessels are identified, doubly ligated, and divided. This
mobilization, which would be very difficult and bloody in the adult, is
accomplished more easily in the child.
Once the entire length, including the bifurcation, has been mobilized, an
acutely-curved DeBakey clamp is used to occlude the most cephalad portion of
the inferior vena cava (D). The left iliac vein is divided flush with the inferior
vena cava and the distal end oversewn with a continuous 5-0 synthetic
nonabsorbable suture.
The right common iliac vein is mobilized down to its bifurcation. This is to
provide additional length, in case the inferior vena cava itself is not long enough
to reach the superior mesenteric vein. It is necessary to identify, mobilize, and
retract the right ureter off the right iliac vein to avoid injury. The iliac vein is
then clamped with vascular clamps just prior to the take-off of the internal iliac
vein and divided.
 Inferior
~--~------~~-------- venacava

~ ______ ~~ _________ Aorta

Lumbar v.

A. iliac a. and v.

Right colon Duodenum

R. renal v.

~-- \leila
--
cava

L
--___ iiac v_

R iliac a and ,,_

R w eter
 he distal end of the right iliac vein is oversewn with a continuous 5-0

T synthetic nonabsorbable suture. A hole is made in the mobilized

mesentery to the right colon, just anterior to the duodenum, to allow
the inferior vena cava to be brought into approximation with the
superior mesenteric vein (£).
Prior to transposing the inferior vena cava, the medial and lateral aspects
of the right iliac vein are marked with sutures. This facilitates passing of the
inferior vena cava through the opening made in the mesentery to the right colon
and also helps the surgeon maintain orientation of the vein. The vein is then
passed through the window (inset) so that it can be approximated to the
superior mesenteric vein.
The inferior vena cava and right iliac vein are trimmed so that the
systemic vessel can be anastomosed to the superior mesenteric vein without
tension, but also without redundancy. Often the entire right iliac vein can be
excised (F).
 I
II
Tunnel
T ,.--'-;--'-- - - in mesocolon
Duodenum Tunnel

R. colon

~ TransversE
mesocolo-

Pancreas

R. colon
 he superior mesenteric vein is clamped proximally and distally with

T straight Cooley clamps. Any large branches into this segment of the
superior mesenteric vein, such as the inferior mesenteric vein, are
controlled with vessel loops.
An ellipse is excised from the right lateral wall of the superior mesenteric
vein (G).
An end·to·side anastomosis is performed with continuous 5-0 synthetic
nonabsorbable suture. Stay sutures are placed at either end of the anastomosis
passing from outside in on the superior mesenteric vein and inside out on the
inferior vena cava. The most cephalad suture is secured, and one needle is
passed on the inferior vena cava side to within the anastomosis. The posterior
row is then run in an over·and·over continuous fashion to the lower stay suture,
which is then secured. The needle is passed outside through the inferior vena
cava and tied to the lower stay suture. The running of this posterior row is
often made easier by placing stay sutures midway along the anterior wall of the
inferior vena cava and superior mesenteric vein (H).
Since this shunt is performed in children, the anterior layer should be
interrupted to allow for growth. This is performed by placing a number of 5-0
synthetic nonabsorbable horizontal mattress sutures everting the anterior
suture line (I).
This shunt is a total shunt diverting the entire mesenteric blood flow into
the end of the inferior vena cava (J). Since this shunt is usually done in the
presence of a thrombosed portal vein, the subsequent consequences of a total
shunt that are seen in adults with parenchymal liver disease are generally not
seen. However, emotional disturbances have been identified in some individuals
who have survived for many years after this shunt was performed in childhood.
 _ -',:;.---_ _ _ Superior mesenteri c v.

r'erior vena cava

Inferior
vena cava

-:-''::-___ Superior mesenteric v.

-'

Duodenum _ __ _ __ --''';-_

Superior
mesenteric v.
ts oi Surgery

Mesoatrial Shunt

Operative Indications
n most instances when portal hypertension is an indication for a

I mesenteric-systemic venous decompression procedure, the inferior vena

cava is used as the receptacle. In unusual instances, however, the inferior
vena cava may be thrombosed or have a venous pressure that approaches
the portal pressure. In those instances the inferior vena cava is not a suitable or
appropriate receptacle for a mesenteric-systemic venous shunt. The situation in
which this is most commonly found is the Budd-Chiari syndrome. In the Budd-
Chiari syndrome a significant percentage of patients have thrombosis of the
inferior vena cava as well as thrombosis of their hepatic veins. In others,
because of the marked congestion of the liver and hypertrophy of the caudate
lobe, the inferior vena cava is compressed, resulting in such a high pressure
that its use as a receptacle for a shunt is obviated.
In those instances when decompression of the mesenteric venous system is
deemed necessary, a mesoatrial shunt is the shunt procedure of choice. The
typical patient will be an individual with the Budd-Chiari syndrome, in whom
the diagnosis has been confirmed by liver biopsy and by attempted
catheterization of the hepatic veins.
Angiography should be performed to demonstrate a patent mesenteric
venous system. Inferior vena cavography should be performed to look for
inferior vena cava occlusion or an inferior vena cava compressed with
a high pressure.

Operative Technique
he mesoatrial shunt is performed through a long midline abdominal

T incision and a right anterior thoracotomy.

After entering the peritoneal cavity, the abdomen is explored to
rule out other pathology. The liver will be markedly congested (A). H
a liver biopsy has not been performed preoperatively, one should be performed.
Massive ascites will generally be present, and this should be suctioned fire.
Congested
liver

.~~~~~~~______________ Tr~
colon

299
 he initial steps of a mesoatrial shunt are identical to those of a

T mesocaval shunt. The transverse colon and omentum are reflected in

a cephalad direction. The root of the transverse mesocolon is
dissected to identify the superior mesenteric vein. There are no clear
landmarks to lead one to the superior mesenteric vein. The superior mesenteric
artery is to the left and posterior to the superior mesenteric vein. However , the
relationships of these two structures are variable and palpating for the superior
mesenteric artery generally does not help in identifying the superior mesenteric
vein. However, if the dissection is widened and deepened through the root of the
transverse mesocolon , the superior mesenteric vein is always identified (B).
There are many large lymphatic channels in the retroperitoneum, and to
decrease the amount of ascites form ation subsequently, these tissues should be
clamped, divided , and ligated.
Once the superior mesenteric vein has been identified, a 6- or 7-cm length is
mobilized circumferentially (C). Small venous branches are ligated and divided.
Large branches are controlled by doubly looping with vessel loops.
Once a long length of superior mesenteric vein has been cleaned up to the
inferior border of the neck of the pancreas, the root of the transverse mesocolon
is divided and the lesser sac entered (D). This requires exposing a short length
of the inferior border of the pancreas. It also often requires dividing sizable
arterial branches, occasionally including the middle colic artery, coursing
anteriorly from the superior mesenteric artery. If an artery is so large that one
is concerned with viability of the colon, the artery should be occluded with a
bulldog clamp temporarily to be certain that a good pulse remains in the
marginal artery.
- aarc sa

posterior
Large
branch
-------------1t~--~
of .
Superior mesenteric v.

Superior
mesenteric v.

Transverse
mesocolon

To lesser sac

t-l~-,-;~-~::----~. SuperIOr
II
•
: lIlae w..

Pancreas
 he prosthesis used for a mesoatrial shunt is a 16-mm Goretex graft

T with external support rings. In addition, an 8-cm Silas tic cuff is

bonded to the mid portion of the prosthesis. The Silastic cuff will be
positioned under the sternum to prevent compression of the graft.
In preparing the course for the mesoatrial prosthesis, one passes one's hand
into the lesser sac through the opening previously made in the root of the
transverse mesocolon. A second opening is then made in the omentum in the
midline, just below the gastroepiploic vessels.
The caudal portion of the prosthesis will pass from the area of the superior
mesen teric vein through the opening made in the root of the transverse
mesocolon into the lesser sac and then out the opening in the omentum. The
prosthesis then passes anterior to the stomach and anterior to the left lobe of
the liver.
A right anterior thoracotomy is then performed through the fifth
intercostal space.
Once the thoracotomy incision has been made, the abdominal and thoracic
wounds are connected by passing one's fingers directly under the sternum into
the anterior mediastinum and then out through the mediastinal pleura into the
right chest (E).
 Goretex graft

Silastic
cuff

/ -~, . /

Xiphoid
A. anterolateral
thoracotomy
inCISiOn

Stomach

~t:':""'-7}~~-------- Transven;e color.

~..
. .t:'
 he mesoatrial prosthesis is anastomosed first to the superior

T mesenteric vein. The superior mesenteric vein is occluded proximally

with an acutely·curved Cooley clamp and distally with a straight
Cooley clamp. A small ellipse is removed from the anterior surface of
the superior mesenteric vein.
The mesoatrial prosthesis is cut with the appropriate bevel. The
anastomosis is performed with continuous 5-0 synthetic nonabsorbable suture.
Mattress sutures are placed at each end of the anastomosis by passing the
suture material from outside in on the superior mesenteric vein, then inside out
on the prosthesis. The suture then passes outside in on the prosthesis and
inside out on the vessel (F).
The anastomosis is performed by first securing the most cephalad stay
suture and then running down the right lateral side with a continuous over-and-
over suture (G). It is tied to the secured inferior stay suture.
The right lateral suture line is then run from above downward and
downward up to meet in the mid portion of the anastomosis (H).
When the anastomosis has been completed, the prosthesis is clamped, and
one Cooley clamp is removed from the superior mesenteric vein to be certain
that the anastomosis is secure. The Cooley clamp is then replaced and the
prosthesis clamp removed.
 Transverse
:.-'l'' - - - -- - -- mesocolon

_---.:;~-:,.,:..T--------Goretex graft

)
( .

Superior
mesenteric v.

Gorelex
graft

Superior
mesenteric v. _ _ _ _ _ _ _-
 he atrial anastomosis is performed next. It is very important prior to

T performing either anastomosis to be certain that the prosthesis is

positioned so the Silastic cuff resides under the sternum and on top
of the hypertrophied left lobe of the liver. Once the position of the
Silastic cuff is determined, only then is the inferior prosthesis length determined
and the bevel cut.
After performing the anastomosis between the prosthesis and the superior
mesenteric vein, the pericardium is opened, and the right atrium and atrial
appendage are grasped in a Satinsky partial occlusion clamp. The clamp is
placed in the same oblique direction that the prosthesis enters the right pleural
cavity and approaches the atrium.
The atrial appendage is excised and the trabeculi within the atrial
appendage divided. The mesoatrial prosthesis is cut with the appropriate bevel
and to the appropriate length.
The atrial anastomosis is performed with continuous 4-0 synthetic
nonabsorbable suture. Stay sutures are placed at each end of the anastomosis,
passing from outside in on the atrium and inside out on the prosthesis (1). The
most cephalad stay suture is secured and then passed inside through the
prosthesis.
The posterior suture line is run from within over-and-over down to the
inferior stay (J). The suture is then passed to the outside of the prosthesis and
secured to the inferior stay suture. The anterior row of the anastomosis is then
completed by running the cephalad suture down caudally (K and L).
 •
.. ~
/ col "-
~

!
"-
~
. "'

lliJ
R atrium

.,lL- - Goretex - -
graft

Xi phoid

LNer

l
 nce both anastomoses have been completed with the vascular clamps

O on, a large bore 19-9auge needle is placed into the prosthesis at its
highest point where it passes over the left lobe of the liver (M).
The clamps are removed from the superior mesen teric vein, and
the prosthesis is allowed to fill with blood, evacuating all the air through the
needle. When one is certain that all air has been eliminated from the prosthesis,
the right atrial clamp is removed and flow is established.
Utilizing the previously placed needle, pressures can be measured. The
needle is connected via intravenous tubing to a water manometer. When the
prosthesis is clamped on the atrial side of the needle, the resulting pressure is
interpreted as un decompressed portal pressure. When it is clamped on t he
superior mesenteric venous side of the needle, the pressure is interpreted as
right atrial pressure. With no clamp, the pressure represents the decompressed
portal venous pressure.
Goretex _ _ _ _ _-'::..-
grall

~ si lasticc uff

Xiphoid

Transverse _ - -=--- - - - - Goretex

graft
colon

~r-------~~------ su~
mesenteric v.
 he most common route for the mesoatrial prosthesis passes from the

T superior mesenteric vein through the transverse mesocolon into the

lesser sac, out through the greater omentum anterior to the stomach,
and anterior to the left lobe of the liver. It then passes underneath
the sternum, protected from compression by the Silastic cuff, into the anterior
mediastinum, and then into the right chest to be anastomosed to the right
atrium (N).
Occasionally the liver is so hypertrophied and congested that the prosthesis
cannot easily pass anterior to the lower edge of the liver. In those instances we
have routed the prosthesis into the lesser sac, posterior to the stomach, and
through the diaphragm into the right chest just anterior and lateral to the
inferior vena cava. Thus the prosthesis passes from the superior mesenteric
vein into the lesser sac through the transverse mesocolon, posterior to the
stomach, then through the diaphragm into the right chest, prior to being
anastomosed to the right atrium. In these instances it is not necessary to use a
prosthesis to which has been bonded a Silastic cuff.
In the first instance the prosthesis passes directly posterior to the sternum
into the mediastinum and right chest, and in the second it passes through the
diaphragm, just anterior and lateral to the inferior vena cava (P).
 R. atrium - - - - -J::
\\ :_-';-_ _ Stern um

-4. - - - Silastic cuft

+-_____ G'oretex graft ____________----'\

~ -------------7~

~ ------------~. Pancreas _ _ --':-'-:''-

S:>peiiOl mesen eric v. _ __ _ _ _--',:\

f-- - -- Omentum
Duodenum ________~, \~
Transverse
mesocolon

Transverse
colon

\"'-+~-'--- _ _ Small bowel

Xiphoid

I
," ~,
... .. ., .

Diaphragm
In erior
venacava ________~~-=~~----_j"\
f)1.-- - - -- - --:--":-- -- - Esophag us

Vi

~------~----------- Aocm
 Le Veen Shunt

Operative Indications
ost patients with asci tes secondary to portal hypertension an3 -

M disease are amenable to medical management. T his might req -

severe sodium restriction and large doses of diuretics_ With
and appropriate medical management, however, most patients
with ascites can be managed satisfactorily. However, in some instances, even
with the strictest, most fastidious management, ascites will persist and be
intractable. Such patients are candidates for the LeVeen shunt. In addition,
there is a s maller group of patients with malignant ascites, whose overall stahl
of health suggests that they have a significant chance for continuing urvival
In these patients the inconvenience of massive ascites with pulmonary
compromise might be such that a LeVeen shunt is indicated.
Relative contraindications for performing the LeVeen shunt include
significant liver failure, with an uncorrectable coagulopathy or a serum
bilirubin greater than 10 mg%. Experience indicates th at few of these patients
do well. In addition, adequate renal function must be present as a successful
LeVeen shunt requires marked diuresis of the ascitic fluid shunted into the
vascular system. Lastly, there should be no history of heart failure, a a si7;lbl!!
volume load wi ll be placed on the heart following LeVeen shunt placement.

Operative Technique
Leveen shunt can be placed on either side, but generally the right siiI

A is preferred, as the thoracic duct is avoided. The transverse

abdominal incision to insert the one-way valve is placed 201" 3 ioc:Ir'
below the costal margin, in the anterior axillary line. The neck
incision to expose the internal jugular vein is placed obliquely along the auto.
border of the sternocleidomastoid muscle (A). The procedure can be perlarDlllld
under local anesthesia. With an ill patient with severe liver disease. local
anesthesia is an excellent choice. In other patients general anesthesia is wdI
tolerated.
The neck incision is made along the anterior border of the
sternocleidomastoid muscle and deepened down through platysma. The
sternocleidomastoid muscle is retracted laterally and the carotid pulse palpated
) The jugular vein will reside just lateral to the carotid artery (A).
The internal jugular vein is cleaned and mobilized for a 3- or 4-cm Ie
(B). Once the internal jugular vein has been mobilized adequately. the wound ~
packed with a sponge soaked in an antibiotic-containing saline solution_
 Internal jugular v.

ICff ,:1:1'
I,ll r.~

\ ,. ,

StemoCle;.:fonlasi,oiid m.

'-;-_ _ __ R. camtid a

Hema!
".
 '\:- - - - -_ _ _ __ Jl bclon1 inal incision

Small opening

Transversus abdominis m. ______ _ _~:,_~

Peritoneum _ _ _ _ _ _ _~
 variety of instruments can be used to make the subcutaneous tract

A that passes from the abdominal incision to the neck (E). We generally
have used bronchoscopy forceps with alligator tips.
If the procedure is performed under local, at this point the patient
should be mildly sedated, and the tract infiltrated with local anesthesia. Once
the instrument has been passed up into the neck wound over the clavicle (F), an
umbilical tape is secured to the instrument, and then retracted back down
through the tract (G).
Small oPI9nilng ._ _ _ _ _ _t/J~

Bronchoscooy
forceps

Subcutaneous
tract
 he LeVeen shunt valve with attached venous tubing is then

T positioned by first passing a tonsil clamp through the muscular

layers of the anterior abdominal wall to the area of the peritoneum
through which the LeVeen shunt valve will be inserted (H).
With the LeVeen shunt now positioned so that the tubing on the end of the
valve can be inserted into the peritoneal cavity (I), it is time to place the two
pursestrings in the peritoneum. The pursestrings consist of 2-0 or 3-0 synthetic
nonabsorbable suture material. The pursestrings are not placed until the valve
and its tubing are positioned for insertion, because as the sutures are placed
through the peritoneum, ascitic fluid begins to leak.
Once the two concentric pursestrings have been placed, a small opening is
made in the center (K). The LeVeen valve tubing is then inserted into the
peritoneal cavity. The abdominal tubing should be shortened prior to insertion
so that no more than 8 in are inserted into the peritoneal cavity.
 R-- - Peritoneum

Small oOl, ri il'o

in abdominal
wall muscles

_ _ _ _ _ Valve

___ Ve nous tubing

_ __ AhOOrnir,,'
tubing

Peritoneum

--------------- Umbilical tape

I
J~

....j

, .
<
 rior to inserting the Le\-een sbmn mlWng into the peritooeal canty,

P some oi the ascite5 can be ~ ~ suaioning .11. This ckrreases

the amount of ascites and endotoxin that \\'il\ enter the vascular spare,
thus decreasing the likelihood of disseminated intravascular
coagulation.
T he tubi ng is then inserted. maki ng an effort to guide it in a caudal
direction towards the pelvis (M ).
Once the abdominal tubing has been inserted and the valve seated, the two
pursestrings are secured. The outer pursestring is then further tied around the
valve neck to which the venous tubing is attached (N). The LeVeen shunt is
now seated such that it resides on top of the peritoneum, but underneath the
muscle layers of the anterior abdominal wall.
The venous tubing passes through a small hole in the muscle layers into
the subcutaneous space (inset). The end of the venous tubing is then tied to the
umbilical tape that resides in the subcutaneous tunnel (0 ). T he tubing is pulled
up through the track into the neck by withdrawing the umbilical tape into the
neck incision. The flow of ascitic fluid is immediately evident from the end of
the intravenous tubing. It is allowed to flow into a small basin.
 __~~______ .e~ bng

::;:::io:=t::::--- -- - - Periton eum

~-- ,,..~

Abdomina l wall muscles

Umbilical ----------
tape

'-.,;. ~:!'\-- " ~_~ Abdominallubing

) )

Peritoneum
enous ____ Valve

Venous tubing

Ven ous tubing

Peritoneum

Transversus m.
\
~__ Internal oblique m.

' -____ External oblique m.

'-________________~t~=======j-- Abdominal tubing

 he YenOU5 t'Jbing is then inserted into the internal jugular yein.. A

T pu.::etJing of -l-O synthetic nmabscrbabIe suture is placed in the

anterior wall of the jugular yein ,P '.
\\"ith the segment of internal jugular vein containing the
pursestring occluded proximally and distally \\ith \·esselloops, a small
\·enotOmy is made. The length of venous tubing to be inserted should be
carefully measured ..-illteriorly it can be brought out on the chest wall and CUt
off at the lewl of the second rib (Q). Generally this is a length of tubing that
extends into the jugular vein for approximately 4 to ;) in. The tubing hould
reside in the superior vena cava or right atrium. If it is cut too short and resides
in the internal jugular vein, malfunction and thrombosis will almost certainly
follow. It is important to have the catheter reside in the chest and be in the
environment of the negative intrapleural pressure.
Once positioned, the pursestring is secured (R), and then the vessel loops
removed (S).
An alternative means of securing the venous catheter in the internal
jugular vein is to place a ligature superiorly, and then after the venous tubing
has been positioned, place a 2-0 silk liga ture around the vein and tubing
inferiorly (T). Some feel this interruption of venous flow makes thrombosis and
malfunction of the shunt more likely. If one inserts the tubing through a
pursestring, flow continues in the jugular vein.
When the shunt has been successfully inserted, the abdominal tubing from
the valve will reside in the pelvis (U). Ascitic fluid will enter the tubing, traverse
the one-way valve being propelled by the positive intra·abdominal pressure
against a gradient of the negative intrapleural pressure. If the venous tubing is
appropriately placed, it will reside in the superior vena cava or right atrium..
At this point a fine needle should be inserted obliquely into the shunt
tubing, clamping the tubing distally, and fluid withdrawn until blood is seen.
The clamp is then removed and the blood shou ld be washed out, thus
confirming function of the shunt.
Contrast media can also be injected via the needle and radiographic
confirmation of function obtained. Radiographic confirmation of right atrial
placement of the shunt can also be obtained intraoperatively.

322
I

Lateral
jugular v. _

Internal
~jugUlarv_

H-- - R. carotid a. ve~ous _

tubing
_,./ "
i"
;;
:~
,
,~ \

:\
.'\\'
m /
7 )
- ;;::-
Tip in r. atrium

:: :
~ tI
,',
" "

"

:: "

..,
I.- ::
:,

.'
Abdominal tubing
--'--- _ __' _ Venous tubing
SecoOO nb~
.. /

/
to' III I

/
/'
/ '
The Pancreas
Longitudinal
Pancreaticojejunostomy:
Puestow Procedure

Operative Indications
atients with chronic pancreatitis, abdominal pain, and a dilated

P pancreatic duct are candidates for longitudinal pancreaticojejunostomy,

or the Puestow procedure. There is no evidence that endocrine or
exocrine insufficiency is improved by the Puestow procedure, but 75 to
85 percent of patients with pain achieve significant relief. Patients with
calcification in their pancreas appear to be more apt to benefit from this
operation than those without calcification. Among those patients with
abdominal pain secondary to chronic pancreatitis, less than 50 percent have a
dilated pancreatic duct (8 mm in diameter or greater) and are thus candidates
for the Puestow procedure. The remaining patients with abdominal pain and
chronic pancreatitis, without a dilated pancreatic duct, are candidates for an
ablative procedure if surgical therapy is required.

Operative Technique
he chain of lakes pattern of pancreatic duct dilatation (A) lends itself

T well to the Puestow procedure. This anatomic pattern is actually

seen somewhat less frequently than the pattern where the entire
pancreatic duct is dilated, without multiple intervening strictures..
The operative procedure can be done either through a midline or a bilateral
subcostal incision.
Once the abdomen is entered the pancreas is exposed through the lesse!" sac
by dividing the greater omentum (B).
COmmon ________~~----~
bile
duct

Superior
mesenteric
a and v.

Head of pancreas
Duodenum
Pancreaticoduodenal
arcade

Stomach

,
 he entire pancreas should be ellmed and palpated ilirougfi ~\es§

T sac and by kocherizing the duodenum. Once the tail, body, neck. ant
head of the pancreas have been e.xposed, the dilated pancreatic duel
frequently can be identified by finger palpation along the anterior
surface of the gland. Its position is confirmed by aspirating with a 19-9auge
needle and a 10·ml syringe (C).
Once clear pancreatic secretions are obtained, using an electrocautery a
pancreatotomy is made along the needle down into the dilated pancreatic duct
The needle is then removed, and a right·angle clamp is inserted into the dilate
duct. The duct is filleted open for its entire length using the electrocautery (DJ
Several studies have demonstrated that the pancreaticojejunostomy needs to 1
at least 6 em in length to maximize good long-term results.
Once the duct is filleted open, an attempt should be made topa a ~
dilator carefully into the proximal pancreatic duct, through the ampulla. and
into the duodenum. If this is not possible, some surgeons recommend
performing a duodenotomy and sphincteroplasty. This procedure is
demonstrated on pages 18-27. In addition, most pancreatic surgeons feel that a
cholecystectomy should be performed at the same time a Puestow procedure is
carried out if the gallbladder is still in place, even though definite gallbladder-
pathology may not have been demonstrated. The technique of cholecystectomy
is depicted on pages 2-9.
 Dilated pancreatic duct
Asplrabon of
dilated duct

' r - - - r - - - Dividett
orne

. '--_ _ _ Spleen

Stomach

Dilated
pancreatic duct

Pancreas
 RoUX-en-y jejunal loop 60 cm in length is constructed. It is our feel ing

A that the loop should be 60 cm in length, rather than 45 cm , for two

reasons: the longer loop should provide better protection against
reflux of enteric contents to the end of the jejunal loop; and if a
reoperative procedure is requ ired in the future and the Roux-en-Y anastomosis
has to be revised, there is enough length such that a new Roux-en-Y loop will
not have to be created_
During construction of the Roux loop, the jejunum should be divided as
close to the ligament of Treitz as good arcades will allow. It is often helpful ,
particularly with a fatty mesentery, to turn off the operating room lights and to
\-isualize the vascular arcade by having the headlight directed on the small
bowel mesentery (inset). Once a convenient area is located, the mesentery is
divided (E) and cleaned from the anti mesenteric surface of the bowel down
towards the root of the mesentery (F)-
 Pro"""a1 jejt.nJn

Vascular
arcade in
small bowel
meseme<y

Transillumination of Mesentery

rr--'":"-- -- - D,vided
vascular arcaoe
 nce the mesentery has been divided, the small bowel is divided with

O either a GIA stapler (G) or any number of intestinal clamps.

Following division of the bowel, the distal end of the jejunum
(which will become the proximal end of the Roux·en-Y jejunal loop) is
closed with an inverting layer of 3-0 silk sutures (H,I).
The sutures are then divided (J), except for the two end sutures, which are
kept to aid in passing the Roux-en-Y loop through a rent in the transverse
mesocolon (K) and into the lesser sac.
 Roux-€n-Y jejunal loop m
Staple line _ _ _ __

J
- - - - Mesentery

{fL

Opening in
transverse
mesocolon _~c-_-'--.J.~_ _ -I

Middle colic a. - - ';"'-:'--"':"':4

.,.-- ,: -- - -- Roux -en-y jejun al loop-----~,..+-

 nteric continuity is reestablished by an end-to-side jejunojejunostomy_

E The end of the proximal jejunum is anastomosed to the side of the

Roux-en-Y jejunal loop, approximately 60 cm from the closed end of
the Roux loop. The small bowel anastomosis is performed in the
classic fashion with an outer interrupted layer of 3-0 silk sutures and an inner
continuous layer of 3-0 synthetic absorbable sutures.
After the outer interrupted posterior row of silk sutures is placed (L), the
previously placed staple line is excised using the electrocautery. The inner
posterior layer of the anastomosis is then placed using a continuous locking
suture (M). This suture is continued as the anterior inner layer using a Connell-
type stitch (N).
The anastomosis is completed with an outer row of silk sutures on the
anterior layer of the anastomosis (0). The rent in the small bowel mesentery
can be closed with either interrupted 4- 0 silk sutures, as pictured here (P), or
with a continuous suture of 4- 0 silk.
 Outer layer of
posterior row
(r

Inner layer of
anterior row

.-

Roux-en-Y
// . jejunal _

.,0
~/~.f/ loop
~A
Outer layer of
,. anterior row
,

Mesentenc
defect

E::&&sode W no• unostomy

 nce the Roux-en-Y loop has been delivered into the lesser sac via a

O retrocolic approach, the longitudinal side-to-side

pancreaticojejunostomy is performed. When there is a very large
dilated duct, as pictured here, the anastomosis is performed in two
layers-an outer interrupted layer of 3-0 silk and an inner continuous layer of
3-0 synthetic absorbable suture. If the duct is dilated, but is less than 1 cm in
diameter, the anastomosis is generally performed with only the outer
interrupted layer of 3-0 silk, without placing an inner continuous layer.
The anastomosis is started by placing the outer layer of interrupted 3-0
silk sutures between the antimesenteric surface of the jejunal loop and the
inferior margin of the pancreatotomy (Q). The sutures on the pancreatic side
come out in pancreatic parenchyma, adjacent to the duct epithelium (Q).
Once this layer has been completed, an enterotomy is made in the jejunal
loop (R). The inner layer is then started utilizing an over-and-over locking stitch
of synthetic absorbable material (S). This stitch passes through pancreatic duct
epithelium (inset).
 Roux-en-Y
jejunal loop

Outer layer

I
,
Enterotomy

TNO-Iayer anastomosis

Inner layer
 he inner layer can then be continued along the upper line of the

T anastomosis utilizing either an over-and-over stitch as pictured here

(T), or the Connell stitch. This layer ensures good mucosal to
mucosal approximation (inset 1) between the pancreatic duct and the
jejunal loop.
The anastomosis is completed by placing the outer row of silk sutures
along the superior aspect of the pancreaticojejunostomy (U). This anastomosis
ensures excellent decompression of the pancreatic duct into the jejunal loop
with good approximation of the dilated pancreatic duct and the jejunal lumen
(inset 2).
 Inner layer

Two· /ayer anastomosis

Roux-en-Y
jejunal loop

Sp.eruc a and v.
Outer
layer

Pancreas Jejunum

Mesentery
Pancreatic
duel eprthelium ~I
... ( Io-mucosa anastomosis
 he procedure is completed by tacking the jejunal loop to the rent in

T the transverse mesocolon with interrupted 4-0 silks (V). The

Puestow procedure ensures excellent dependent drainage of the
pancreatic duct into a defunctionalized jejunal loop that resides
nicely in the lesser sac, passing down through the transverse mesocolon to
rejoin the enteric pathway (cross section). The anastomosis is drained with
Penrose or closed suction drains.
 SagJttaJ SecIJon

1-- - - - - Pancreas
Stomach
JL~----- Duct

~ _ _ __ ______ Duodenum Roux -en-Y

Transverse
mesocolon

Roux -en -Y
jejunal loop
"t
Omentum
Transverse
colon

,
\
\
\

,
\
\
Transyerse colon
, ,
I

Transverse
mesocolon tac ked
to jejunal loop

"'=-'-____ End-to-side jejullOjejw lOSU' '1

 cno-ro-tna t'ancreaucojejunostomy:
DuVal Procedure

Operati\-e Indications
he DuVal procedure is only infrequentl\- indicated. It is an operai: ::

T for patients with chronic pancreatitis, unmanageable abdomina:

pain, and with a single stricture in the pancreatic dUCL This
generally follows trau ma, where the pancreas has been injured (;.- i:~
the spine, resulting in a single duct injury, with a normal proximal duct. T ht
distal duct is dilated beyond the stricture. In this situation, many surgeono
perform a longitudinal pancreaticojejunostomy (puestow procedure) in
preference to performing the end-to-end pancreaticojejunostomy (D u\'al
procedure), Occasionally, however, instead of the Puestow procedure, \\'hico
does not require a splenectomy, surgeons may choose to perform the Du \ 'al
procedure, which usually is performed with a splenectomy .
•

Operative Technique
ither a midline or a bilateral subcostal incision can be utilized. T~t

1
'i
E lesser sac is entered by dividing the greater omentu m. T he E:n:~ri:
pancreas should be exposed and palpated through the lesser sac ane
by kocherizing the duodenum, The spleen is mobilized out of the
retroperitoneum (A).

: . ,"
.~ -
 Stomach

Solenoc,n liic ligament

Transverse colon

Dilated
greater pancreatic
omentum duct
 he splenic artery is identified along the superior surface of the tail of

T the pancreas, triply ligated, and divided (B). The spleen and tail of
the pancreas are further mobilized out of the retroperitoneum. The
splenic vein is dissected out of the groove on the posterior aspect of
the pancreas, triply ligated, and divided (C).
Following division of the vasa brevia between the stomach and the superior
pole of the spleen and division of the splenic attachments from the inferior pole
to the colon, the tip of the tail of the pancreas is divided with the electrocautery
(D). At this point, if adequate pancreatography has not been obtained prior to
surgery, it can be performed in a retrograde fashion.
 Spleen
t-__ Spleen

Tail of pancreas

Splenic a.
splenic a

Splenic v.

Tail of pancreas

_ _ _ Spleen
 Roux-en-Y jejunal loop 60 cm in length is constructed as depicted on

A pages 330-335. The end of the Roux-en-Y loop, however, is not closed.
After the loop is brought into the lesser sac through a rent in the
transverse mesocolon, an end· to-end pancreaticojejunostomy is
performed. A two-layer anastomosis is performed, invaginating approximately
11/2 in of pancreas into the jejunum. This is carried out utilizing an outer
interrupted layer of 3-0 silk and an inner interrupted layer of 3-0 synthetic
absorbable suture (E). Two or three of the inner-layer synthetic absorbable
sutures are passed through the dilated pancreatic duct (F).
 Divided
greater

,,
l

,,
Opening in Iransverse
mesocolon

Inner layer
(includes ducI)

DIlated
pancreatic duct - - --If'---BUi

End-la-side
jejunojejunostomy

Roux-en -Y
jejunal loop
 he inner layer of synthetic absorbable sutures is placed in an

T interrupted fashion for the anterior row of the anastomosis. Again,

two or three of these sutures are passed through the dilated
pancreatic duct (G).
The anastomosis is completed by an outer interrupted layer of 3-0 silk
sutures placed in the pancreas approximately 11/2 in from the end of the
divided pancreas and in the jejunum 11/2 in from the end of the jejunal loop
(H). This results in an invagination of the pancreas into the jejunal loop for
approximately 11/2 in (inset). This anastomosis utilizes the invagination
technique, but it also results, in part, in a mucosa-to-mucosa anastomosis
between the dilated duct and the jejunal loop.
The operative procedure is completed by tacking the jejunal loop to the
rent in the transverse mesocolon using interrupted 4-0 silks. The
anastomosis is drained by placing Penrose or closed suction drains adjacent
to the anastomosis and by bringing them out through a stab wound in the
left upper quadrant.
 QuterJayer

Roux-en -Y ---~:.....::'-­
jejunal loop

OJ End-to-end
Pancreaticojejunostomy j

Dilated
Stomach pancreatic
duct

,'-.

-.'
Invaginated pancreas

- -f-......:-=-- ' - - - - - - Roux-en -Y

jejunal loop

Duodenum

End-to-side
"li~ _ _ _ __ __ jejunojejunostomy
Distal Pancreatectom for Chronic
Pancreatitis

Operative Indications
he majority of patients with chronic pancreatitis do not have a

T dilated pancreatic duct and are not candidates for a Puestow

procedure. Thus, if surgical therapy is required for pain control, an
ablative procedure has to be performed.
In chronic pancreatitis the gross disease distribution can take several
patterns. Often the disease seems to be most severe in the body and tail, with
relative sparing of the head and uncinate process. This pattern is often seen in
patients with distal chronic pancreatitis secondary to trauma, where the main
pancreatic duct overlying the spine has been injured. This pattern is seen less
frequently with alcohol-induced chronic pancreatitis. When this pattern i
present, however, it lends itself well to distal pancreatectomy. The cla ic distal
pancreatectomy is performed over to the superior mesenteric vein and i
referred to as an 85 percent distal pancreatectomy.

Operative Technique
he operation can be performed through either a midline or a bilater.ll

T subcostal incision. Once the abdomen is opened the lesser sac is

entered by dividing the greater omentum. The entire tail, body, and
neck of the gland can be exposed (A) and palpated through the !esse:
sac, and the extent of the disease can be evaluated.
The duodenum is then kocherized and the head and uncinate process
carefully palpated (B). If it is felt that the head and uncinate process are
reasonably normal and that most of the disease resides in the body and taiL a
distal 85 percent pancreatectomy can be initiated.
 Divided
omentum

Pancreas

Strictured pancreatic duct

Gallbladder - - - = ---1

'~\J-'t~fi~=l-::----"--:------ Kocherized duodenum

iJ~~~1'i:t:>::-;-:-''\----- Pancreas
 he spleen is mobilized out of the retroperitoneum (C). The vasa

T brevia are then divided, as well as the attachments between the

lower pole of the spleen and the omentum and splenic flexure of the
colon (D).
 ;

Stomach

\i-- - Spleen

- -- - Colon

Pancreas
 he tail and body of the pancreas are mobilized out of the

T retroperitoneum (E). Care should be taken to avoid injury to the

inferior mesenteric vein and its junction with the splenic vein (see G
and H).
Once the tail and body have been mobilized out of the retroperitoneum, the
spenic artery is identified at its origin from the celiac axis. The artery is triply
clamped, divided, and triply ligated (F).
 __ ~_----- Stomach

- Retroperitoneal bed

S :

Cetiac
axis
Stomach

Ouooenum

Pancreas
 he posterior aspect of the body of the pancreas is further mobilized

T out of the retroperitoneum until the inferior mesenteric vein is

clearly identified as joining the splenic vein (G). At this point the
splenic vein is cleaned distal to its junction with the inferior
mesenteric vein, triply clamped, divided, and triply ligated.
From this point on the splenic vein should be preserved and carefully
dissected away from the posterior aspect of the pancreas. Much of this can be
done bluntly, but there are small veins between the pancreas and the splenic
vein that need to be identified, ligated, and divided.
The dissection along the splenic vein is continued until the splenic vein
joins the superior mesenteric vein to form the portal vein (H). At this point one
is at the neck of the pancreas, and the dissection is stopped.
aspedol
paiUea5I

we:::c-=---____ Retroperitoneal bed

Inferior
mesenteric v.

Head of
pancreas

Inferior mesente ric v.

Superior
mesenteric v.

Splenic v.
 rior to dividing the neck of the pancreas, a row of 3-0 synthetic

P absorbable mattress sutures is placed overlying the portal vein and the
superior mesenteric vein (I). One has to take care to snug these sutures
down firmly enough to achieve hemostasis, but not so hard as to cut
through the parenchyma. If the gland is markedly fibrotic in this area, these
sutures are easily placed. However, if the pancreas is relatively normal in this
location, great care has to be taken.
Once the row of sutures has been placed, the neck of the gland is divided
with the electrocautery (J).
A second row of synthetic absorbable 3-0 sutures is placed in a figure·of·
eight fashion over the end of the pancreas (K). A separate suture is placed in a
mattress fashion around the divided pancreatic duct, if it can be identified.
The inset demonstrates the portion of pancreas that has been removed.
 Spew:
aandv.

Be enc-,

Portal v.

\
Overlapping
mattress
sutures

Pancreatic Inferior
neck mesenteric v.

Superior
mesenteric
v. and a.

Uncinate
process

Inferior
pancreaticoduodenal
vessels

Portal v.

Head of
pancreas - - -.3",,;,------'';7.
Neck of
pancreas

Superior
mesenteric v.
 n alternative method for dividing and oversewing the pancreas is

A shown. Utilizing the electrocautery, the neck of the pancreas is

divided with a beveled cut (L).
Once the specimen is removed from the operative field, a
mattress suture of 3-0 synthetic absorbable material is placed around the
pancreatic duct (M). Utilizing vertical mattress sutures of 3-0 synthetic
absorbable material, the end of the pancreas is closed (N). With this technique
good approximation can be obtained between the anterior and posterior capsules
of the pancreas.
Whichever technique for closure is used, the pancreas is drained with
either Penrose or closed suction drains placed near the end of the pancreatic
remnant and brought out through a stab wound in the left upper quadrant.
 Be ' 'cut

Neck of pancreas

Superior mesenteric v. and a.

_________ Proximal jejunum

Duodenum

Ligating
pancreatic
duct

Superior
j,-..'''-C-!:'--~-------- mesenteric
v. and a.
:\.,i-;.....~-------- Unci nate process
Ninety-Five Percent Distal
Pancreatectomy for Chromc
Pancreatitis

Operative Indications
or the patient with chronic pancreatitis and a nondilated pancreatic

F duct, with uniform severe involvement of the entire gland, few

operative procedures ar!! available. One can perform a
pancreaticoduodenectomy (Whipple procedure). This is a major
operation that requires one enteric and two ductal anastomoses for
reconstruction. Distal 95 percent pancreatectomy has some appeal in that it
removes virtually all of the pancreatic tissue but does not require an intestinal
or ductal anastomosis. Its major disadvantage is that most patients who are not
insulin dependent prior to the procedure will become insulin dependent after
this major resection. Virtually all of these patients will already be exocrine
insufficient and thus will already be on pancreatic enzyme supplements.
Another disadvantage of the operative procedure is that some pancreatic tissue
is left behind, and an occasional patient will continue to have mild to moderate
symptoms because of the pancreatic remnant. It has proven, however, to be a
procedure that can be safely performed with low mortality and morbidity and
with good to excellent results in the majority of patients.

Operative Technique
his procedure will be demonstrated as an extension of Distal

T Pancreatectomy for Chronic Pancreatitis (pages 350-361). Once the rail..

body, and neck of the pancreas have been mobilized away from the
splenic, portal, and superior mesenteric veins, the uncinate process is
exposed by dissecting the lateral and posterior aspects of the superior
mesenteric vein away from the pancreatic tissue (inset). The superior
mesenteric vein must be retracted medially to the extent that the superior
mesenteric artery posterior and medial to it is exposed. This allows dissection of
the uncinate process away from the superior mesenteric artery. This is done
with the operator's left hand placed posteriorly, behind the extensively
kocherized duodenum and head of the pancreas.
Once the uncinate process has been mobilized, it can be grasped with
clamps so that further dissection from under the superior mesenteric vein and
away from the superior mesenteric artery is facilitated. At this point all of the
pancreatic tissue, except for that portion that resides in the duodenal C loop,
has been mobilized. The tail, body, and neck of the pancreas have been
mobilized out of the retroperitoneum. The uncinate process ha been mobilized
from underneath the superior mesenteric vein and portal \-ein and away from
the superior mesenteric anery.
Prior to di\icling the pancreas in the duodenal C loop, it is essential that
either a Bakes dilator or a balloon catheter is placed in the commoo duct down
through the ampulla into:hf CuOOffiUIn ,,,\I. If a cholecystectomy bas DOl
 Uncinate process
Head of pancreas

Gallbladder fossa

Balloon catheter

Kochenzed
duoden.rn
previously been performed, it is performed, and a balloon catheter is passed
through the cystic duct into the ampulla. This allows one to identify the
location of the common duct as it courses through the posterior aspect of the
pancreas, medially to the second portion of the duodenum, before coursing
laterally to enter the duodenum via the ampulla. If the gallbladder has been
removed previously, the common duct should be opened and a Bakes dilator
passed through the ampulla into the duodenum.
Once the course of the common duct has been identified, using the
electrocautery, the pancreas is divided as close as possible to the duodenal C
loop, while carefully staying away from the common duct (A). The inferior and
superior pancreaticoduodenal vessels course in the groove at the junction of the
pancreas and the medial aspect of the duodenal C loop. There is little danger of
injuring these vessels, since one needs to stay at least 0.5 cm away from the C
loop to avoid injuring the common duct. There is both a posterior and an
anterior pancreaticoduodenal arcade, and as long as one of these arcades is left
intact, there is no concern about duodenal viability.
Once the pancreatic tissue has been completely divided, one is left with a
strip of pancreatic tissue in the duodenal C loop (B). The pancreatic duct is
identified and sutured with a mattress suture of 3-0 synthetic absorbable .
material. The remnant at this point is small, unless the head of the pancreas is
markedly enlarged; in the latter case a relatively broad remnant of pancreas is
left behind. It is in these patients that further symptoms are occasionally seen.
In most instances, however, most of the pancreatic tissue can be shaved away
from the duodenal C loop without risk of injury to the common duct or vascular
supply to the duodenum. The remnant is drained with either Penrose or closed
suction drains that are brought out through a stab wound in the left upper
quadrant.
 SpIefw: Y.

PonaJ v.

Cyslic duct stump

Stomach

Galtbladder
fossa

Retropeo beaJ
bed

__ ~~ __ ~ ____ T~

colon

Inferior mesenteric v.

Superior mesenteric v.

Pancreatic remnant
Pancreatic duct
Superior
pancreaticoduodenal
vessels
Accessory Duct Papillotomy for
Pancreas Divisum

Operative Indications
ancreas divisum is a relatively common anomaly of the pancreatic

P ductal system that is present in as many as 7 percent of the general

population. Whether or not this anomaly, which results from a failure
of fusion of the dorsal pancreatic duct and the duct draining the
uncinate process and head of the pancreas (A), is causative in producing
pancreatitis and abdominal pain remains unclear. There is some evidence to
suggest that abdominal pain associated with amylase elevations may occur
when this anomaly is associated with a relative mucosal stenosis of the
accessory papilla.
Clinically this combination of pancreas divisum associated with abdonUnal
pain and hyperamylasemia is seen most often in young females. If the
combination of abdominal pain, hyperamylasemia, and pancreas divisum is
present and no other causes of pancreatitis can be identified, many surgeons feel
that an accessory duct papillotomy is indicated. Some authors report success in
the range of 70 percent in ameliorating abdominal pain when these conditions
are met.

Operative Technique
he abdomen can be entered through either a midline or a right

T subcostal incision. If the gallbladder is still present, a

cholecystectomy is generally performed. This is to eliminate any
possibility of the gallbladder playing a role in the pancreatitis. Othus
have also suggested that a sphincteroplasty of the main ampulla should be
performed as well. These procedures are described on pages 2-9 and 18- 27
respectively. Only the accessory papillotomy will be described here.
A longitudinal duodenotomy is performed after palpating the ampulla to
identify the location for the enterotomy (B). The accessory papilla is generally 1
to 2 cm proximal to the main ampulla and about 0.5 cm more anteriorly located.
Once the duodenotomy has been performed, the accessory papilla and its
pinpoint opening usually can be identified with careful palpation and
visualization. We prefer routinely to give secretin (inset), because this makes
identification of the opening certain, and the flow of pancreatic juice allows for
easier, safer cannulation with a small lacrimal duct probe.
One has to be certain to cannulate the accessory papilla atraumatically (C).
It any trauma occurs and edema and/or a hematoma results, thereafter
cannulation is virtually impossible. If one takes great care, however, the
accessory papilla can always be identified and safely cannulated.
 Common dud _ _ _--;:

T
Accessory ---~---;-,i~~cr;:;
papilla
Accessory
papilla

Ampu lla - -- -t;;:-- -"

Duodenum

Duct to uncinate process

Secretin InjecUon

Accessory
papilla

Duodenotomy

Lacrimal duct
probe

Duct to uncinate
process
 nce a small lacrimal duct probe is inserted, a papillotomy is performed

O using the electrocautery. Because the dorsal pancreatic duct enters the
duodenal wall and accessory papilla perpendicularly, unlike the main
ampulla, the papillotomy can be extended for only a 3 to 4 mm length.
Once the papilla is opened, the ductal and duodenal mucosa are
approximated with interrupted 5-0 synthetic absorbable sutures (D).
When the papillotomy is completed, the largest lacrimal duct probe and/or
the smallest Bakes dilator should be accommodated (E). Following the
papillotomy, pancreatic juice, which initially spurted out of the ampulla with a
stream, flows out easily and rapidly, unimpeded.
The dUodenotomy is closed with an inner continuous layer of synthetic
absorbable 3- 0 suture placed in a Connell fashion. The outer layer is placed
using interruped 3- 0 silk sutures. The duodenotomy is drained with Penrose or
closed suction drains.
o

Papillotomy

Duodenal
"""" ' ~='-_ mucosa

Duct
mucosa
 Drainage of Pancreatic Pseudocyst
into Roux-en-Y Jejunal Loop

Operative Indications
pancreatic pseudocyst results from disruption of the main pancreati

A duct. This often is associated with an episode of acute pancreatitis,

but a pseudocyst can also develop in the setting of chronic
inflammation. Even less commonly, a pancreatic pseudocyst can
develop following trauma or behind a pancreatic neoplasm.
Many pancreatic pseudocysts resolve spontaneously. The duct disruptiao
will cicatrize close, and the pancreatic secretions in the cyst will be rapidly
reabsorbed. If the cyst does not resolve, operative drainage is required foc IDOS
cysts over 5 cm in diameter.
Pseudocysts can cause pain, duodenal obstruction , and biliary obst:ructim
they can erode into adjacent structures, most commonly colon; they can bema
secondarily infected; and they can be associated with hemorrhage, often from
false aneurysm bleeding into the cyst. For these reasons most pseudocysts 1M
5 em in aiameter tnE! do not spontaneously resolve after a period of observatiI
and/or remain symptomatic should undergo drainage. The drainage Plotl'iiw ~
of choice, if the cyst can be drained dependently, is through the transverse
mesocolon into a Roux·en·Y jejunal loop.

Operative Technique
ither a bilateral subcostal or a midline incision can be used.. In this

E example a sizable pseudocyst can be visualized and palpated bebinr

the stomach (A). Since the cyst is directly behind the stomach, wid:
the posterior wall of the stomach comprising the anterior wall d tb
cyst, it could easily be drained via a cystogastrostomy. However, to avoid t:bI'
constant alkaline bathing of the antrum that results following a
cystogastrostomy, and to eliminate the small incidence of bleeding following
cystogastrostomies, we favor a cystojejunostomy whenever possible.
Hepatic _ _ , _ ;.-
flexure of
colon

.....'."!I
:;."
·':';I
,

Ome ntum
 fter retracting the transverse colon in a cephalad direction, the

A pseudocyst can be seen presenting through the transverse mesocolon.

This allows ideal access for dependent drainage into a Roux-en·Y
jejunal loop.
At this point the cyst is aspirated to confirm its presence in the area
palpated (B). Do not remove all the cyst contents, as this will make subsequent
entry into the cyst more difficult.
If there is any discrepancy between the size of the mass that is palpated
and the size of the cyst identified on CT scan or sonogram, a cystogram can be
performed by injecting contrast media into the cyst and taking an operative
radiograph. This operative radiograph ought to produce an image that
corresponds to the size of the palpable mass. If it doesn't, one has to be
concerned that there may be a second pseudocyst or a loculated pseudocyst that
would not be drained entirely through the access route identified with the
needle aspiration.
 Transverse colon _ __ ----;?-_~~_ ·

~ransverse m,'socolon .---:!t~-,...,.-'!~f-~-2f~~'-=::-

Pseudocyst - ---i7l-:;....------;.T.!--,.!""ll""--c

"" I
 RoUX-en-y loop 60 cm in length is constructed. Although it is probably

A satisfactory to construct a Roux-en-Y loop as short as 40 or 45 cm, we

favor the longer loop. This ensures that reflux of intestinal contents
up to the end of the Roux-en-Y loop will not occur. In addition, if the
patient has to be operated upon in the future and the end of the Roux-en-Y loop
must be sacrificed, the loop will still be long enough to reuse. Construction of
the Roux-en-Y jejunal loop has previously been described on pages 330-335.
The Roux-en-Y loop is placed in a comfortable position adjacent to the cyst,
which has been previously identified by needle aspiration. The
cystojejunostomy is performed in two layers. The outer posterior layer consists
of a series of interrupted 3-0 silk (C).
 Transverse colon _ _ ~:--==.:;=.'-

Pseudocyst- - -",f-- -- - - -i-- -,::c---- - - -

- ransverse - - - -T.-- - - - -- .}-- -- -

mesoco!on

./
/

Roux-en-Y
jejunal loop

a
 fter the outer posterior layer is completed, an opening is made into the

A cyst. This can be performed with either a scalpel or with the

electrocautery. Once the cyst is opened the contents are aspirated
with the suction (D).
A section of the cyst wall (E) is excised for frozen section, to eliminate any
concern about the lesion being a cystic neoplasm.
The inner layer of the posterior row is then placed using a continuous
locking suture of 3-0 absorbable synthetic suture (F). It is continued anteriorly
for the inner layer with a Connell type stitch (G). We prefer a synthetic,
absorbable suture, rather than chromic catgut, because chromic catgut is
dissolved by pancreatic secretions and the synthetic suture materials are not.
 Pseudocyst ------''--c;---i~--=--------

Middle colic a . _ _ __ --==---.!:..._ _ _ _ _.

Cystotomy _ __ _ __ _ _ __ _ _ _ _ _~~

Outer layer

Roux-en- Y----1--
jejunal
loop

I!

Inner layer
of posterior
row

Inner
layer 01
ameriof-
ro,'(

Enterotomy
 he outer interrupted layer of the anterior row is completed with 3-0

T silk (H).
Once the anastomosis is completed one should be able to easily
palpate a sizable anastomosis (I). The anastomosis is drained with
Penrose or closed suction drains.
The inset depicts the anatomy from a lateral view. In this instance the cyst
is firmly adherent to the posterior wall of the stomach, so a cystogastrostomy
could easily have been performed. However , as this diagram demonstrates, a
Roux-en-Y jejunal loop provides ideal dependent drainage to a segment of the
intestinal tract that is defunctionalized.
 live< ----;---r-~...

Outer layer of
anterior row

DuCI ----f~_T~~--~~~~ ·

Transverse mE'so,col,Dn--i-----:i~;::r;,~

)( Transverse cOlon ------1---- ---'Tf-

Omenlum - - f - - -_ _ ---;'J

Transverse colon - ----.!c....;-:--,,----

I
Roux-en-Y
jejunal loop

Cystoje)unoslomy - - -- -- - - -- -} l

Roux -en- Y _ _ _ ' -_

jejunal loop

_I
Atlas of Surgery

Drainage of Pancreatic Pseudocyst

into the Stomach

Operative Indications
he operative indications for drainage of a pseudocyst into the

T stomach are the same as listed for Drainage of Pancreatic PserIdoq

into a Roux·en· Y Loop (pages 370- 379). Drainage of a pseudocyst ir-
a Roux·en·Y loop is our preferred approach. However, in some
instances the cyst resides high in the abdomen and does not present throug.
the transverse mesocolon, so that dependent drainage with a Roux-en·Y jejur
loop is not possible. In most of these instances the cyst is adherent to the
posterior wall of the stomach: the posterior wall of the stomach makes up tIr
anterior wall of the pancreatic pseudocyst (inset). In this instance
cystogastrostomy is the operative procedure of choice.

Operative Techinque
ither a bilateral subcostal or a midline incision is appropriate. OnCE

E the abdomen is entered the pseudocyst can be easily palpated and

visualized as displacing the stomach. Stay sutures of 3- 0 silk are
placed in the anterior wall of the stomach and a gastrotomy is
performed with the electrocautery (A).
r The location of the cyst is confirmed by aspirating through the posterio£
wall of the stomach into the cyst with a 19-9auge needle and a 1O-m! syringe
cross section). Not all of the cyst contents should be aspirated, as this will rna
subsequent entry into the cyst more difficult.
If there is a discrepancy between the size of the palpable mass and the -
or number of pseudocysts as identified preoperatively by CT scan or sonogrm::;
a cystogram can be performed by injecting contrast media into the cyst a.n<t
performing an operative roentgenogram.
The cross section demonstrates the anatomic relationships between thf
pancreas, the disrupted pancreatic duct, the pseudocyst, and the stornacb.. T

that the posterior wall of the stomach comprises a portion of the anterior wa
the pseudocyst.
 Gasu ...... lly

liver

Stomach

(,)f<I""IEI
ISANDONE
Sagittal Section

Hepatic flexure

Liver _+-__ ---,~....!.--

Pancreas_+-_ _~~~~~~~=--~~~

( duct

Aspiration

Omentum

Transverse colon

Transverse lies ' ... -.

 fter the position of the pseudocyst has been confirmed by needle

A aspiration, the cyst is entered by incising through the posterior wall

of the stomach using the electrocautery (C). A portion of the cyst wall
is sent for frozen section to be certain that one is not dealing with a
cystic neoplasm (D).
If the incision into the cyst does not appear to gape widely open, an ellipse
of stomach and cyst wall can be excised. Once good communication between the
stomach and cyst cavity has been established, the edges of the pseudocyst and
stomach are sutured together with a continuous locking suture of 3-0 synthetic
absorbable suture (E). This row is placed primarily for hemostasis, but it also
probably aids in keeping the communication between the cyst and the stomach
open until the cyst has collapsed and resolved (inset).
The anterior gastrotomy is then closed with an inner layer of 3-0 synthetic
absorbable suture placed in a continuous Connell fashion. The outer layer is
placed utilizing interrupted 3-0 silk sutures (F).
 Stomach _ __ ~ _ _

Posterior wall _---:-''';;---;-__ ~

gas otomy

I (
Biopsy of
cyst wall
j

Anterior
CORINNEI
ISANDONE. and
Posterior _ __
wail of
stomach

cavity

\
J

Closure of gastrotomy

Cyst wall

Posterior wall
of stomach
Urajnage ot Pancrea udocyst
into the Duodenum

Operative Indications
he vast majority of pseudocysts can be drained into a Roux-en-Y

T jejunal loop or into the stomach_ Rarely, however, a pseudocyst i

located in the head of the pancreas, so that the only option for good
dependent drainage is into the adjacent duodenum. The same
indications for cyst drainage that were outlined for cystojejunostomy pertain to
drainage of a pseudocyst into the duodenum.

Operative Technique
he abdomen is entered through either a right subcostal or an upper

T .
midline incision. The pseudocyst, which resides in the duodenal C
loop in the head of the pancreas, is exposed, and the omen tum is
cleaned from the anterior wall of the cyst. The duodenum is
kocherized (A). A posterior row of interrupted 3- 0 silk sutures is placed between
the cyst and the medial aspect of the duodenum.
After the cyst location has been identified by needle aspiration as depicted
for cystojejunostomy and cystogastrostomy, an opening into the pseudocyst is
made with the electrocautery (B). A parellel opening into the duodenum i made,
also with the electrocautery. The cyst wall is biopsied.
An inner continuous locking layer of 3-0 synthetic absorbable sutures is
placed (C) and then brought anteriorly in a Connell fashion. This row is placed
for hemostasis, as well as for good approximation of the cyst wall and
duodenum.
The outer layer of the anterior row is placed, again utilizing 3- 0 ilk
sutures (D). The anastomosis is drained with Penrose or closed suction drains.
The inset demonstrates the anatomic relationships between the head of the
pancreas and pancreatic duct, the pseudocyst, and the duodenum with the
cystoduodenostomy.
 Duodenotomy - --:_-.,

Duodenum _ _-',-

Stomach

N
Ii

Pseudocyst

Koc herized
duodenum layer of
L post.erj,or row

Duodenuml_---''---_ - - _,;,:::-- _ -'-_ PsE

Duodenum

Stomach

Pancreanc duct
 - - - - - - - - - - - - - - - - - - . . . . . . - - -..........J

~orus-Preserving ·pple
Procedure)

Operative Indications
ancreaticoduodenectomy may be indicated for a variety of benign and

P malignant diseases. It is most commonly performed for periampullar:

carcinoma. The periampullary tumors consist of adenocarcinomas that
arise in the head of the pancreas, ampulla, distal bile duct, and
duodenum. The procedure is also utilized for other less common neoplasms tbaa .
may arise in the head of the pancreas. These include the cystic neoplasms, both
cystadenomas and cystadenocarcinomas, islet cell tumors (both benign and
malignant), and cystic and papillary neoplasms (Hamoudi tumor).
Some pancreatic surgeons feel that pancreaticoduodenectomy is the
procedure of choice for chronic pancreatitis when a dilated duct is not present
and a Puestow procedure cannot be performed. It is a particularly attractive
operation for chronic pancreatitis when the disease is most severe in the head
and uncinate process, with less extensive involvement of the body and tail of
the gland. Rarely, pancreaticoduodenectomy may be indicated for extensive
pancreatic and duodenal trauma, when it is felt that duodenal repair and
pancreatic drainage would be inadequate surgical management.
In most instances, however, a pancreaticoduodenectomy is performed fur' a
malignant neoplasm arising in the periampullary region. The pylOruS-PiCsu vq
modification of the classic Whipple procedure has become our standard, and it is
*
utilized in over 80 percent of the pancreaticoduodenectomies done for neap! 16

Operative Technique
he operative procedure can be performed through either a bilatelal

T subcostal or an upper midline incision. Once the abdomen i enteRd,.

thorough exploration must be carried out to detect any evidence ci
tumor spread outside the limits of resection. The liver is carefully
examined, as are all serosal surfaces, for metastatic spread or peritoneal
dissemination. In addition, lymph node spread outside the boundaries of
resection has to be determined. The periportal and celiac axis are the area that
most frequently are involved, eliminating the possibility of a
pancreaticoduodenectomy (A). The root of the transverse mesocolon also has to
be examined, to be certain there is no direct tumor extension into thi area_
Once tumor dissemination has been ruled out, the duodenum is extensively
mobilized (B). The duodenum, head of the pancreas, and tumor are always
easily elevated from the inferior vena cava and aorta. Direct extension
,. posteriorly into these structures is very unusual. This maneuver i important.
however, to be certain that tumor has not extended into uncinate process to
involve the superior mesenteric artery. For this reason an extensive
kocherization should be performed so that one can palpate the superior
mesenteric artery and be certain that there is normal uncinate process adjacent
to it (inset). If upon performing till maneuver, one feels tumor extending over
to and invol\-ing the superior mesenteric artery, the lesion is not resectable.
386
 Stomach

Gallbladder

Duodenum

__)
~'-_ _ _ _ Stom ach

,
ochenzed _ _ _ _ _ _ _ _ --c-':
doodenum
Head of pancreas

Superior mesenteric
Duodenum v. and a.

,+ - ---4- - - ,

\
<-'
--J\
\

Pancreas Tumor

Inferior
vena cava
 he portal vein is identified. The quickest and most direct route to

T expose the portal vein is medial to the common duct and lateral to
the common hepatic artery (C). Identification of the portal vein is
made easier if the common duct is first looped with a vessel loop and
retracted laterally. A combination of both blunt and sharp dissection will
quickly expose the anterior surface of the portal vein.
One should next identify the superior mesenteric vein. This can be done
through the lesser sac, if the surgeon prefers this approach. However, it is most
easily and rapidly accomplished if one extends the kocherization of the second
portion of the duodenum to include the third portion. As one proceeds medially
with the kocherization along the third portion of the duodenum, the superior
mesenteric vein is encountered (D). This should be done carefully, because the
superior mesenteric vein may be quickly and unexpectedly encoun tered and
injured if this is not done with great care. This is a much more rapid and easier
means of identifying the superior mesenteric vein than going through the lesser
sac (as is demonstrated in E). If one goes through the lesser sac, there are no
clear boundaries to identify where along the inferior border of the pancreas one
should start dissecting. It is often difficult to palpate the superior mesenteric
artery, and even if it is identified, the relationship of it to the superior
mesenteric vein is variable.
The next step is to be certain that the anterior surfaces of the superior
mesenteric vein and the portal vein can be separated from the under surface of
the pancreas and tumor. One should be able to connect the dissection space
posterior to the neck of the pancreas from both above and below (E). There are
generally no branches that come off directly anteriorly from the portal vein and
superior mesenteric vein (inset). Thus, this maneuver can be safely
accomplished with a combination of blunt and sharp dissection. If tumor
involves the portal vein or superior mesenteric vein and one cannot develop this
space, the lesion is unresectable.
This maneuver combined with the extensive kocherization over to the
superior mesenteric artery demonstrates that the major vessels in this region
are uninvolved by tumor. The exceptions to this are the medial and inferior
aspects of the superior mesenteric vein. Involvement in these areas cannot be
determined, unfortunately, until near the end of the resection.
 Portal v.

Gal/bladder
'-'-_--'--C--,--_ Common _ __ Su~

duct
mesen!alc

Stomach _____ ~~~~~~:_-----~

Third portion of duodenum

Duodenum _____ , ; -

/
-T-- ~

r - -- - paJJaE -

Neck of
pancreas

Supe~ior
mesfJteriC

C~p-+--- Superior
Duodenum---jhr- 1~_-1 mesenteric a.

Superior
mesenteric v.

Inferior Aorta
vena cava
Uncinate
process
 he first portion of the duodenum is mobilized and cleaned. Generally,

T even with a large tumor in the head of the pancreas, a 2·cm segment
of duodenum can be mobilized distal to the pylorus and still have an
adequate margin from the tumor in which to divide the duodenum.
The first portion of the duodenum can be divided between intestinal clamps, as
pictured here (F), or perhaps more conveniently with a GIA stapler. Only a 2-cm
segment of duodenum distal to the pylorus needs to be preserved.
After the first portion of the duodenum has been divided, the
gastroduodenal artery is encountered. The gastroduodenal artery should be
dissected sufficiently so that one can clamp, divide, and ligate it without risk of
injuring the common hepatic artery, from whence it originates (G). If
angiography has been performed prior to laparotomy and one knows that the
vascular anatomy is classic, one can proceed with dividing the gastroduodenal
artery without hesitation. However, if angiography has not been performed and
one is not certain whether or not there is a replaced right hepatic artery arising
from the superior mesenteric artery, one has to proceed with caution. If there is
a replaced right hepatic artery it often courses posterior to the duodenum in the
same location as a gastroduodenal artery. A gastroduodenal artery can always
be differentiated from a replaced right hepatic artery by looping the vessel with
a vessel loop. If one then occludes the vessel with the loop, if anatomy is classic
and you have occluded the gastroduodenal artery, the pulse should disappear
inferiorly to the vessel loop. However, if the vessel is a replaced right hepatic
artery, the pulse will remain in the inferior portion of the vessel but will
disappear in the cephalad direction. If a replaced right hepatic artery is present,
it should not be divided.
If the replaced right hepatic courses through the neoplasm and it is
necessary to divide it, it should be reimplanted. Even though a normal liver can
frequently tolerate ligation of the common, right, and/or left hepatic arteries, it
carries significant risk if this is carried out for a periampullary neoplasm. These
patients are usually in an older age group, some degree of liver injury and
fibrosis is present because of biliary obstruction, and portal venous blood flow
may be decreased. Thus, if it is necessary to interrupt the arterial blood supply
to the liver during a pancreatic resection, revascularization via reimplantation
should be performed.
 Rgash:a

FII"SI poI1Joo
oIduodenum _ _ __ ----:,-::.~

StOlT\G

I
~I

Gallbladder

Portal v.

Hepalic a.

w;".- - - - - Gastrod uode nal a.

liver

DMded first Divided

porooo 01 duodenum r. gastroeplpiotc a
 he extrahepatic biliary tree, which has previously been looped with a

T vessel loop, is mobilized, and the gallbladder is dissected free (H). The
common hepatic duct is then divided (1).
It is our practice to routinely have a Ring catheter inserted a day
or two prior to surgery at the time of percutaneous transhepatic
cholangiography (J). Cholangiography is important in identifying the level of
obstruction and in helping to identify the site of origin of the lesion. In addition,
the Ring catheter is subsequently of great help to the surgeon. Often the patient
has been operated upon in the recent past, and dissection of the porta hepatis
may be difficult. The dissection is eased considerably by having a Ring catheter
in place.
Once the common hepatic duct has been divided, the proximal end towards
the liver is clamped with a bulldog clamp to prevent bile spillage (K). After
extracting the Ring catheter, the distal biliary tree is ligated (K).
The neck of the pancreas is divided with the electrocautery (L). The
operator should place his or her left index finger underneath the neck of the
pancreas to protect the portal and superior mesenteric veins during this
maneuver. One should take an extra cross·section shaving from either the
proximal or distal end to send for frozen section.
 Divided
gastroduodenal a.
Cystic duct Common duct

Commo n
hepatic duct _ __

/)
Ring catheter ""'" / Divided
~' common hepatic
duct

Stomach

/
L

- ........

Neck of pancreas _ _ _ _ _----'''-_ _ -''

Duodenum _ _ _ _""""_ _ __ _

~
EtLV

393
 he portal and superior mesenteric veins are dissected from the

T uncinate process of the pancreas (M). The uncinate process is that

portion which arises directly posteriorly from the head of the
pancreas and extends posterior to the superior mesenteric vein to end
at the superior mesenteric artery. The portal vein and superior mesenteric vein
should be completely dissected from the uncinate process. There are
surprisingly few branches that come off these two venous structures and enter
the uncinate process; however, the few veins that do should be carefully
identified, clamped, divided, and ligated.
The dissection of the uncinate process should be carried medially until the
superior mesenteric artery is clearly identified (M). The uncinate process is then
removed from the superior mesenteric artery. This should be accomplished with
full exposure of the superior mesenteric artery; this allows one to remove all of
the uncinate process. The area of the uncinate process is often where the
margin of normal pancreas between tumor and line of resection is the
narrowest. Thus, removing the uncinate process directly from the superior
mesenteric artery increases the margin. In addition, there is less risk of direct
injury to the superior mesenteric artery if it is identified and exposed. There are
multiple small branches that come directly from the superior mesenteric artery
and enter the uncinate process, and these require ligation and division (N).
 1
.f
I
"-t"
..-- >..: -~=
-..: :. '" ~-;;-...,.
/
Po<1aJ v. _ __ _ -;:-

' - ---t--t-"'A ~--;--:;-7-~------ Superior mesenteric a.

-'-1f-'=~--''7-+---C.--:--------- Superior mesenteric v.
, _.....l!'-~!-,j;;- _ _ _ _ _ ---;::-_ ___ _ _ _ ____ _ Uncinate process

OuOOenum

Divided first
portion of
duodenum

process

Superior mesenteric
a and v.
 he proximal jejunum is exposed and divided within several inches of

T the ligament of Treitz. This can be performed with intestinal clamps,

as pictured here (0). However, a GIA stapler can also conveniently
and rapidly accomplish this.
Once the jejunum is divided, the mesentery is clamped, divided, and ligated
down to the ligament of Treitz. The proximal jejunum is then passed
underneath the superior mesenteric vessels and over to the right side of the
abdomen (P). During this maneuver, the third and fourth portions of the
duodenum are mobilized. This is generally accomplished rapidly and with very
little blood loss. Most attachments are avascular.
 -:_ -;-_ __ _ _ _ _ Transverne a*=

-::---::'":-.:,L.::.-::;;----c'-::---- - -__ Proximal j,."..

- .,.,,.,

Common - - -- -- -":
hepatic
duct

Mobilized
gallbladder _ _ _ --.:: ', ~,.L-,-+->;----'----+--;c-~____ Body o'
.' , ....L pancreas
,'-

-',\1;--- - - --;-.-":..'- ;-- Superior

mesenteric v.
I
I

ead of
pancreas

Jejunum

- 'a&:swase
 he specimen now remains attached via only the inferior portion of

T the uncinate process (Q) and some areolar attachments of the third
portion of the duodenum. These are divided, and the specimen is
removed from the operative field.
The specimen consists of the distal portion of the first part of the
duodenum, all of the second, third, and fourth portions of the duodenum, and
several inches of proximal jejunum. In addition, the neck, head, and all of the
uncinate process are included, as are the gallbladder and distal biliary tree (R).
 ~~~~------------ BOO¥d
pruueas

-A-..,t;#~--..L~~~------- Superior mesenteric 8 . and v.

'--c-+- - - - -- - - - - - - Uncinate
process

Duodenum /

--:ll!:--'-'-+ - - - Proximal
jejunum Resection Specimen

Gallbladder
Head and
neck of pancreas

Distal ul"i3ry _ _ _ _ _ _ _ __ _ _--':,~

tree

Duodenum _ _ _ _ _ _ _ _ __ ~---

R
 here are a variety of ways to perform the pancreaticojejunostomy;

T many have been used very effectively, with a low incidence of

pancreatic leakage and with little morbidity and mortality. We prefer
invaginating the end of the pancreas into the end of the jejunum
(inset 1). Other pancreatic surgeons prefer to perform a mucosa-to-mucosa
pancreaticojejunostomy, often in an end-to-side fashion. We will demonstrate
the invagination technique that we use most frequently.
This anastomosis is carried out in two layers: an outer interrupted layer of
3-0 silk and an inner interrupted layer of 3-0 synthetic absorbable material.
The jejunum is positioned in the lesser sac through a rent in the transverse
mesocolon. The outer row of the posterior layer is placed first. The 3-0 silks are
placed 1 to 1.5 in from the divided surfaces of the pancreas and jejunum (S).
When this has been completed, the inner layer of interrupted 3-0 synthetic
absorbable sutures is placed. When there is a dilated pancreatic duct, the two or
three middle sutures of the inner layer include the pancreatic duct (T).
The inner layer of the anterior row of the anastomosis is performed next.
This again consists of 3-0 synthetic absorbable suture material, and the middlE
sutures incorporate the dilated pancreatic duct (U).
The outer layer of the anterior row is completed by placing 3-0 silk sutures
approximately 1 to 1.5 in from the divided surfaces of the pancreas and
jejunum, thus invaginating the pancreas into the jejunum as this layer is
completed (IfJ. Often the pancreas seems edematous and somewhat large to fit
into the end of the jejunum. However, if glucagon is administered intravenously
20 minutes prior to performing the anastomosis, the jejunum will become
flaccid and dilate, and it is nearly always possible to perform an end-to-end
anastomosis.
If there is still a size discrepancy after glucagon is administered, the end of
the jejunum loop should be closed and an end-to-side pancreaticojejunostomy
performed (see LL to PP). This does not allow as much invagination of the
pancreas into the jejunum, however, and an end-to-end anastomosis is preferred.
This anastomosis actually combines the invagination technique with a
modification of mucosa-to-mucosa anastomosis of the duct to the jejunum
(inset 2).
 End-to-end pancreaticojejunoslDmy

Jejunum
Pancreas

Inner layer of
Inner layer of anterior row
posterior row lincludes duct)
lincludes duct)

Outer layer of
anterior row

I Sutures
I
j duct

Invag inated pancreas

 he hepaticojejunostomy (inset) is periormed with one layer, utilizing

T 4-0 interrupted synthetic absorbable sutures. Some biliary surgeons

periorm this anastomosis with two layers; if the duct is large, this
can easily be accomplished. A single·layer anastomosis, however, can
be periormed more rapidly and is just as satisfactory.
Our technique for periorming this anastomosis utilizes a single layer of
synthetic absorbable sutures placed as a posterior row prior to an enterotomy
being periormed (W).
Once this layer has been placed and secured , an enterotomy is periormed
utilizing the electrocautery (X). The Ring catheter, which was placed
preoperatively, is then inserted through the enterotomy into the jejunum \fl.
Because one is periorming a hepaticojejunostomy with normal tissues, it is
obviously not necessary to stent this anastomosis. We prefer, however, to
decompress it for a two· or th ree-week period. Thus, if a Ring catheter has not
been placed preoperatively, we place aT-tube and exit it through the common
hepatic duct. Having a Ring catheter in place saves operative time and is
preferred.
Once the Ring catheter has been inserted into the enterotomy, the anterior
row of interrupted synthetic absorbable sutures is placed with the knots on the
outside (Z). The knots of the posterior layer are on the inside, but since they are
absorbable sutures, this is not a disadvantage. Even though technically the
posterior row is not mucosa to mucosa, the approximation is s uch that in effect
it acts as if it is. This technique can be peformed rapidly, and has proven to be
entirely satisfactory.
Once the anastomosis has been completed, the jejunallocp is tacked up to
soft tissue on the under suriace of the liver and periportal area with two or
three interrupted 3-0 silks (AA).
 __ - L __
~ ________________

End-la-side hepali~

Ring calheter

Jejunum

Posterior
row

(
sf
 he final anastomosis is an end-to-side duodenojejunostomy (inset). If

T one leaves only a 2-cm cuff of the duodenum on the pylorus, it is not
necessary to preserve the right gastric artery. The right gastric
artery is small, often difficult to identify, and its identification can
prolong the operation if one insists upon its preservation. In an extensive
experience at several institutions it is now clear that it is not necessary to
preserve the right gastric artery to ensure viability of a 2-cm cuff of duodenum.
The duodenojejunostomy is performed with an outer interrupted layer of
3-0 silk and an inner continuous layer of 3-0 synthetic absorbable suture. Once
the outer layer of the back row of the anastomosis has been placed (BB), the
sutures are secured, and an enterotomy is made in the side of the jejunum (CC).
The inner layer of the posterior row is carried out using an over-and-over
locking suture of 3-0 synthetic absorbable material (DD). It is continued
anteriorly as the inner row using a Connell suture (EE, FF).
The anastomosis is completed with an outer layer of interrupted 3-0 silk
sutures (GG).
 r
Frn portion 0{
..., " Ii 'n"oosaa If _ _ _...... -l--- _ _ duodaraJrn

- _ Slomach

End-to-side duodenojejt.lnosb;ly

Inner lay", 0{
anterior
row

_-,,----=~_=_- Pylorus

- --;-- - Stomach
 hen performing the pylorus-preserving Whipple operation, a

W portion of the first part of the duodenum, all of the second, third,
and fourth parts of the duodenum, and the proximal jejunum are
resected along with the neck, head, and uncinate process of the
pancreas. Also removed are the gallbladder and distal biliary tree (HH).
Although there are many ways to perform the reconstruction following
such a resection, as just demonstrated we prefer the end-to-end
pancreaticojejunostomy, an end-to-side hepaticojejunostomy, and then an end-to-
side duodenojejunostomy (II).
Two modifications that are occasionally performed when carrying out a
pancreaticoduodenectomy are the end-to-side pancreaticojejunostomy OJ) and
the classic Whipple, in which a hemigastrectomy is performed (KK) instead of
pylorous preservation. These two modifications will be demonstrated.
 .., R....

End-Io-SIde
duodenojejunoslomy

Prox jmal
_ .!-_ _ jejunum

,1 ,
Duodenum 3

Tumor

Pancreas

Reconstruction Alternatives

End-Io-slde Hemigaslreclomy
pancreabco,ejUI1OSalmy with gastrojejunostomy
 hen the end of the pancreas is too large to be invaginated into the

W jejunum, the end of the jejunum is closed with an inner

continuous layer of 3-0 synthetic absorbable suture and an outer
layer of interrupted 3-0 silk (inset). The end-to-side
pancreaticojejunostomy is performed in an identical fashion to the end-to-end
pancreaticojejunostomy (see pages 400-401), except that instead of placing the
outer layer of sutures 1 to 1.5 in from the divided end of the pancreas, they are
placed approximately 0.5 in from the end of the pancreas (LL).
Once the outer layer of the posterior row has been placed and secured, an
enterotomy on the anti mesenteric surface of the jejunum is made with the
electrocautery (MM), and the inner layer is placed utilizing interrupted 3-0
synthetic absorbable sutures.
If the pancreatic duct is dilated, it is incorporated into two or three of the
middle sutures (NN).
The inner layer of the anterior row is placed with 3-0 synthetic absorbable
sutures, once again incorporating the dilated pancreatic duct (00).
The anastomosis is completed with an outer layer of 3-0 silk s utures place<
approximately 0.5 in from the edge of the pancreas and 0.5 in from the edge of
the enterotomy in the jejunum (PP).
This anastomosis does not invaginate as much pancreas into the jejunum
as does the end-to-end pancreaticojejunostomy (see pages 400-401), but it is a
reasonable alternative if the pancreas will not fit into the end of the jejunum.
 End-to-side pancreaticoi£>;; -

I
Enterotomy

Inner layer of
anterior row Outer layer of
!includes anterior row
duct)
 f one determines that pylorus preservation is not possible because of an

I inadequate margin, by leaving a segment of the first part of the duodenum,

a classic Whipple (which includes a hemigastrectomy) can be performed.
This decision would be made after identifying and freeing the anterior
surfaces of the superior mesenteric and portal veins. The greater and lesser
curvatures of the stomach are cleaned at its mid portion and then divided with
the electrocautery between two sets of Kocher clamps (QQ).
Duodenum

Divided
greater omentum
 he lesser curvature of the stomach is closed with an inner continuous

T layer of 3-0 synthetic absorbable suture that is run back and forth in
a horizontal mattress fashion underneath the Kocher clamp (RR).
The Kocher clamp is then removed and the same suture is
carried back using an over-and-over locking stitch (SS).
The closure of the lesser curvature is completed with an outer layer of
interrupted 3-0 silk sutures (TT).
After the resection has been completed and the pancreatic and biliary
anastomoses have been performed, a Hofmeister gastrojejunostomy is carried
out with an inner continuous layer of 3-0 synthetic absorbable sutures and an
outer layer of interrupted 3-0 black silk (inset).
Prior to closing the abdomen, the rent in the transverse mesocolon should
be tacked to the jejunum so as to obliterate any potential space for herniation of
bowel.
Finally, the biliary and pancreatic anastomoses should be well drained
with Penrose or closed suction drains. Morbidity and mortality do not
necessarily follow disruption of either anastomosis if they are well drained;
however, they invariably follow if the anastomoses are not adequately drained.
 Biliary
anastomosis

Transverse colon

Outer layer

Hemigastrectomy with
gastrojejunostomy
 PaDjati e Bypasses for Unresectable
PeriampuIlary Cancer

Operative Indications
f a patient with a periampullary carcinoma is explored and is found to haw

I disseminated and/or locally unresectable tumor, duodenal and biliary

bypasses should be performed. Even if a patient has had biliary
decompression performed preoperatively, either endoscopically or
percutaneously, an internal biliary bypass should be carried out to eliminate till
need for an endoprosthesis or a percutaneous stent.
In addition, even though it is somewhat controversial as to whether a
duodenal bypass should be performed, we support the routine use of
gastrojejunostomy. Most studies have demonstrated that somewhere betwfen
15 and 20 percent of patients who do not undergo a gastrojejunostomy will ~
to be reexplored and undergo a duodenal bypass subsequently. In addition, thenl
are many other patients who present with duodenal obstruction late in their
course, but nutritionally are unable to withstand an operative procedure. FOI'
these reasons we feel that both biliary and duodenal bypasses should be
performed.

Operative Technique
n this instance (A), local tumor involvement of the portal vei n has

I eliminated the possibility of a pancreaticoduodenectomy. The cystic do::t

joins the hepatic duct well above the tumor, so the patient is suitable for' a
cholecystojejunostomy if the surgeon favors this procedure. We prete!' a
posterior gastrojejunostomy (B). There is a theoretical disadvantage in ~
the anastomosis adjacent to the body of the pancreas, through the I:ransva'se
mesocolon, because of the proximity to the pancreatic tumor. We have ne¥e'
seen a retrocolic gastrojejunostomy occluded by direct tumor extension. We feel
it is far preferable to perform a dependent gastrojejunostomy that will drain
readily, rather than place the anastomosis in an antecolic position and have the
patient remain in the hospital for a prolonged period because of failure of the
anastomosis to function.
• The greater curvature of the stomach is cleaned along its most dependent
portion by dividing the omentum. The first loop of jejunum distal to the

I ligament of Treitz is brought up through a rent in the transverse mesocolon

into the lesser sac and out through the opening along the greater curvature of
the stomach, and a gastrojejunostomy is performed. This is carried out utilizing

~ an outer interrupted layer of 3-0 silk sutures and an inner continuous layer d
3-0 synthetic absorbable material. The posterior layer of silk sutures has been
placed, and a gastrotomy and enterotomy are performed with the electrocautesy
(B).

414
 SplenIC v.

"':;;,.<'----4'-- -- - - Encasement of
Obstructed portal v.
common duct ----!,+-n

Superior
--==-.!_ _ _ mesenteric v.

Pancreatic duct
Gastrotomy

r
Gallbladder
Stomach V Outer layer of
posterior row

,,
- .... _--_ . . .. . . I
,,
,,
,
'-
--- ,, ,
,,

Proximal ieilmum
 he inner layer of the posterior row is placed utilizing a continuous

T over-and-over locking suture of 3-0 synthetic absorbable material (C).

The inner layer is brought anteriorly utilizing a Connell stitch
(D and E).
The anastomosis is completed with an outer interrupted layer of 3-0 silk
sutures (F). The stoma should accommodate two fingers.
Once the anastomosis has been completed, the rent in the transverse
mesocolon is sutured to the anastomosis on the gastric side (G) to prevent
herniation of the afferent and efferent jejunal loops up into the lesser sac.
A vagotomy is not performed. Patients with unresectable periampullary
carcinoma have a limited life expectancy and are maintained on HZ blockers to
avoid marginal ulceration.
 lmerlayefol
postencr row Inner Iayef
01 anlerior raw

.,
J'
,.,
---

Outer layer of
anterior

\~
I
- - - JeplaI
loop
 Pproximately 18 in distal to the gastrojejunostomy, a loop of jejunum

A is brought up in a retrocolic fashion to anastomose to the gallbladder.

In choosing between a cholecystojejunostomy and a
hepaticojejunostomy, several aspects have to be considered. If the
gallbladder is used to decompress the biliary tree, one has to be certain either
cholangiographically or by direct visualization that the cystic duct is far enough
removed from the tumor so that early occlusion will not result in a recurrence
of jaundice (see A). If the cystic duct is involved in the tumor or is very close to
the neoplasm, the gallbladder cannot be used and one should perform a
hepaticojejunostomy. In addition, if the patient is relatively healthy and there is
a small tumor burden, one should strongly consider performing a
hepaticojejunostomy rather than a cholecystojejunostomy. Even though most
patients will be satisfactorily decompressed for their remaining life with a
cholecystojejunostomy, a hepaticojejunostomy is more satisfactory and is more
likely to achieve adequate biliary decompression for a patient who survives for a
prolonged period of time.
If cholecystojejunostomy is chosen, a loop of jejunum is brought up through
the transverse mesocolon, generally immediately adjacent to the second portion
of the duodenum, and placed next to the gallbladder (H).
The cholecystojejunostomy is performed with an outer interrupted layer of
3- 0 silk and an inner continuous layer of 3- 0 synthetic absorbable material. The
posterior outer layer is placed first with 3-0 silk sutures (I). Once they have
been secured, a cholecystotomy and jejunotomy are performed with the
electrocautery (I). The inner layer of the posterior row of the anastomosis is
performed with a continuous over·and-over locking suture of 3- 0 synthetic
absorbable material (J).
 ,

Stomach

Transverse mesocolon
tacked to stomach

,,
,
\ ,. . ... '" ,
,, I I'
I

,,
,
,, ,,
, \
\ , I
, I
---
, \ , .,
_",' I I
\ I , I

\ 1 ,
, I I
I I
r- _
,,
I
Retrocolic I
I
I I
jejunal I I
/ - - -- ...
I
I
I
loop I " , I I
I
, I I
, I
I
, ,i , ,
, ,, "
,,
I \ I' ,
,, ,
A

,
I ,, I / I
I

,,
I 'I I
I /' ! I

Cholecystotomy

Outer lay er of Inner layer

posterior row ofpostaD ...

I
Enterotomy

19
 be mner layer of the anterior row of the anasrcmosis is ,.11' imof

T ~ith the 3--0 synthetic absorbable surure, utilizing the Connell

stitch ,K ,.
The anastomosis is completed \\ith an outer layer of interruptfd
3--0 ilk sutures (l l.
..\lthough many surgeons do not feel it i necessary, we favor an
enteroenterostomy between the afferent and efferent loops going to the
cholecystojejunostomy. We perform thi below the transverse mesocolon. This
not only diverts the enteric stream away from the biliary anastomosi ,but it
also avoids intesti nal obstruction if tumor extension should involve the area of
the gallbladder and jejunal loop above the transverse mesocolon.
The enteroenterostomy is performed using an outer layer of interrujXed 3-0
silk sutures and an inner layer of continuous 3- 0 synthetic absorbable suture
(M and N). The jejunal loops are tacked to the rent in the transverse mesocolm
to prevent herniation .

20
 Ou'.erlayerol"
an enor raN

Inner layer 01
anterior row

Relrocolic
jejunal loop Hepatic
flexure 01_--''---_
colon

\
\
\

Transverse col0o/-_ ---'--"---

I

Opening in
transverse _ _ _ ---,;:-_ _ _ ~

mesocolon

Outer layer
01 posterior _ _ __ __ +___ ~*.
row

Enterotomies
 nce the duodenal and biliary bypasses have been completed, we

O perform a chemical splanchnicectomy to palliate the abdominal and

back pain, hopefully for the remaining portion of the patient's life.
This is carried out by injecting 25 ml of 50 percent alcohol on either
side of the aorta at the level of the celiac axis (0). The cholecystojejunostomy
should be drained with Penrose or closed suction drains.
 Stomach

Gastrojejunostomy

Transverse
mesocolon
tacked to
stomach

~ ,

/
,
1/ I
,,
, ,
,, ' ' •I
,, , '\
,
\ ,
\

, •
I
,
I

I
p,
, ,1
I " ,
,• I" I
I
, I
I

,
A-
I I
! ,I I

,
I

, •
~
I
I \ ,
(

aizca ..... If
 f a patient undergoing palliative biliary and duodenal bypasses is not a

I candidate for a cholecystojejunostomy because of tumor involvement of the

cystic duct (P) or prior cholecystectomy or because the surgeon chooses not
to use the gallbladder, a hepaticojejunostomy should be performed. The
porta hepatis is dissected, the cystic duct is identified, and the cystic artery is
doubly clamped, divided, and ligated.
The gallbladder is then mobilized, and the common hepatic duct is divided
just above the junction with the cystic duct (Q).
The common duct is divided distally, and the gallbladder and segment of
bile duct are removed from the operative field (R). The distal biliary tree is
oversewn with interrupted 3-0 silks.
As with most patients with periampullary carcinoma that are being
explored, a Ring catheter has been inserted preoperatively at the time of
percutaneous trans hepatic cholangiography. This can be utilized to decompress
the biliary enteric anastomosis for two or three weeks postoperatively and
obviates the need to insert aT-tube. Many surgeons prefer to cut off the distal
tip of the Ring catheter.
 ./
Encasement of
portal v.

Gallbladder _ _ _ _---;

Tumor
involvement
of cystic duct

liver
Tumor

Pancreatic

Superiel
mesen eric Y.
Gallbladder
Division of
common hepatic
duct

Gallbladder
fossa

Hepatic fle)(U"l~:-:¥I...c.._-:::~~
of colon
Duodenum

Distal
common duct
overseWfl
 standard hepaticojejunostomy is performed with a single layer of

A interrupted sutures. The posterior row of the anastomosis is inserted

with 4-0 interrupted synthetic absorbable sutures placed prior to
performing an enterotomy (5).
Once this posterior row has been placed and secured, an enterotomy is
made with the electrocautery (T).
The Ring catheter is placed in the enterotomy and the anastomosis
completed with an anterior row of interrupted 3-0 synthetic absorbable suture
material (U).
As with the cholecystojejunostomy, we prefer to perform a
jejunojejunostomy between the afferent and efferent loops of jejunum going to
the biliary anastomosis, to divert the enteric stream away from the
anastomosis M.
We also prefer to perform an end-to·side hepaticojejunostomy, after dividing
the hepatic duct, rather than carrying out a side-to-side hepaticojejunostomy,
without dividing the duct. In our experience, many of the anastomoses
performed in the latter fashion do not function adequately or function for just a
short time.
The anastomosis is drained with Penrose or closed suction drains.
~
0ISIal
COi.M.Klfl duct _ __

Ou:xfenum Posterior row

~r
Ring catheter
Enterotomy
Jejunal loop

Liver

Gallbladder fossa

~~-;:--;-7'T-";--~ End-to-side
hepaticojejunostomy

,
j.,

r - -- ff-- --l':::'-- - Retrocolic jejunal loop

>--:;;;-40- - Ring cath eter

,,

, ,,
,, ~

,
,,
,
,,
,,
...
,.
.t
"
''( ,
f ,~\
----,
,,
,

,
'I
,
/ -- _J
,
"
,
,,
,
,,
,
,,
,' ....
, - _.. --- "
.- ,,
.
,,
.
,
 Distal Pancreatectomy for Tumor

Operative Indications
ost adenocarcinomas arise in the head, neck, and uncinate process

M of the pancreas. The pancreatic adenocarcinomas that arise in the

body or tail are rarely resectable. However, the majon ty of cystic
neoplasms and most Hamoudi tumors, as well as many islet cell
tumors, arise in the body and tail of the gland. Thus, there are some instances
in which a distal pancreatectomy is performed for a pancreatic neoplasm.

Operative Technique
• ither a midline incision or a left subcostal incision extended over to the

E right can be used. We prefer the latter incision for neoplasms of the
body and tail of the pancreas.
Once the abdomen is entered, evidence of tumor dissemination is
searched for. If none is present the tumor is exposed by dividing the greater
omentum and entering the lesser sac (A).
If the tumor is mobile and there is no other evidence suggesting that it is
unresectable, the spleen is mobilized out of the retroperitoneum and the vasa
brevia are divided and ligated (B).
 .,..,...;.'----_ _ _ _ Spleen

_ _ _ _ _ _ Tail 01 pancreas

Divided
;",-_ _ _~----_ greater
omentum

Divided
I vasa brevia
Transverse
colon

Stomach

Tumor

Pancreas

_ __ Spleen

1/

Splenic
Tail of flexure 01
pancreas colon
 he spleen is further mobilized and its lower pole attachments to the

T omentum and splenic flexure of the colon are divided (C). The tail
and body of the pancreas are easily mobilized out of the
retroperitoneum with both sharp and blunt dissection.
In this instance, since the inferior mesenteric vein appeared to enter the
tumor prior to joining the splenic vein, the inferior mesenteric vein was divided
(D). Although it is preferable to preserve the inferior mesenteric vein when
possible, its division carries no adverse consequences. The ends of the inferior
mesenteric vein are ligated with 2-0 silk.
 ligament

Splenic
flexure - - - --f:- -:;ur-:;:-
of colon

Tai l of
V ';-""--pancreas

"'-:'';;:-_ _ Splenic v.
Tumor _ _ _ _ __ _

- - - - - Retrope ritoneal bed

Head oj

Duodenum
/
 nce the distal pancreas is mobilized over to the midline, the splenic

O artery is identified along the superior border of the pancreas. The

splenic artery is triply ligated and divided near its origin from the
celiac axis (E).
The dissection of the posterior aspect of the pancreas is carried over further
to the right, and the superior mesenteric vein is identified and cleaned. At this
point enough of the pancreas is mobilized so that there is a 2-cm margin of
normal pancreas proximal to the tumor.
The splenic vein is mobilized off the posterior aspect of the pancreas just
before its junction with the superior mesenteric vein. The vein is divided at this
point and securely ligated (F).
 Posterior
aspects of
pancreas
Duodenum
'_ -'-'''-_ _ ___ Tumor

DMded
anor
nteric v.

Divided splenic a.

Divided
Inferior mesenteric v.

Duooanum Superior
mese encv

..
 rior to dividing the neck of the pancreas, a row of overlapping

P horizontal mattress sutures are inserted. A synthetic absorbable

material (3-0) should be used, and it often helps to straighten out the
curve of the needle to allow more accurate placement (G).
The neck of the pancreas is divided with the electrocautery (H). A full cross
section of either the proximal or distal margin should be sent for frozen section
to be certain that there is a clear margin.
A second row of 3-0 synthetic absorbable sutures is placed over the
resected end of the proximal pancreas in a figure-of-eight fashion (I). If the
pancreatic duct is identified, it also should be secured with a mattress suture.
Penrose or closed suction drains are used to drain the pancreatic remnant.
 Tumor

In ericr
Ti:c== '-..,...,,--- ----,_ -- - mesenteric v.
Overlapping
mattress
sutures

\~~~~;=:~~~~~ ___ Uncinate process

I
Superior Tail of
. -::-::-_--''-_ _ mesen teric
v. and a.

of
pancreas

Tumor

_ __ Retro peritoneal
bed poocess

Superior
mesenteric a.

Inferior Superior Head of

pancreaticoduodenal mesenteric v.
pancreas -----""\Ii::'~: '..~Jj:
v. and a.

v. anda
l4s of Surgery

LaparotoDlyforInsulinoDla

Operative Indications
nce the diagnosis of an insulinoma has been confirmed on the basis

O of serum glucose and insulin levels, most surgeons prefer that

angiography be performed. In 40 to 85 percent of instances, the
location of the islet cell tumor will be identified by a vascular blush.
In many instances, however, the patient will be explored with the suspected
diagnosis of an insulinoma, but without knowing its exact location.

Operative Technique
• ither a bilateral subcostal or a midline incision can be used .

E Once the abdomen has been entered, a thorough exploration is

carried out for evidence of tumor dissemination. Since most insulin·
secreting islet cell tumors are benign, however, rarely would one find
evidence of metastatic disease.
The duodenum is extensively kocherized and the head, uncinate process,
and neck of the pancreas carefully palpated for evidence of a tumor (A). This i
the thickest portion of the pancreas, and a small tumor may be particularly
difficult to palpate in this location (inset).
 Head of
pancreas

Duodenum

Body of
pancreas

jl~
~
7.~!iC~~~t~?=-"_::':_=
: _..jt--_-_-_-_-_Superior mesenteric a
Superior mesenteric v.

Uncinate
Head of pancreas process

Palpation of Head and Uncinate Process of Pancreas

 he lesser sac is entered by dividing the greater omentum. The

T peritoneal reflection along the lower border of the pancreas is incised,

and the body and tail of the gland are mobilized out of the
retroperitoneum (B).
It is particularly important when exploring a patient for an insulinoma that
one be able to visualize and palpate the entire pancreas. Once the body and tail
have been mobilized one can easily palpate both anteriorly and posteriorly for
evidence of a mass (C).
When the insulinoma is identified, it usually can be shelled out without
performing a formal pancreatic resection. Some insulinomas, however, are
malignant, and if such a lesion is encountered a formal pancreatic resection will
be necessary. In addition, even with some benign lesions, the adherence of the
lesion to surrounding pancreatic tissue and/or its size may make a formal
resection necessary. If the lesion is in the head, this might require a
pancreaticoduodenectomy (see pages 386- 413). If the lesion is in the body or tail
and cannot be shelled out, a distal pancreatectomy will be necessary (see pages
428-435).
Body of ....... aas

Slomach

Divided
greater omenIlI::>

2.~_--;--;;~_-,- ;-___ Inferior

border of pancreas

Palpation of
body and
of pancreas
 ecause of the relatively thin nature of the pancreas, and because

B insulinomas are spherical, often a portion of the neoplasm will be

evident underneath the capsule of the pancreas (D). It will usually
appear to have a bluish coloration, although occasionally lesions are
flesh colored.
Such lesions will usually shell out with a combination of blunt and sharp
dissection (E). A variety of techniques can be used, but placing smali ligaclips on
the pancreas slide and cauterizing toward the insulinoma side will provide for a
rapid, bloodless mobilization of the lesion (inset).
Once the lesion is removed, one should examine the bed of the tumor
carefully to be certain there is no evidence of a major pancreatic duct injury that
occurred during the dissection (F). If not, the remaining portion of the gland
should be carefully examined again to be certain that a second lesion is not
present. Penrose or closed suction drains are left in the area of the insulinoma
removal and are brought out through a stab wound in the left upper quadrant.
If after thorough examination, an islet cell tumor cannot be identified, most
surgeons prefer to perform a distal 85 percent pancreatectomy, since this will
encompass the pancreatic tissue where statistically most lesions reside. In
addition, if islet cell hyperplasia is present, this procedure may be of benefit.
 Cauterize vesse ls Clip~s
on tumor onpanoreas

Islet cell tumor Shelling out of Islet Cell Tumor

Pancreatic bed of
islet ce ll tumor
Atlas of Surgery

Drainage of a Pancreatic Abscess

Operative Indications
ancreatic abscess and/or sepsis is the major cause of morbidity and

P mortality in acute pancreatitis. Early diagnosis is essential if

pancreatic debridement and drainage is to be performed early enough
to prevent life-threatening morbidity. With CT scanning to iden tify
peri pancreatic fluid collections and areas of necrotic pancreas with or without
air bubbles and with the ability to fine-needle aspirate fluid collections to look
for bacteria, the diagnosis of a pancreatic abscess often can now be made
relatively early in its development. When the diagnosis is made, the patient
should be stabilized and taken to the operating room as soon as possible.

Operative Technique
ither a long midline or a bilateral subcostal incision can be used .

E Adequate exposure is particularly important as it is essential that the

entire abdomen be explored for extensions of the abscess away from
the pancreas, down either paracolic gutter, into the transverse
mesocolon, or into the left or right upper quadrants.
Once the abdomen is entered the omentum is divided widely so that the
entire lesser sac can be exposed (A). Rather than large collections of pus, the
more frequent finding is of grumous necrotic material filling the lesser sac and
surrounding the pancreas.
 Omentum

.'"

Transverse cok>n
 t is essential that the entire abdomen be explored for extensions of the

I abscess out of the lesser sac. The transverse colon is being reflected in a
cephalad direction, identifying extension of the abscess inferiorly in the
retroperitoneum, and into the root of the transverse mesocolon (B).
Transverse
mesocolon

Proximal
jejunum
Retropentoneal
extensl()(\ cA abscess

:;
 t is important to take down the hepatic flexure and mobilize the right colon

I out of the retroperitoneum to be certain the abscess does not extend down
the right gutter (C). This is one of the most common sites of extension that
is missed at laparotomy for a pancreatic abscess.
Generally, this is a good time to extensively kocherize the duodenum to be
certain there are no extensions from the head of the gland in a cephalad
direction. The left colon should be mobilized in a similar fashion.
Extension of the abscess down the left gutter can be seen (D).
Debridement of the necrotic grumous material has begun at the root of the
transverse mesocolon. Debridement can be carried out sharply using scissors,
but generally blunt debridement using one's fingers or instruments such as the
sponge forceps pictured here (E) is preferred.
 MotJiIized ,. colon

Transverse
colon

ExI"..5"""

R. paracolic gutter

Transverse
colon
!
Root of transverse
mesocolon

L. colon

L. colon

ProXJmal I"Junum
 hat often appears initially to be necrotic pancreas is usually fat

W necrosis and inflammatory debris that is actually on top of and

surrounding a still viable pancreas (F). During this phase of the
debridement it is essential to follow the abscess out to the tip of
the tail of the pancreas, to be certain that one does not miss extension of the
abscess into the left upper quadrant under the left hemidiaphragm.
Once the debridement has progressed to the point where further
debridement results in bleeding, extensive irrigation should be carried out (G).
We prefer a dilute antibiotic·containing saline solution. Overly aggressive
debridement can lead to bleeding that is very difficult to control.
 It

Transverse
colon

Stomach
Irrigation of lesser sac

I~I

T~
colon
 ollowing adequate debridement, two options are available to achieve

F drainage. One option is to insert a series of silastic sump and Penrose

drains into all of the various extensions of the abscess. In this patient,
the lesser sac, left para colic gu tter, the root of the transverse
mesocolon, and the retroperitoneum at the root of the mesocolon have all been
debrided and drained (H).
Once the drains have been inserted, the abdomen is closed (assuming that
all of the nonvital tissue has been removed). As the patient improves , sinograms
can be obtained through the axiom sump drains, and eventually all of the drains
will be slowly advanced out as healing occurs.
Stomach

Ptaremelll:
01
drains

of
pancreatic
abscess

Transverse colon
 nother option for drainage is to pack the entire lesser sac and all

A extensions of the abscess with Mikulicz's pads (1). The corner of each
Mikulicz's pad with the ring tag is brought out through the middle of
the incision (J). These packs are placed with the intention of changing
them every two or three days. thereby continuing to mechanically debride the
abscess cavities.
The upper and lower portions of the wound are closed with large stay
sutures of No.1 nylon. with rubber bumpers constructed from French catheters
(J. inset). The dressings can be periodically saturated postoperatively with
antibiotic-containing solutions. The initial repacking should be done under
general anesthesia in the operating room in 48 hours. Eventually. however. the
repackings may be performed under heavy sedation in the intensive care unit.
The packing changes continue every two or three days until the abscess is
thoroughly debrided and the cavity has started granulating. This usually takes
several packing changes.
At this point one can insert Penrose and sump drains as demonstrated
previously (see pages 450-451) and close the abdominal wound. The other option is
to continue the packings until granulation and contracture have progressed to
the point where the cavity has actually closed. This option takes longer. but is
perhaps safer.
 Pancreas

Open
packing

Transverse cokD

Divided
om e~

Bed ol
paoc:reatic abscess

Transverse colon

OJ
•
Stay suture

f'aliol!l - - - --
 Diverticu1arization of the Duodenum
and Pancreatic Drainage for
Combined Duodenal and Pancreatic
Trauma

Operative Indications
he surgical management of combined pancreatic and duodenal

T trauma can be very challenging to the trauma surgeon. These

combined injuries carry a high morbidity and significant mortality.

Operative Technique
irtually all patients with blunt or penetrating trauma should be

V explored through a long midline incision. Once the abdomen ha been

completely explored and only the pancreatic and duodenal injuries
found, these lesions are attended to.
In this instance there is a contusion of the duodenum with two perforatioos
and a stellate injury to the head and neck of the pancreas (A).
In such instances, if the patient is stable, one should rule out a major injury
to the biliary tree and pancreatic duct radiographically. Occasionally the
ampulla can be cannulated and cholangiography and pancreatography carried
out through one of the duodenotomy wounds. If the ampulla is not easily
accessible, contrast can be injected into the gall bladder and then forced into the
• biliary tree. However, with an unstable patient, visualization and palpatioo at
the time of surgery may be all that one can do to rule in or out a major duct
Inj ury.
If combined pancreatic and duodenal trauma is so severe that the
duodenum and ampulla are destroyed and reconstruction cannot be carried out.
a pancreaticoduodenectomy (see pages 386-413) may rarely be necessary. In ID05t
instances, however, duodenal repair can be carried out and pancreatic drainage
performed.
 Slomach _ _ _ _ _ _----'_

wounds

Divided
greater
omentum

Hepalic flexure Body of pancreas

of colon

Stellale injury
of pancreas
 f the duodenal and pancreatic lesions are severe but repairable, one may

I decide to perform the diverticularization procedure. This requires resection

of the antrum of the stomach, closure of the duodenum to divert gastric
flow, and decompression of the duodenum with a duodenostomy tube.
The duodenal injuries are repaired, and the pancreatic injury is drained.
Enteric continuity is reestablished via a gastrojejunostomy. The mid portion of
the stomach is divided between two sets of Kocher clamps (B). The first portion
of the duodenum is divided between stone clamps, although a GIA stapler can
also be conveniently used. The two duodenal perforations have been closed.
 G 'E¥OEX

Proxim al stomach

First
portIOn of
,

Antrum of
stomach

\\

Re paired
duodenal Pancreatic
wounds injury

DIvided
greater
omenn.m
 he end of the normal duodenum is closed around a Foley catheter,

T using two inverting purse strings of 3-0 silk (C). This catheter serves
to decompress the duodenum and allows for safer healing of the
contused duodenotomies. If one of the closed duodenal lesions opens
and a duodenocutaneous fistula develops, having the duodenostomy tube in
place should facilitate decompression of the duodenum and closure of the
fistula.
The lesser curvature of the stomach is closed with an inner layer of 3-0
synthetic absorbable suture run in a horizontal mattress fashion underneath
the Kocher clamp and then carried back in an over·and·over locking fashion.
Repaired
duodenal --lCL..~-!7Ii"
wounds

Transverse
colon
Pancreatic
injury

Body
of
pancreas
 n inverting outer layer of interrupted 3-0 silk sutures is placed on the

A lesser curvature, and then a gastrojejunostomy is performed to the

proximal jejunal loop. This is carried out with an inner continuous
layer of 3-0 synthetic absorbable sutures and an outer layer of
interrupted 3-0 silk (D).
Often the surgeon will decide to perform a cholecystectomy and decompress
the biliary tree by inserting aT- tube. This is particularly important if one has
not been able to evaluate the biliary tree cholangiographically or if it has been
identified cholangiographically and an injury is present.
The pancreatic injury is debrided carefully to remove devitalized tissue.
Great care should be taken to avoid injuring the pancreatic duct.
The duodenal closures as well as the T -tube insertion site are drained with
Penrose drains. The stellate pancreatic injury is drained with a silas tic sump
brought out through a separate stab wound in the right upper quadrant.
 -tube in
common
duct

-~--
•

Hepatic
Ilexure 01
colon
Proximal
jejunum

Pancreatic injury

Repaired
duodenal
wounds
-- ...-.

Pyloric Exclusion and Pancreatic

Drainage for Combined Duodenal
and Pancreatic Trauma

Operative Indications
n some instances of combined duodenal and pancreatic trauma, the injury

I may not be extensive enough to warrant a hemigastrectomy and

diverticularization of the duodenum. In addition, the patient may be
unstable, and the surgeon may prefer not to perform a hemigastrectomy
but still desire to divert gastric contents away from the injured duodenum. In
these instances pyloric exclusion is an attractive alternative to duodenal
diverticularization.

Operative Technique
ll abdominal trauma patients are explored through a midline incision.

A The abdomen is thoroughly explored to identify all

intraperitoneal injuries. In this instance there is a contusion of the
duodenum with two perforations and a stellate injury to the head and
neck of the pancreas. As in the prior procedure (see pages 454-461), an attempt
should be made, if the patient is stable, to look for a major duct injury. If the
ampulla has been exposed by one of the duodenal injuries, cholangiography and
pancreatography might be possible; if not, contrast can be injected into the
gallbladder and then forced into the biliary tree.
If one decides to perform pyloric exclusion, a distal gastrotomy is made
with the electrocautery (A), and the pylorus is closed from within usi ng a
continuous 3-0 synthetic absorbable suture (B).
 Stomach

Gallbladder

Stomach
Liver _~--,lj.i;

Duodenal
wounds

I
Pylorus
 he gastrotomy is closed with an inner continuous layer of 3-0

T synthetic absorbable suture and an outer layer of interrupted 3-0 silk

sutures.
A gastrojejunostomy is performed to empty the stomach for the
two· or three-week period that the pyloric closure stays intact. The
gastrojejunostomy is carried out with an inner continuous layer of 3-0 synthetic
absorbable suture and an outer interrupted layer of 3-0 silk sutures (e).
A vagotomy should be performed if the clinical situation allows. If not, the
patient will require long· term treatment with H2 blockers.
The duodenal injuries are repaired, using two· layer closures if possible. As
with duodenal diverticularization, if adequate cholangiography has not been
obtained, or if a biliary injury has been identified, the gallbladder should be
removed and the common duct decompressed with aT-tube. Insertion of a
duodenotomy tube in this instance is optional.
 Divided
cystic duct

Gallbladder

Gastrojejunostomy

I f
T -tube in
common duct _ __ _ _ __ _ _ _ _ __ Common
duct

Repaired
duodena l -----L~-~-,~
wounds

,, ,••
,
,, I , , ,, ,
,, ,, \
,, ,
,, ....., , ,, ,,
,
,,
~
-- -- \

--
,
\
\
,
\....... ...
,

\
, •

I~F: NI.r. I
'ANIlON t;.

Transve rse mesocolon

Gastrotomy
closure Omentum

Stell ate
injury of
pancreas
 he operative procedure is completed by suturing the transverse

T mesocolon to the gastrojejunostomy on the gastric side with

interrupted 4- 0 silks (D, inset).
The pancreatic injury is debrided carefully and drained with a
silastic sump. The duodenal closures and the T -tube insertion site are drained
with Penrose drains (E).
The synthetic absorbable sutures in the pylorus will generally stay intact
for two or three weeks, effectively diverting the gastric contents into the
jejunum. If the patient does well, oral intake can be resumed while duodenal
healing continues. After two or three weeks, the pyloric sutures will slough and
the pylorus will reopen.
 Transverse colon

~y ~------~--~

Omentum --+----:1j

Transverse
Small bowel
colon
mesentery

Jejunal loop

Gastrojejunostomy
Index

Biliary stricrure(s)
benign, resection of. 38-57
Abdomi nal pain distal
pancreas divisum and, 366 secondary to sclerosing cholangitis.
pancreaticojejunostomy for 108- 115
end-to-end,342 side-to-side choledochoduodenosromy and,
longitudinal, 326 28
Abscess(es) Biliary tree, 152
liver, 224-235 exploration of, instruments for, 12- 15
pancreatic, 442-453 intrahepatic, dilatation of, 100, 101
Accessory duct papillotomy, for pancreas retraction of, 276, 277
divisum, 366-369 stones in, 10
Adenocarcinomas transhepatic stenting of, 2
distal pancreatectomy for, 428-435 benign biliary stricture and, 44-47
periampullary, pancreaticoduodenectomy Caroli's disease and, 128- 141
for, 386 proximal cholangiocarcinoma and, 64-71 ,
Alcohol, in chemical splanchnicectomy, 422, 82-83,84-89
423 sclerosing cholangitis and, 102, 103
Ampulla. See also Periampullary carcinoma Biliary tumor(s), proximal. See Proximal
comrnon duct exploration through, cholangiocarcinoma
sphincteroplasty and, 18. See also Bowel, small division of, 332, 333
Sphincteroplasty Budd-C hiari syndrome, 252-254
patency of, 14 inferior vena cava and, 298
Amylase elevations, pancreas divisum and,
366
Anastomoses. See specific type or procedure C
Angiography. See also Cholangiography
Calculi,2
distal splenorenal shunt and, 266
common duc t, 10
portacaval shunt and, 276
proximal cholangiocarcinoma and, 58 side-to-side choledochoduodenostomy and.
Arteries. See specific arlery
28
Arteriography, mesenteric, portacaval shunt
sphincteroplasty and. See Sphincteroplasty
and, 276 Calot's triangle, dissection of, 4
Arteriotomy, infusion catheter insertion Cannulation, accessory papilla, 366
Carcinoma_ See also Metastases; specific type
through, 204
distal pancreatectomy for , 428-435
Asci tes, 266
gall bladder, wedge resection of liver and
LeVeen shunt and, 312, 320, 321
regional lymph node dissection for.
portacaval shunt and, 282
142- 149
Atria l anastomosis, mesoalrial shunt and, 306
periampu llary
Atriotomy, hepatic vein injury and, 248
pancreaticoduodenectomy for, 386
unresectable, 414-427
B Caroli's disease, transhepat ic stenting for
indications for, 128
Bakes dilators, 14 , 15 technique for , 128- 141
Silastic transhepatic biliary stent and , 46, Catheter(s). See also Cholangiocatheter
102 balloon
Balloon catheter biliary, 12, 13
bilia,,-. 12. 13 ninety·five percent distal pancreateCtomy
ainety-fiy€ percent distal pancreatectomy and,362-364
and. 362 -36-! eoude. See Coude cathetelisl
B : :u!"ca~ ion. hepatic duct. Sec Heparic due: French. biliary tree and. 14. 15
'='::'J:-ca: io::. infusion. 204
B:;:;:r:: ~ a i k)o') :1 ca:r.t:c:-. ::2. ~ 3 :or ?Dnal pressure measurement. 276
E:::::.:-:.- =-:.-;:..a55 . '..::-.:--:~-::.:::::::: ;t:::-:2:-:-.;r~~~ !e::g. Sa Ring catheter> s ,
3:jas:r.:. liyer a~ and. 23t 235
C~:a:t :-:-:..:. e:d-:o-~id~ portacaval shunt
 and. 2ii2. 2;'3 lIl5U WlitillSlor. 12- 15
Chemical spla,)chni=wm y. 422. 423 technique f.... 10-1;
Chcmmher4?Eutlc agents. hepatic anery rransampul/ary. spluncteroplasty and. 1
mfusion of. Infusaid pump for. 200-205 Sa also phmcrerop!asty
Children. direer mesoca"al shunt ior. 288 Twbe insertion ai[er. If l"i
Cholangiocarcinoma Common dUCl stones, side· to-side
Caroli's disease and. 128, 132 choledochoduodenostomy and. 2
proximal. See Proximal cholangiocarcinoma Connell·type sritch, 334. 335
Cholangiocatheter. 8, 9 Contusions, duodenal. 45-1, 455
Cholangiography. See also Angiography Cooley clamps
cholecystectomy and, 8 distal splenorenal shunt and, 270
closing, 16 trisegmen leclOmy and, 194
common duct exploration and, 10 Coronary vein , distal splenarenal shunt and.
pancreaticoduodenectomy and, 392 272
proxima l choiangiocarcinoma and, 58 Coude catheter(s)
Ring catheter insertion during. 38 benign biliary stricture and. -14.-15
Cholangi tis, sclerosing, 94-107 Caroli 's disease and, 134
distal stricturing secondary to, 108-11 5 proximal cholangiocarcinoma and, 64. 65.
Cholecystectomy 82,83,88, 89
benign bile duct strictures and. 38 sclerosing cholangitis and . 100, 101
biliary drainage and. 8 Cyst(s). See also Pancreatic pseudocyst
cholangiography and, 8 choledochal
indications for, 2 Caroli's disease and, 128
Puestow procedure and, 328 resection of, 116-127
right hepatic artery occlusion and, massive hepatic
liver trauma and, 244 aspiration of, 206, 207
technique for , 2-9 simple. 206-209
trauma and, 460 hydatid. 206
Cholecystojej unostomy management of, 210-223
hepaticojejunostomy versus. unresectable Cystadenocarcinomas, 208, 386
periampul lary carcinoma and, 418 Cystadenomas, 386
technique for, 41 8-423 Cystic artery
Choledochal cyst identification of, 4-6
Caroli's disease and. 128 ligation of, 6, 7
resection of right hepatic lobectomy and , 182. I'
indications for. 116 Cystic du ct
technique for, 116-127 looping of, 4. 5
Choledochoduodenostom y, side·to·side right hepatic lobectomy and. 182. 1
indications for, 28 unresectable periampullary carcinoma
technique for , 28-37 involving. 424, 425
Choledochoscopy, 16, 17, 110, III Cystic duct stump. ligation of, 8. 9
in Caroli's disease, 132, 133 Cystic neoplasms, distal pancreatectomy for.
Choledochotom y, 10-12. 32 428
anterior, 110, 111 Cystoduodenostomy, 384 -385
hepaticajejunostomy and. for distal Cystogastrostomy, 370, 380-383
stricturing secondary to sclerosing Cystogram. 372
cholangi tis, 114, 115 Cystojejunostomy, 370-379
Chromic catgut mattress sutures, liver
resection and
lateral segment of left lobe, 164. 165 D
wedge, 146. 147. 158
Closing cholangiography, 16 Dacron prosthesis, interposition mesoca\'al
Colon, right. direct mesocaval shunt and, 292, shunt and. 258-265
293 DeBakey clamp
Colorectal metastases, to liver, 2 direct mesoca\'al shunt and. 292. 293
hepatic arrery infusion and. 200 distal splenorenal shunt and. 270
Common duct Debridement. pancreatic abscess drainage
distal. di"ision of. 60-62. 120. 121 and. -1-16--14
hepaticojejunosrorny anc. -!~·t -t25 Deep stellate injury. oi Ii"er. 2-10. 241
Idenri:ication or. nme::.-·::',-c ;:.c:-,:r:,,_: ::3:a.~ De\-ascularization. of left hepaoc lobe. l:--t
. - -,
~- -

;>ar.c-ea:c.::c::::.' a.:::. :r._- :r.:: D,"~hragm. nght hepatic lobectomy and. 1

;>a.-;''::-fa:;.:-c':'.::~-c:-.'C"...-:_:-_:. l.::.: :.:;..-; ;"-:.;. D::a:or, . Bake;. 14. 15
(_.::-.z:(.:: c:,: ..-: =.x~:·:.:;:y:: O':i;;.,:x :rac.,ne;l3:lC ~)llia:o ;:em a.'ld. -16 .
.:::·:...a..--6A~;:~:'- :.:.::c. :':'2
~:.;:('"~:_c :"
 " - • • =0=: _ • .....oIE'

Ib hi -z --., 22II~"
DisuI .1'!IIIric ""r·d'.....
~~nmu.~~~D~~~,
DisW p;m<l!12:lJ0I""'f -435
f..- duunic .............. JSD.359 entenllOmJ' and, 426" m
nioety-fu-e JII'IllI5ii. ~-JIl3 gastrotomy and, 380, 38J
for rumor, 428-435 pyloric exclusion and, 462, 463
Distal spIenormaI shunt longitudinal pancreaticojejunostnmy
indications for, 266 328,329
technique for, 266--273 wedge resection and, 158
Diverticularization. duodenal. trauma and, End-t<H!nd pancreatirojejlloostomy
45-1-461 indications for, 342
Drain(s) technique for, 342-349
cholecystectomy and, 8, 9 End-to-side duodenojejunostomy, 40f
choledochoduodenostomy and , 36 End-to-side hepaticojejunostomy, 426
choledochotomy and, 16 End-to-side jejunojejunostomy, SO,51
distal pancreatectomy and, 360 Puestow procedure and, 334
duodenotomy and, 368 End- to-s ide pancreaticojejunostomy, 406-409
end-to-end pancreaticojejunostomy and , 348 End-to-side pcrtacaval shunt, 274, 276-281
hepaticojejunostomy and, 56 Enteroenterostomy, cholecystojej unostOmJ
massive liver trauma and, 242, 243 and, 420, 421
pancreaticoduodenectomy and, 412 Enterotomy(ies), 50, 51
Drainage accessory du ct papillotomy and, 366,"!Gl
of abscess bilateral, 68, 69
liver, 224-235 choledochal cyst and, 124, 125
pancreatic, 442-453 hepaticojejunostomy and, 426, 427
pancreatic, trauma and, 454-461 longitudinal pancreaticojejunostomy and,
pancreatic pseudocyst 336,337
into duodenum , 384-385 proximal cholangiocarcinoma and, 90.9I
into Roux-en-Y jejunal loop, 370-379 Esophageal varices _See alsa GastrutSl,. ;g::al
into stomach , 380-383 varices
Duodenal bypass, unresectable periampu llary direct mesocaval shu nt for, 288
carcinoma and, 414-427 pcrtacaval shu nt for, 274
Duode nal C loop, ninety-five percent distal Extracorpcreal shock wave lithotripsy, 2
pancreatectomy and, 362-365
Duodenojeju nostomy, end-to-side, 404 F
Duodenotomy, 20-22, 26, 27, 32, 33
clos ure of, 368 Faltiform liga ment, 152- 154
drainage of, 368 reattachment of, 166, 167
longitudinal, accessory duct papillotomy Fat necrosis, 448, 449
and, 366, 367 Figure-of-eight sutu res, distal pancreateClIlCJ
Duodenum and,358,359, 434, 435
dive rticularization of, trau ma and, 454-461 Forceps, Randall Stone, 12, 13
first portion of, division of, 390, 391 French catheter, biliary tree and,14,15
kocheri zation of, 108- 109,384-385
common duct exploration and, 10- 11
pancreaticoduodenectomy and, 386-389 G
side-to-side choledochod uodenostomy and,
30-31 Gallbladder, 154
mobilization of, portacaval shun t and, 278, carcinoma of, wedge resection of ti,-er and
279 regional lymph node dissection 1..-,
pancreatic pseudocyst drainage into, 142- 149
384-385 dissection of, 6, 7
trauma to, 454-461 , 462-467 hepatic lobectomy and
DuVal procedure left, 170, 171
indications for, 342 right, 182
technique for, 342-349 lymphatic hypertension and, 2J6
pancreaticod uodenectomy and, ~,~i:J
trisegmentectomy and, 192
Gallstones, 2_ See also Calculi;
E Cholecystectomy
Gast roduodena l artery
Echinococcus granulosa. Sa H;-daod qs dissection of, pancrealti-arl':loClB:!=,,--
disease and,390,391
 Infasaid pnmp and. 200. 2(W
Gastroepiploic .-ems. distaJ splenorenal shunt
and. 268
Gastroesopbageal varices. See also Esophageal
vances
distal splenorenal shunt and, 266
Gastrojej unostomy
Hofmeister, 412
transverse mesocolon suturing to, 466. 467
trauma and, 460. 461, 464. 465
unresectable periampullary carc inoma and,
414-417
Gastrotom y
distal , pyloric exclusion and, 462, 463
pancreatic pseudocyst drainage and, 380,
381
Glisson's capsule, Silastic transhepatic biliary
stent and. 46, 47
Glucagon , pancreaticoduodenectomy and, 400
Graft. See Prosthesis
H "H" graft. interposition, 274, 286-287
Hamoudi tumor, 386
distal pancreatectomy for, 428
Heart failure, LeVeen shunt and, 312
Hemigastrectomy, Whipple procedure and,
406,407,41O-4l3
Hemostasis
massive liver trauma and
packing of wound and, 246, 247
Pringle maneuver and, 244, 245
right hepatic lobectomy and, 184
Hepatic abscess, drainage of, 224-235
Hepatic artery, 152
anatomical variability of. 200
right. 182. 183
trisegmentectomy and , 192, 193
Hepatic artery infusion , Infusaid pump
insertion for
indications for, 200
techn ique for. 200-205
Hepatic cyst, simple, resection of, 206-209
Hepatic duct
common . See Common duct entries
left, left hepatic lobectomy and, 170, 171
right, right hepatic lobectomy and, 182. 183
Hepatic duct bifurcation
choledochal cyst and. 116
exposure and dissection of, 60-63, 74 , 75
resection of, sclerosing cholangitis and ,
96-99
trisegmentectomy and, 192
Hepatic lobectomy. See also Liver resection(s)
left, 168-177
proximal cholangiocarcinoma and , 76-81
right, 178- 189
Hepaticojejunostomy(ies)
benign biliary stricture and. 54-57
bilateral
proximal choiangIoc:arci and. 68-71
sclerosing ddangltls '"""- 1 •
~1AY--".""''''''tstC~tabie
jbM .. ,: B .) <», 11'
.1 A, W -.
f..- disIaI $Ilium"", .......mry to
sdaosillg. h .....gja is 108-115
end-1I>Side, 426
hepatic lobectomy and. proximal
cholangiocarcinoma and.
palliative biliary and duodenal bypasses
and, 424-427
pancreaticoduodenectomy and, 402
proximal choiangiocarcinoma palliation
and,90-93
Hepatic parenchyma, division of, 78, 79, 174
Hepatic resection(s). See Li ver resection(s)
Hepatic reserve, 190
Hepatic trauma, massive, management of,
236-249
Hepatic vein(s), 152
di vision of, 172, 173
trisegmentectomy and , 194
left . left hepatic lobectomy and , 170
right, right hepatic lobectomy and, 184
stellate injuries in volving, 248, 249
Hilar ana tomy, 152
Hofmeister gastrojejunostomy, 412
Hydatid cys t disease
management of, 210-223
simple cyst of liver versus, 206
Hyperamylasemia, pancreas divisum an d, 366
Hypertension
lymphatic, gallbladder and , 276
portal , shun ts and. See Shun t(s)
Hypertonic sali ne, as scolecidal agent, 212
I
Il iac vein , direct mesocaval shunt and.
292-295
Inferi or mesenteric vein, distal
pancreatectomy and , 356, 357
Inferior vena cava
Budd-Chiari syndrome and , 298
mesocaval shunt and
direct, 292-295
interposition, 256-262
portacaval shunt and
end· to·side. 280, 281
side·to·side. 282, 283
Infusaid pum p, 2
insertion of, for hepatic artery infusion,
200-205
Instrum ents. See also sjJecljic instruments
fo r biliary tree exploration, 12- 15
[nsul inoma, laparotomy for, 436-441
Internal jugular vein, LeVeen shunt and , 312,
313.322
Interpos ition "H" grait , 274. 2 -2 7
In terposi{ion mesocaval shum
indication for. 252-254
technique lOT. 254- 265
inteStine, small division Ill. 332. 333
Inll'lhepatic biliary nee. dilawion Ill.
sdaOSlLl!< ·hl 'f;P is and. 100. 101
L.,6ux :~ .so:Cs. ;x:.rs :if~ra~';""t :-a6ot b::2;>:'- InP"'V,.".,-aJ
2.."':c. jJroXJrnal choia."1g:,.xa.;-(1:1·zr.a and. jndjcarjoos f«. 1:i6
32 .92 technique for. 1 ~ 161
I;ngat:o:: . ;>ancre a~ic ab3ce~:s dral r.agt and. proximal cboIangJocarcinoma and, i 6-S1
+4.S . +t9 right lobe, I i 189
I31er cell t:.ImOfS. ..,- . Sa aL~o Insulinoma plus medial segment of left lobe, 190-199
wedge. 156. 158-159
for carcinoma of gallbladder, 144-147
J Lobectomy, hepatic. See a/so Liver resect ion(s)
left ,168- 177
jaundice. sclerosing cholangi tis and , 94 proximal cholangiocarcinoma and, 76-81
jejunal loop. Roux·en·Y . See Roux·en·Y loop right, 178- 189
jeju nojejunostomy Longitudinal pancreaticojejunoscom y
end·to·side, 50, 51 indications for, 326
Pues tow procedure and, 334 technique for, 326-341
hepaticojejunostomy and, 426, 427 Lymphatic hypertension, gallbladder and, 276
jej unostomv. See Hepaticojejunostomy(ies); Lymph flow , interposition mesocaval shu nt
Pancreaticojejunos tomy and, 254
jejunum, proximal, division of, 396 Lymph node dissection , regional, for
j ugular vein , LeVeen shunt and, 312, 313, 322, carcinoma of gallbladder, 148- 149
323
M

Malignant disease. See Carci noma

K
Mattress suture(s)
Ki dney. See Renal entries
Caroli's disease and, 138
Klatskin tu mors, 58
chromic catgut
Kling, packing with, massive liver trauma
resection of lateral segment of left lobe of
and,246,247
liver and, 164, 165
Knit ted Dacron prosthesis, interposit ion
wedge resection of liver and, 146, 147
mesocaval shunt and, 258-265
distal pancreatectomy and, 358-361
Kocher clamps, Whipple procedure and,
interposition mesocaval shunt and, 258, 259
410-413
mesoa trial shunt and, 304, 305
Kocherization, duodenal. See Duodenum,
nonanatomicalliver resection and, 158, 159
kocherization of
Median sternotomy
hepatic vein injury and, 248
trisegmentectomy and, 190
L Mesenteric arteriograph y, portaca\'aI sham
and,276
Lacrimal duct probe, in accessory duct Mesenteric-systemic venous shunts~ 252.. Z;-L
papiliotomy,368 See also Shun t(s); speciJIc 1)1>t
Mesenteric vein. See Inferior mesentf7lC ~
Laparotomy Superior mesenteric \'ein
for insulinoma, 436-441 Mesentery, Puestow procedure and. Dl331
proximal cholangiocarcinomas and, 58, 59 Mesoatrial shunt
LeVeen shun t indications for , 298
indications for, 312 technique for , 298-311
technique for, 312-323 Mesocaval shunt
Li thotripsy, extracorporeal shock wave, 2 direct
Liver. See also Hepatic entries indications for, 288
abscesses of, drainage of, 224-235 technique for 288-297
anatomy of, 152- 155 interposition
colorectal metastases to, 2, 156 indications for, 252-254
hvdatid cyst disease of, 206, 210-223 technique for, 254-265
mesoatrial shunt and, 298, 299 Mesocolon, transverse, sutured to
simple cyst of, resection of, 206-209 gastrojejunostomy, 466, 46i
trauma to, massive, 236-249 Metastases, colorectal. to liver, 2, 200
Li\'er bed, drainage of, cholecystectomy and, Mikulicz pads, packing with
8,9 massive liver trauma and, 246, 247
Lil,'er failu re. LeYeen shum and. 312 pancreatic abscess drainage and . 452, .\53
U·;tr ft 3eGrionrSI
ie:: lotJt;
c..:':a :'l.."'1Jla:iza;:icc. !::: . . - ,
~h.~'~l~ . :a : . ~ . +49
~Co:~~a3 :-:::: . Sri C2.!'cino:::la: !pi,-,{r.t llX41WII ()T

.)?,
o Pcor-..ac:avai shunt
O?eraToc ci:.-:~~;;r.:.~. 8. Su also
Cbolar:gxgra;>ie.-
commor. dth..~ c.~lvratlor: ai1d. 10
Operan ...c rraurr.4. Je:-ngn bile duct strictures
and.~
Qyer· and.-o\"er stitch. 338. 339
p Portal pressure, measurement 01. ~6. T:7
Packing
hemostasis and, massive liver trauma and
246,247
pancreatic abscess drainage and, 452, 453
Pain, abdominal
pancreas divisum and, 366
pancreaticojejunostomy for
end-to-end,342
longitudinal,326
Pancreas
drainage of, trauma and, 454- 461,462,467
exposure of, 326-328
insulinoma and, 436-439
Pancreas divisum, accessory duct papillotomy
for, 366-369
Pancreatectomy, distal
for chronic pancreatitis, 350- 359
ninety-five percent, 362- 365
for tumor, 428-435
Pancreatic abscess, drainage of, 442- 453
Pancreatic duct dilata tion, 326- 329
Pancreaticoduodenectomy, 362
indications for, 386
technique for, 386-413
Pancreaticojejunostomy
end-to-end
indications for, 342
technique for, 342- 349
end-to-side, 406- 409
longitudinal
in dications for, 326
technique for, 326- 341
Pancreatic pseudocyst, drainage of
into duodenum, 384- 385
into Roux-en-Y jejunal loop, 370-379
into stomach, 380- 383
Pancreatitis, sphincteropiasty for . See
Sphincteroplasty
Pancreatotomy, 328
Papillary neoplasms, 386
Papillotomy, accessory duct, for pancreas
divisum, 366-369
Pediatric patients, direct mesocaval shunt for
288
Perforations, pancreatic, 454, 455
Periampullary carcinoma
pancreaticoduodenectomy for, 366
unresectable, palliati';t jY~5SC5 for,
·n ~ -·fZ ~
Perironeal ca'.-1::;. ::'YCc:iC ::.~:5
Pui:;cystic li';::: :" :::~-=<, :~~...:
P(.I:.--:f:~':':-:·':·:·=-x:':'-_:'-:t'::-:: ~.~.::
::.:t:-?:J5:::'::::: :: ;:-1!;..';"_ ~
end-t&->ide. Z;;;_ T.6-281
Inter;x>sllioo '"w gnlft. Z~ 4. 286-2S:-
indications ior. 2-;-4. 276
side-ro-side.282-2" -
Porta hepatis
anatom y of. 152
clamping of. in Pringle maneu\"er. 2-1-4
drainage of. cholecystectomy and. .9
Portal hypertension, shunts and. Su huno:i l
Portal vein, 152
hepatic lobectom y and
left , 170, 171
'
right , 182 , 183
pancreaticoduodenectomy and, 388. 389
portacaval shunt and
end-to-side, 280, 281
side-t~-side, 282, 283
tri segment ectomy and, 192, 193
Portasystemic decompress ion , 266. See also
Shunt(s)
Pott's scissors, septotom y with, 22. 23
Pringle maneuver, 244, 245
hepatic vein injury and , 248
Prosthesis
interposition "H" graft and , 274, 2ll6-2ir.
knitted, interposition mesocaval shunt and.
258-265
mesoatrial shunt and , 302- 305
Proximal cholangiocarcinoma
palliation of, transhepatic stem ing and
hepaticojejunostom y in, 84 -93
resection of, transhepatic stenting and
hepaticojejunostomy in
bilateral,58- 71
hepatic lobectomy and, 72-
Pseudocyst, pancreatic. See Pancreatic
pseudocyst
Puestow procedure
indications for , 326
technique for, 326- 34 1
Pump, Infusaid, 2
for hepatic artery infusion. 200-205
Pyloric exclusion, pancreatic drainage and. tar
combined duodenal and pancreatic
trauma, 462- 467
Pylorus-preserving Wh ipple procedure
indications for , 386
technique for , 386-41 3
R
Radiotherapy, postoperat iR proximal
' cholangiocarcinoma and. 82. 9'2
Ra nda ll Ston e forceps. 12_ 13
Renal function . l,e\'een shunt and. 312
Rena l ,-ein_ leit. distal splenorenal >hun! and.
2,0
Retroperironeum. distal S?ienorena1 5b1I!l1
a::.~ :::2 and. 26S. 209
Ring ca:hetef15'
::r ~nigr. biliary ~:rk.t~ a.~" -12_ -L1
y Ca..~A:' ~ disea.,< ar.c. 1:l:~ :34
 ~. ;.p .... acmoma and. 64--:1
:-:::,~,:-:<c..a: =:.-s: ;C.: :~: =:~. ~~. =~.5 hepatic IOOFnrmy and. 82-83
::t~::'::~.f~:':::·:1S : :::::.- a:.:.~": ;>alliatioo rio N-i'9
;t:=.::.::eE.:t..:-xb:Ci'::a..-:,x:::: a::':. ~~2. 3~3. Small bo...e!. di\isioo ai. Puesrm< procedure
~=r]
and. 332, 333
;:t!'(,x:::.:ai c::ola::gE:~C::".o17la a1".d. S-E-cil. Sphincteroplasty
~ :? - ~ 5.~~ incision length for. 22
Roux-en ·Y loo?~. 52. 53 indications for, 18
Caroli', dis""", and. 136- 1&3 technique for, 18- 27
choledochal Cyst and. 12 4 - 12~ Sphincterotomy, 18, 22, 23
const ru ction of. -t.8. 49 Splanchn icectomy, chemical, 422, 423
end· to-side jejunojejunostomY and. 50, 51 Spleen, mobilization of
hepaticojejunosromyand . distal pancreatectomy and, 352, 353
ben ign bilia ry stricture and, 54- 57 end· to-end pancreaticojejunostomy and.
distal stricturing secondary to sclerosing 342, 343
cholangitis and , 114 Splenic artery
proximal cholangiocarcinorn a and, 66- 71, distal pancreatectomy and, 432, 433
82-83, 90-93 end-to·end pancreaticojejunostomy and,
sclerosing cholangitis and, 104 344,345
pancreaticojejunostomy and Splenic vein
end·to·end,346 distal pancreatectomy and, 356, 357, 432,
longitud inal,330-335 433
pancreatic pseudocyst drai nage into, distal splenorenal shunt and, 268- 273
370-379,380 end-to-end pancreaticojejunostomy and ,
344,345
S Splenorenal shunt, distal
indications for, 266
Saline, hypertonic, as scolecidal agent, 212 technique for, 266-273
Satinsky clamp Stell ate injury
interposit ion "H" graft and, 286, 287 of liver, 238-249
interposition mesocaval shu nt and, 258, 259 of pancreas, 454, 455, 460
Sclerosi ng cholangitis, 94- 107 Stenting, transhepatic, of biliary tree. See
di s tal strictu ring secondary to, Transhepatic stenting of biliary tree
hepaticojejunostomy for, 108-115 Sternocleidomastoid muscle, LeVeen shunt
Sclerotherapy, 266, 274 and,312,313
Scolecidal agents, 212 Sternotomy, med ian
Scoops, for biliary tree exploration, 12 , 13 hepa tic vein injury and, 248
Sepsis, acute pancreatitis and, 442 trisegmentectomy and, 190
Septotomy , sphincteroplasty and, 22, 23 Stomach, pancreatic pseudocyst drainage
Shun t(s) into, 380-383
Le Veen "Sump syndrome," 36
indications fOT, 312 Superior mesenteric artery,
technique for, 312-323 pancreaticoduodenectomy and , 394.
mesoatrial 395
ind ications for, 298 Superior mesenteric vein
technique for, 298-311 mesoatrial shunt and, 300, 301
mesocaval mesocaval shunt and
direct, 288-297 direct, 290, 291 , 294-297
in terposition, 252-265 interpos ition, 254-257
place men t of, hepatic vein injury and, 248 pancreaticoduodenectomy and, 388, 389
po rtacaval Suture(s)
end·to·side, 275, 276- 281 cholecystojejunostomy and , 418- 421
" H," 286- 287 cystoduodenostomy and , 384, 385
ind ica tions fo r, 274, 276 cystojejunostomy and, 376- 379
side·to·side, 282- 285 distal pancreatectomy and, 358- 361. 434,
splenorenal, distal, 266-273 435
Side·to·side choledochoduodenostomy, 28- 37 end-to-end pancrea ticojejunostomy and.
Side· to-side pancreaticojejunostomy , 348.349
longitudinal. 336- 341 gastrojejunostomv and. 414-41~. -I&I.-l65
Side-ta-side ponacayai shunt. 2-; 4. ~~:2 - :?~;:; hepaticojejunostomy and. 426. 42:-
matt ress
5ilastic cuff. mesoatrial Jro5thesis c:::. :=':':2
5!ias::t: :!a:1Shepatic Ji::~:-: S:t:::::-.£' Caroli's disease and. 138
:-2:-.:g:: Jili2ry s:r1c:'''::-': ;:-.::. ~ -.;: chromic catgu t. 1.,16. I·C . l6-t 1';;;
C.;. ~ :::·S di3ec.x a:::. =~~<~:
ce?lEition me..'-0C3\·al clam? and. 25e.
2':;~
 mesoatrial shunt and , 304, 305 Tumors. See Carcinoma; specific /oca/ilm or
nonanatomicalliver resection and. 158, 159 type
pancreaticoduodenectomy and , 400-405
pyloric exclusion and, 462-464, 466
u
T Ultrasonic dissector, 160
Umbilical ta pe, hepatic vein injury and, 248
Thoracotomy Umbilical ve in, distal splenorenal shunt and,
hydatid cyst and, 218 272
mesoatrial shunt and, 302, 303 Uncinate process, dissection of,
Thrombosis, in Budd-Chiari syndrome, 298 pancreaticod uoden ectomy and, 394.
Transhepatic stenting of bi liary tree, 2 395
benign biliary st ricture and, 44-47
Caroli's disease and, 128-141
v
proximal choiangiocarcinoma and
palliation of, 84-89
Vagotomy, 464
resec tion of, 64-71 , 82-83
Varices
sclerosing cholangitis and, 102, 103
esophageal
Transverse mesocolon , sutured to
direct mesocaval shunt for. 288
gastrojejunostomy, 466, 467
portacaval shunt for , 274
Trau ma
gastroesophageal, distal s plenorenal shunt
accessory papilla cann ulation and , 366
for , 266
chronic pancreatitis due to, distal
Vasa brevia, di vision of, 352, 353
pancreatectomy for, 350
Veins. See specl/ic veins
combined duodenal and pancreatic
Vena cava, inferior. See Inferior vena cava
duodenal diverticularization and
Venous shunt, mesenteric-systemic, 252 , 274.
pancreatic drainage for, 454-461
See alsa Shu nt(s); specIfic type
pyloric exclusion and pancreatic drainage
for, 462-467
liver, massive, 236-249 w
operative, benign bile duct strict ures and,
38 Wedge resection, of liver, 156, 158- 159
Trisegmentectomy for carcinoma of gallbladder, 144- 147
indications for , 190 Whipple procedure, 362, 406, 407, 410-413
technique fo r, 190-199 pylorus-preserving
T-tube, insertion of, after common ducl indications for, 386
exploration, 16, 17 tech nique fo r, 386-413