Professional Documents
Culture Documents
Contents
J()
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
72
The Liver
Anatomy of the Li\'er
152
19(1
SJ
The Pancreas
Longitud inal Pancreat icojejullostomy: PueslOw Procedure 326
EndtoEnd Pancreaticojejunostorny: DuVal Procedure 342
Distal Pancreatectomy fo r Chro nic Pancreatitis 350
Cholecystectomy
Operative Indications
atients with symptomatic gallstones are candidates for
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.
lIoith
Some patients with symptomatic gallstone disease may be man
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
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).
he:Jabc a
Cystic duct
Cystic a.
and duct
~_~
_ _ __ __
~~'-_
R hepabc a
\
Cysbc a
Serosal
reflection
Mobilized
gallbladder
- - - --J
O
I
_I
Common
hepatic
duct
C-a
-adder fossa - --
- - -- - ----Jr-'ir.
Cystic a. and
duct stumps ----,~'7"
Operative Technique
nce the decision is made to perform a com mon duct exploration. the
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 3cm 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
Cystic a.
and
duct
Choledochotomy
Kocherized
duodenum
II
here are a variety of instruments that one can utilize to explore the
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 tangled 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
Irriga 'on
catheter
_I
..>
Catheter tip
.a_--'-'_ _ _ _ through
ampull a
~3
Bakes
dilator
_ats-g.,y
Rigid
;.-_ _ _ choledochoscope
f-_ _ _
Biliary
balioon
calheler
0;--;.-----_ _ _ _ _ _
Choledocholomy
closure
Sphincteroplasty, Including
Transampullary Common Duct
Exploration
Operative Indications
phincteroplasty is an operative procedure that has been used in a
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
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
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
Ampu lla
Biliary
balloon
catheter
Pancreatic
duct orifice
Probe in
It------ - - pancreatic
duct
Clamps on
cystic duct
.:.
Ligated ~
cystic duct
stump
~i------ Sphincteroplast)
Randall
Sto ne lorceps
~L-_ __
Biliary
balloon
catheter
Balloon
deflated
--.:.,_ _ _ _ Balloon
inflated
he lateral stay sutu res are removed from the duodenum, and fay
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
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 furprimary 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
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
).
Cystic
duct
stump
Kochen:zed _
_ __ _ _----y
c:Uxlenu!:J
Head of
~--:'tr-.-------- pancreas
31
stone
~_ _......_....,._
_ -'-_ _ _ Duodenotomy
Lateral
slay
suture
/ _ _ _ _ _ Apex suture
nterrupted sutures of 3-0 ilk are then placed. alway pa ing from
'
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
Completed
Side-ta_side
anastomoSis
Operative Techniques
ost patients with benign biliary strictures will have undergone a
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).
~\ \
I
Ring
cath eter into
duodenum _ _ _ __
CO \\
);
Adhes.,ns
betlteen liver
and omentum
Strictured
common duc~
(conta ining Ring
catheter)
f
Openmg normal
coovnon hepatic duct
Ring catheter _
Sludge
and
small
stones
nce all the calculus material has been removed, stay utu res are
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
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(
+-____
_ __ _ _ GUIdewwe
a Ring catheter has not been placed preoperati\'ely, other techniqu are
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 jcontained within the liver and in that portion which is to be placed in the RouxenY 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
,
Ligament
of Treilz
_ --,"_
Transverse
colon
Middle
COI IO-_=
;'"
vessels
Duoden,um
Distal
jejunum
1
I
I
I
Slone
clamps
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
_ _
Hepatic duct
bifurcation
-en-Y
Duodenum
Middle
colic vessels
Silastic
biliary
stent
"-_ _ _ _ _ _ Portal v.
r-- - - - --
Common hepatic a.
- ---,O;I--- - -
Raux -en- Y
jejunal loop
>
,/
,/
Posterior row of
hepaticojelunostomy
Sliasbc
biliary
stent
Enterotomy
rowol
anastomosis _ _ _ _~=--
~~ ----~-----
_
in
cc
Hepat.cote u'o.5IOI_
Sllasbc bi ary
stent In
Jejunum
-'
Transverse colon
End-Io-side
jejunojeJmoslcmy
..K~ection
of 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
chol angiography over th e past decade, an increasing number
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
R "9 catheters
atients are prepped and draped so that the surgeon ha access to both
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
Gallbladder
- - - - ---t-'+
Hepatic
flexure
of co lon
Duodenum
Tumor
invoMlg
hepalicdld
bifurcalion
GaWb" - ,
fossa
"If.:--:;--- - -
Mobilized
gallbladder
, /I'
!
Common _ _ _ __
duct
- .~
Tumor involving
hepatic duct
bifurcation
; ,-
Duodenum _ _~_
- - - CJvip."
"on
?II
arly division of the common duct allows one to dissect the bifurcation
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
~~~~~,: ""'-1~f--
Portal v. bifurcation
R. hepalic duel
i!ii;;;~~-=:::::~- R. and I.
hepatic aa.
Oversewn _ __ --:_
common
duct
Duodenum _ _ __
Bifurcation of
r. hepatic duct
:/
.I
Tumor
R. hepatic duct
Specimen
L hepatic dud
Commooducl
oth the right and left hepatic ducts are intubated with Silastic
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
cath eters
Guidewire
Mattress suture
stent
\, I~I
ften the point of division of the right hepatic duct is close to the
bifurcation of the anterior and posterior segments. If this i? the case,
the spur is divided and one anastomosis is performed (K). A RouxenY 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.
Roux -en -Y _ _ __
I"I'lllalioop
_ _~
--"'t-~-4+~---
- -- - - bEry
Roux-en-Y
jejunal loop
Hepaticojejunostomies
=='-:-:-=-==-"::"_':::"~=_---=-_Transverse
me$ocolon
tacked to jejunal loop
71
Resection of a Proximal
Cholangiocar:cinoma With Hepatic
Lobectomy and Reconstruction
Utilizing a Silastic Transhepatic
Biliary Stent and
Hepaticojejunostomy
Operative Indications
Operative Technique
I.
,/
/,
li
\.~\-.,,~_ _ _ _
Ring caIheIeIs
, "'
~)
Gallbladder
fossa
Cystic a.
and duct
- ,,L-_ _
Mobilized
gallbladder
Duodenum _ _---:-_
- --
""-- - - - Ring
catheters
O Llaix:hotomy
Proximal
common duct -------1~
Portal v.
.. ,..L._
Oversewn distal
common duct
R and I.
hepaoc aa.
_ _ L hepa:!ic
duct
nce the hepatic duct bifurcation has been mobi lized and dissected off
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.
..
J
~,L---
Common dud
L. hepatic duct
Divided
r. hepatic _ _.--tlI\
L hepa -ca
duct
Portal v. bifurcation
R. hepatic _ _""-
duel
-'-'-_ _ R. and L hepatic aa.
.\ __ _ _ Ring catheter
Distal common
duct
~_
i-- -- - -
Divided L hepatic a.
L branch of portal v.
divided
!Il
G
FalcLUi
Suprahepatic
inferior
L.lobe
of liver
vena cava
Stomach
OIapIvagm
Spleen
- - -- ----...11
~----------_ L. hepatic v.
Divided
I. hepatic v.
71
f
\
Dividing
parenchyma
Divided I. hepatic v.
Devascularized
I. lobe
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.
Liver sutures _ _ _
4 -"--- -
'1"1-1-- --
Caudate lobe
R. hepatic duct
Oversewn
I. branch
of portal v.
____
_ _ _ _ _ __ _
Duodenum
SiIaslic
biliaJy
sterol
p
Middle hepatic v.
Hepaticojejunostomy
Rouxen-Y
jejunal loop
-~a.--!!...,--
Silastic
biliary
stent
~--'-'-'-----'--_ _
Duodenum
Transverse mesocolon
tacked to jejunal loop
Proximal Cholangiocarcinoma:
Palliation by Transhepatic Stenting
and Hepaticojejunostomy
Operative Indications
ll patients with proximal cholangiocarcinomas are staged
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
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
Encircling common
'#'-,,&-_ _ _ _ _ _ hepatic duct
vessel loop
DMded cys:x: a
Mobilized
gallbladder
I.
D
common
duct
-~
UJ
he curved ends of the Ring catheters are cu t off. The catheters are
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).
_ _--C.;!-~_
_ __
Ring catheters
.)
Coude
catheter
/.
J';r
I
'_~ng
,
C<CJheter
_ _ GUldewtre
Sitastlc
bitiary
stent
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
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 RouxenY 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.
_~
_ ______ Roux-en- Y
e ur.a
Sase
boary
s;.ent
,,
jejunal loop
,,
\
/
'
,
\
Transverse colon
P-"----- -
End-la-side
jeJunojejunoslomy
,,
Ring catheters
Gallbladder _ __ _
\
Duodenum _ __ _ __
Operative Technique
'1 ng catheters
Hepatic duct
bifurcation
Gallbladder
- -r-,,:,-'
Hepatic flexure
of co lon
Duodenum
~\
l -- - Common duct
Mobilized
gallbladder
:4'- ~':-_
He::-=2..
Pcr12I Y.
common
duct
L hepatic duct
99
;L- - --
L. hepatic duct
Larger
Goude catheter
,.c,_ _ _ __ Small
Goude catheter
\
, _ _ _ _ Guidewlre
SI aSLC biliary - - - - - -_ _ __
s:...."
101
1"'-- - --
L. hepatic duct
Olive tip of
Bakes dilator
Sa! es dilator
103
. 1
.~
J
I
"
f.
R. hepatic duct
Posterior
rows of
anastomoses
Enterotomies
Roux-en - Y
jejunal loop
MerU
rows 01
ana::.stai-
oth silastic transhepatic biliary stents emanating from the top of the
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 Rouxen-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 Rouxen-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"
Transverse m'es.x:c>lo<o
lacked 10 le,una 1000
'f-,~~------- End-Io-side
jejunojejunostomy
101
Operative Technique
he patient is explored through a righ t subcostal inci ion. Many
patients will have been operated upon previously; often they
undergone a cholecystectomy with insertion of aT-tube forprolonged T -tube drainage.
At the time of exploration for hepaticojejunostomy, if the gallbladder- in place, it is removed. The duodenum is extensively kocherized (8)-
DIseased disIaI
COIiitiO. doc:t
--
Gallbladder ______
Duodenum __________
Gallbladder
fossa
Kocherized duodelll.m
l ,:::~:-,.---:=------'---- Pancreas
109
rll
.;:;;~~:-
-=~~~
_ _ _ _ __ _ _ _ _ _ _ _ Head ofPancreas
_____________ Duodenum
Endoscopic view of
hepatic duct
bifurcation
Choledochotomy
~a
and duct _ _
_ _-"'---_
\',
Hepatic duct
bifurcation
Choledochoscope
II:
Diseased
/ ~ distal common
duct
/1'
'/
Endoscopic
view of diseased
common duct
::3
,.
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
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 RouxenY 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
16
Gallbladder _ _ _ _ __
Duodenum _ _ _- ;: -_
epaoc flexure
oi colon
cysI
Ring catheter
Distal common
duct
Duodenum
Oversewn distal
commonducl
119
/Hepatica.
Common
hepatic duel
Portal v.
.,.
\
121
... -- ..
Opening in
transverse
mesocolon
_ --"'-_
_ _ Proximal
J8jtnJm
Roux-en -Y
J2Pl2IIoop
/
/
Posterior row
of anastomosis
Ente rotomy
)
Roux -en-Y
jejunal loop
Rng ca:heler -
- -- - -
--.
Anterior row
of anastomosis
125
, ',
,,
,,
,,
,,
Transverse
mesocolon tacked
to jejunal loop "
. ,,
,,
Ioo~
,,
,,
,,
,
,,
'\
,
I
Transverse colon !
ltA~--------
End-to-side
jejunojejunostomy
Disease
Operative Indications
aroli 's disease is a rare disorder that is poorly understood. "
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,
"
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
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 largebore,
thickwalled 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 RouxenY
jejunal loop.
Generally it is preferable to cut off the distal curved tips of the Ring
catheters (D).
Division of common
hepatic duct
_ _ _ _ __ _ Oversewn distal
common duct
.-",~
_ _ _ _ _ _ _ Duodenum
Common
hepatic
duct
Ring cathete rs
[-'3
Ring catheters
"
Hepatic
Portal v.
\~\
\.
.\ .
~\\....,.'
.z..L-_ _ Oversewn c ,o
common dI;c:-
uidewires are threaded through the Ring catheters on both the right
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
133
. .--------------_______ G~~
- -- -- -_ _ __ __ Ring cathelEr
~~----_______
' 1'--:':'1- --
Smrul caooe
catheter
Larger
Goude catheter
./
__+-_
Portru v.
_ - j - _ Hepatic a
"7:- -- - Goude
catheter
\ - -_ _ _ _ Guidewire
Sllasbc biliary
s ents
' 35
Posterior row of
"- anastomosis
r
(
Enterotomy
o:';l
Roux -en- Y
lejunal loop
'/'
I
L
13,
i2(
~'---'
_ _-"--=-_ _ _ _ HepaticoJeJunoslomy
,
, ,,
\,'
,
Transverse mesocolon
tacked to jejunal
loop
\\
,,
,,
,,
\
'., \
,,
,
,
,,
'1'...... _ -
End-to-side
jejunojejunostomy
l~
.--"~_+
_ _ __ Roux -en -Y
jejunal loop
Guoeewrres _ __
~_---LI~
""'\
\
Hepalicojejunoslomy
------~.,....:H
Endoscopic view
01 hepabcojejtJnoslDrrly
Operative Technique
atients are explored through a right subcostal incision. At the time of
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-
ducl
Duodenum
Peoa c
"'BXure
of
colon
Common
hepatic
duct
for wedge
resection
ro
=
I -
Overl apping
mattress sutures
~_
_ __ _ Wedge resection
of gallbladder fossa
I -
SI;e 0/
;edge - ----Tresec on
-'-
Duodenum
1':-- - --
Site of regIonal
lymph nodes
The Liver
Rhe;>aX Y.
L hepancy.
Lateral
segment
structures
Posterior
segment
structures
Left lobe
Medial
segment
structures
- -- - - - -- - - Falciform
ligament
' -- - - - -_ __ Hepatic a.
t. ..- -- - -- -__
Portal v.
Gallbladder
Common duct
' - -0
-"
he gallbladder, arising from the biliary tree via the cystic duct, rests
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.
Caudate lobe _ __ _
.-c
r
LeH lobe
Atght lobe
Falciform
ligament _ _ __ _--'=~
Quadrate lobe _ _ _ _ __ _--\
Portal v.
Common duct
155
urn
oo=:se:
Operative Technique
variety of incisions can be used , including an upper midline, 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 intraalxIDilm2!
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
Duodenum
Stomach
Falc fform
ligament _ _ _ __ _ _ -:-
Stay suture
be
<= be
Gallbladder
Stay suture
Ultrasonic
dissector
Overlapping
mattress
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
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
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).
Ii.
---------------4--F~~~
~---------_I-- p
Coronary ligament
Falciform
ligament
v.
--
Falciform ligament
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
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
Overlapping
_______+ __ mattress
sutures
c,
Falciform
ligament
Spleen _ _--'-~
of liver
~_
Siomach
Gastrohepatic
ligament
ICV
Operative Technique
variety of incisions can be used for a left hepatic lobectomy. 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:
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).
"'-_ = >""-'----___+_
"'~--~---_
Hepatic a
_ _ _ _ _+Portal v.
Coronary ligament
Falciform
ligament
L.lobe
of liver
Lesion
'----~'rr---
Hepatic duct
bifurcation
~---1I\S--- Portal v.
R. bran ch
of portal v.---~=-l
Cystic duct
stump
Divided
I. hepatic
duct
Hepa 'c a
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
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 overandover 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.
,.I . . . . K)~
of .e'
Overlapping
mattress
sutures
OJ
nce the hepatic parenchyma between the right and left lobes has
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,
L. hepatic v. _ __ __ _ _
Resected surfa'oe _ __ _ __ _
of liver
Divodec
portal
strudu(es _ _ _ _ _ _ _ _ _L--L~
Operative Technique
he same variety of incisions available for left hepatic lobecmrr.
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.
Lme o;
resectIon
~-+t-----,=.L---+- Hepatic
_ __
+ _ Portal v.
__
~-----------I__
~+------------__l-
Biliary tree
Gallbladder
Falciform ligament
k - - - - --
R. lobe 0/
Triangular
ligament
he line of division between the right and left lobes passes through the
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-andover 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.
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
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
~~~~------- ~
~
hepatic v. -------I-?---4t.;~
_ __ _ SmaJ""",*
nce the hilar vessels have been divided and the hepatic vein identified
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
lei'
:lMded:
R branch of porta l v.
R hepaIic w.
lJ~""f------ R
,.."
smacedila
Lesion _ _ _ "
Divided
/L--- - -- - portal
sIrucIures
~_
_ __
____
G al~~
189
Operative Indications
f one adds removal of the medial segment of the left lobe of the
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
_
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,
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..<:tanreschest 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
of the hepatic artery, and the right branch of the portal vein are aD diY-idea..
addition, the right, and often the middle hepatic veins are divided (imeJ)
After entering the peritoneal cavity, the abdomen is carefully extllmmlD<
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
I
I
I
I
I
I
/ '"
190
occasinnanr- "-
l esion
_+--1-+'-
rei
~K\;~.,,~--+- Hepatic a
p------------l- Falcilorm . . . . . .
~---------+- Portal v.
~~-------+-- Biliaty tree
~~~------~~~========================r-- Inf~venacava
Falciform ligament
Stomach
'/--;99'------ TI<l1iSVBSe
colon
Gallbladdef
Divided
cystic a.
R hepatic
Cystic duct
Common
duct
Divided
cystic duct
J!.
Line of
resection
R. branch of
portal v.
he hepatic veins are divided next. The right lobe of the liver is
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!
Stomach
Hepatic flexure
of colon
dissector
R
Diapli ayah
Wenar
vela cava
Jed
suface
01_
FaIcibm 1i9aili"'~
Tnsegmentectomy
specimen
R. and
Resected
surface of liver
Divided
/ -_ _ _ _ portal
structures
'---_ _ Gallbladder
199
Operative Technique
he patient is explored through an upper midline incision. The
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
Rhepabc
Splenic a
00
Stomach
Gallbladder
Gastroduodenal a.
R. gastroepiploic
Superior
pancreaticoduodenal a,
Gastrohepatic ligament
Hepatic a.
Lesions
Gallbladder
fossa
or-
Stomach
..Ii
nce the arterial anatomy has been identified, dissected, and made
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
Subcutaneous
pocket
Catheter
Pu mp
Catheter
I
Gastroduodenal a.
L. hepatic a.
A hepatic a.
- ->"'""",--j_
Gastroduodenal a.
Celi ac
axi s
~....,..-:+;t----j--I~ . hepatic a.
arising from
Rectus m.
IngUinal ligament
Operative Technique
atients are generally explored through a right subcostal incision,
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 thinwalled simple
cyst containing clear serous fluid will not be confused with a hydatid cyst.
~-j~--'P:f1.r-~adder
Site of cyst
incision
__~~~
'--,..-jt-____
#hrt---
Cyst
Stomach
-'=-_ _ _ _
Cy st _
-;;;-;-_
Liver
Gallbladder
Surgical Technique
atients can be explored through a right subcostal, an el<.i ended 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;aA 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
Hydatid cyst
with pulmonary
Biliary communication
with hydatid cyst
,,
,ro OJ.
t ...
IN
r{
I"If.J0,
"
Small
hydatid
cyst
Gallbladder
Calcified
wa ll of cyst
211
Inner
germinal layer
Outer
laminated layer
Daughter cysts
Hydatid
fluid
t
~u ~ I f~,'j f'"
I IIM1
Germinal layer
liE
nce the endolining has been removed and the cyst irrigated copiously
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).
O
.
Calcified
layer of
hydatid cyst
Biliary
communicatIon
he large hydatid cyst in the dome of the right lobe was managed
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
Daughter cyst _ __ __ _
211
."..,r - -
Germinal layer
Diaphragm
Cyst cavity
Silasbc~
sump
dra'f1
he third hydatid cyst, in the anterior segment.of the right lobe of the
liver, was managed by first packing the area off fastidiously with
hypertonic salinesoaked 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
daughler
cysls
Calcified
Germinal
ayer
Omentum
HepatIC Fe"""
of COlO"
he fourth hydatid cyst, a small lesion along the anterior edge of the
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
Operative Technique
atients are generally explored through a right subcostal incision. If the
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
/
~
Anaerobic
culture
Aerobic
culture
to
Liver _ _ _ __
Abscess cavity
Antibiotic
containing
saline
solution
he abscess in the right lobe of the liver, which is not visible on the
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
Abscess
231
nce the abscess cavity is opened, further cultures are taken for
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).
t
I
I
,
l
T-extension
Loculations
_ _ _ _ within
abscess
<
!~
Antib iotic
containing
saline
solution
It
Siomach
Liver
Gallbladder
I
A
Operative Technique
FaIcIIorm IigamenI
Stomach
Gallbladder
- - "..:;= - - - - - - - _
he deep stellate injury of the liver is retracted open and its depth
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
widely with multiple Penrose drains and Silas tic sump catheters (E).
~__~~~~~~ FakSoom
ligament
II]
. , - - -- - Gastrohepatic ligament
L _ _ __ _ _ _ Portal v.
L ______ _ _ Hepatic a.
~_ _ _ _ _ _-'-'---_ _
\..
.'
t
2-
lSarge-y
SL~e
wound
,..,.
. ~3!tJ
,
\
Stay suture
Packing
Liver
~~~~::::=~ Portal v.
-'~=iI----- Bile duct
-It---
L-_ _
Aorta
)
Temporary
occlusion of:
,..-- - - - - - - - - - - - - Suprahepatic inferior vena cava
= =----- -- - -- Aorta
6~----=~
Hepatic a.
_ _ __ Portal v.
. 2~-- Common
Caval-atrial shunt
bile duct
" Keeper"
-,."--;--~~r-- Right abium
"Keeper" _ _ _ _ _ _-:;:-'--:;
R. hepatic v. _ _ _ _ _ _ _'----_--;:
Suprahepa!ic DeriDr
~-----~~~-~~- venacava
~~=:...~
wound
infeOOr
vena cava
Portasystemic Shunts
- rarsverse
color
Omentum
- ta.;S.erse _ _ _ __
~
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
BuddChiari 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 BuddChiari 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
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
p '&nO< ---~~'?'T.-'-
vena
CC:Y2
~~~~------------~
mes.. --=,
~~~~=------ Supenor
meserc:enc y
Duodenum
Small
bowe l
mesentery
rl
I
~-'-----,--- ~
InJerJ()( vena
"Kl~~~--- cava
l\
.: =-:-., \
!
I(,.:r
1-".
"-
!'\, .,.
-'
Vascular clamp
)
~ .'
r
,
- I'
IS..
,I
--'
259
::>acron
gran
Pancreas
Supenor
mesemen:;: v
Inferior
vena cava
i.
,/
.~
"
.,
-1
:L
::::c
~1
...:.:j ~
large bore needle is passed into the most anterior portion of the
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.
Duodenum _____-;_
Superior
i-:r-- - - - - mesenteric v.
---i!;......-- - - - - .. c .. graft
-t
s
Lateral view
_,.~m'n'"r
' ),
/ 1':>,:
/ 1.-
.. c .. graft
./~~~~i~----_superior mesenteri c v.
- - - - - - - Transverse
mesocolon
t
---'lI_-i!~~+--- Dacron graft
~....._~~-"~_
Superior
mesenteric
vein
Duodenum
Inferior
vena cava
Superior
mesenteric
Superior
mesenteric
(~~<ein
~
In eoor vena
cava
-:":.
"'-
:J
<-'
Inferior vena
cava
., ,
(\
Inferior vena
cava
265
Distal
Operative Indications
he di tal splenorenal shunt is a selective shunt, in contra t to the
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 distalsplenorenal 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
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
Retroperrtoneum
Transverse colon
Pon entering the abdomen, great care should be taken to divide all
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 7cm 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.
mesenteric v.
Coronary v.
Portal v.
IJ \
' Spl,enic v.
Superior mesenteric
Y.
Ltga2ad coronary Y
Paoeas
SplenIC v
Adrenal v.
Renal
Superior
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
.!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
Pancreas _ _ _ __ _ _-;-
Divided
r. gastroepi ploic v. _ _ __ __ ,
'
1<~!lhE
,Mj~,, ' (r I
a:h" v
Y.
Portacaval Shunt
Operative Indications
oday most patients with liver disease, portal hypertension, and
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:ssmenot 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 huntsignificant, 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 endtoside 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.
Operative Technique
End-to-Side
'-
Common
duel
-tI~!;-r------bile
Duodenum
Iv.
Pancreas
Duodenum
nce an adequate length of portal vein has been mobilized, the inferior
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
R IN II
AtL t
Transverse colon
..... -cava
279
Caudate lobe
J:i
In ferior
venacava __________~~~.
./~
)
)
Superior
mesenteric v.
vena
Gaslroepiploic arcade
l
f
\.
Side-to-Side
ome surgeons prefer a sideto-side portacaval shunt over an endto-side
shunt. This may be driven by personal preference or by massive
intractable ascites that would not be helped by an endtoside
portacaval shun t. In addition, longterm patency rates are probably
highest for this shunt.
The initial steps in performing a sidetoside 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 tensionfree
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 sidetoside 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
..
he
ID
~
/,
;J
lobe
Infenor
Inferior vena
cava
Duodenum
vena cava
Portal .
283
PonaJ
Commonbdeu"'"-_ __
_ ---'-_ _ _ Duodenum
lobe
Side-la-side
portacaval
anastomosis
Spleen
Portal v. ---~
Splenic v.
Superior
mesenteric v.
285
a :lc-,\'
Portal v.
+~cr,
Inferior
vena
cava - - -
Portal v.
graft
JL..odenum
-" =-=-=
~?~
Splenic v
--0::-- _
Superior .
mesenteric v.
Small bowel
Mesenteric v.
:!as of Surgery
Operative Technique
he operative procedure is performed through a midline incision. Upoo
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
Superior
mesenteric v.
Inferior
~--~------~~-------- venacava
~
______
~~
_________ Aorta
Lumbar v.
A. iliac a. and v.
Right colon
Duodenum
R. renal v.
--
~-- \leila
cava
L
--___ iiac v_
R w eter
he distal end of the right iliac vein is oversewn with a continuous 5-0
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).
T ,.--'-;--'-- - -
II
Tunnel
in mesocolon
Duodenum
Tunnel
I
R. colon
~ TransversE
mesocolo-
Pancreas
R. colon
-'
Duodenum _ __ _ __ --''';-_
Superior
mesenteric v.
ts
oi Surgery
Mesoatrial Shunt
Operative Indications
n most instances when portal hypertension is an indication for a
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 BuddChiari 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
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
- aarc
sa
posterior
Large
-------------1t~--~
branch
of
.
Superior mesenteric v.
Superior
mesenteric v.
Transverse
mesocolon
To lesser sac
t-l~-,-;~-~::----~.
Pancreas
SuperIOr
: lIlae w..
II
Goretex graft
Silastic
cuff
/ -~, .
A. anterolateral
/
Xiphoid
thoracotomy
inCISiOn
Stomach
~..
Transverse
:.-'l'' - - - -- - --
mesocolon
_---.:;~-:,.,:..T--------Goretex graft
)
(
Superior
mesenteric v.
Gorelex
graft
Superior
mesenteric v. _ _ _ _ _ _ _-
..
col
"-
R atrium
.,lL- - Goretex -
"-
. "'
lliJ
graft
Xi phoid
LNer
nce both anastomoses have been completed with the vascular clamps
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
colon
_ - -=--- - - - - Goretex
graft
~r-------~~------ su~
mesenteric v.
he most common route for the mesoatrial prosthesis passes from the
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
+-_____
~ -------------7~
~ ------------~.
Pancreas _ _ --':-'-:''-
f-- - --
Omentum
Transverse
mesocolon
Duodenum ________~, \~
Transverse
colon
\"'-+~-'---
_ _
Small bowel
Xiphoid
I
,"
~,
... .. ., .
Diaphragm
In erior
venacava ________~~-=~~----_j"\
f)1.-- - - -- - --:--":-- -- -
Vi
Esophag us
~------~----------- Aocm
Le Veen Shunt
Operative Indications
ost patients with asci tes secondary to portal hypertension an3
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
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
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_
auto.
Internal jugular v.
ICff
I,ll
,:1:1'
r.~
\ ,. ,
StemoCle;.:fonlasi,oiid m.
'-;-_ _ __ R. camtid
Hema!
".
Small opening
Bronchoscooy
forceps
Subcutaneous
tract
R-- - Peritoneum
Small oOl, ri il'o
in abdominal
wall muscles
_ _ _ _ _ Valve
_ __ AhOOrnir,,'
tubing
Peritoneum
I
J~
....j
J
,
<
rior to inserting the Le\-een sbmn mlWng into the peritooeal canty,
some oi the ascite5 can be ~ ~ suaioning .11. This ckrreases
the amount of ascites and endotoxin that \\'il\ enter the vascular spare,
__~~______
.e~
bng
enous ____
Venous tubing
Peritoneum
Transversus m.
~__
Internal oblique m.
'-________________~t~=======j--
Abdominal tubing
322
I
Lateral
jugular v. _
Internal
~jugUlarv_
H-- -
ve~ous _
R. carotid a.
tubing
,~ \
_,./ "
i"
:\
;;
.'\\'
Tip in r. atrium
;;::-
m
/
:
:~
::
~
,',
tI
"
"
"
::
"
I.-
::
..,
:,
.'
SecoOO nb~
--'---
.. /
Abdominal tubing
/
to' III I
/'
/ '
The Pancreas
Longitudinal
Pancreaticojejunostomy:
Puestow Procedure
Operative Indications
atients with chronic pancreatitis, abdominal pain, and a dilated
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
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.
Duodenum
Head of pancreas
Pancreaticoduodenal
arcade
Stomach
dilated duct
' r - - - r - - - Dividett
orne
. '--_ _ _ Spleen
Stomach
Dilated
pancreatic duct
Pancreas
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
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 Rouxen-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.
Staple line _ _ _ __
J
- - - - Mesentery
{fL
Opening in
transverse
mesocolon _~c-_-'--.J.~_ _
Middle colic a. - -
.,.-- ,: -- - --
';"'-:'--"':"':4
-I
Outer layer of
posterior row
(r
I
Inner layer of
anterior row
.-
//
,
.,0
,.
~/~.f/
~A
Outer layer of
anterior row
Roux-en-Y
jejunal _
loop
Mesentenc
defect
E::&&sode W no unostomy
nce the Roux-en-Y loop has been delivered into the lesser sac via a
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
,
Enterotomy
TNO-Iayer anastomosis
Inner layer
he inner layer can then be continued along the upper line of the
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
Roux-en-Y
jejunal loop
Sp.eruc a and v.
Pancreas
Outer
layer
Jejunum
2
Mesentery
Pancreatic
duel eprthelium
... (
Io-mucosa anastomosis
~I
SagJttaJ SecIJon
1-- - - - - Pancreas
Stomach
JL~----- Duct
_ _ __ ______ Duodenum
Roux -en-Y
"t
Transverse
mesocolon
Roux -en -Y
jejunal loop
Omentum
Transverse
colon
,
\
\
,
\
Transyerse colon
Transverse
mesocolon tac ked
to jejunal loop
cno-ro-tna t'ancreaucojejunostomy:
DuVal Procedure
Operati\-e Indications
he DuVal procedure is only infrequentl\- indicated. It is an operai: ::
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
1
'i
. ,"
.~ -
Stomach
Transverse colon
greater
omentum
Dilated
pancreatic
duct
Spleen
t-__ Spleen
Tail of pancreas
Splenic a.
splenic a
Splenic v.
Tail of pancreas
_ _ _ Spleen
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
QuterJayer
Roux-en -Y ---~:.....::'-
jejunal loop
OJ
End-to-end
Pancreaticojejunostomy
Dilated
Stomach
pancreatic
duct
,'-.
-.'
Invaginated pancreas
Duodenum
"li~ _
_ _ __ __
End-to-side
jejunojejunostomy
Operative Technique
he operation can be performed through either a midline or a bilater.ll
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
Gallbladder - - - = ---1
'~\J-'t~fi~=l-::----"--:------
Kocherized duodenum
iJ~~~1'i:t:>::-;-:-''\----- Pancreas
;
Stomach
\i-- - Spleen
- --
Pancreas
Colon
__ ~_----- Stomach
- Retroperitoneal bed
S :
Cetiac
axis
Stomach
Ouooenum
\
Pancreas
aspedol
paiUea5I
we:::c-=---____
Retroperitoneal bed
Inferior
mesenteric v.
Head of
pancreas
Splenic v.
Spew:
aandv.
Be enc-,
Portal v.
\
Overlapping
mattress
sutures
Pancreatic
neck
Inferior
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.
Be '
'cut
Neck of pancreas
Duodenum
Ligating
pancreatic
duct
j,-..'''-C-!:'--~--------
Superior
mesenteric
v. and a.
Operative Technique
his procedure will be demonstrated as an extension of Distal
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
SpIefw: Y.
PonaJ v.
Cyslic duct stump
Stomach
Galtbladder
fossa
Retropeo beaJ
bed
__
~~
__
____
T~
colon
Inferior mesenteric v.
Superior mesenteric v.
Pancreatic remnant
Superior
pancreaticoduodenal
vessels
Pancreatic duct
Operative Technique
he abdomen can be entered through either a midline or a right
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.
T
Accessory ---~---;-,i~~cr;:;
papilla
Accessory
papilla
Ampu lla - --
-t;;:--
-"
Duodenum
Accessory
papilla
Duodenotomy
Lacrimal duct
probe
Duct to uncinate
process
o
Papillotomy
Duodenal
""""
mucosa
Operative Technique
ither a bilateral subcostal or a midline incision can be used.. In this
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
Transverse colon _ __
----;?-_~~_
Pseudocyst - ---i7l-:;....------;.T.!--,.!""ll""--c
""
Transverse colon _ _
~:--==.:;=.'-
./
/
Roux-en-Y
jejunal loop
fter the outer posterior layer is completed, an opening is made into the
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.
--==---.!:..._ _ _ _ _.
Cystotomy _ __ _ __ _ _ __ _ _ _ _ _~~
Outer layer
Roux-en- Y----1-jejunal
loop
I!
Inner layer
of posterior
row
Inner
layer 01
ameriof-
ro,'(
Enterotomy
live< ----;---r-~...
Outer layer of
anterior row
DuCI ----f~_T~~--~~~~
Transverse mE'so,col,Dn--i-----:i~;::r;,~
)(
Omenlum - - f - - -_ _ ---;'J
I
Roux-en-Y
jejunal loop
Cystoje)unoslomy - - -- -- - - -- -} l
_I
Atlas of Surgery
Operative Techinque
liver
Stomach
(,)f<I""IEI
ISANDONE
Sagittal Section
Hepatic flexure
Liver
_+-__
---,~....!.--
Pancreas_+-_ _~~~~~~~=--~~~
duct
Aspiration
Omentum
Transverse colon
Stomach _ __
_ _
Biopsy of
cyst wall
Anterior
and
Posterior _ __
wail of
stomach
CORINNEI
ISANDONE.
cavity
Closure of gastrotomy
Cyst wall
Posterior wall
of stomach
Urajnage ot Pancrea
into the Duodenum
udocyst
Operative Indications
he vast majority of pseudocysts can be drained into a Roux-en-Y
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
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_---''---_
Duodenum
Stomach
Pancreanc duct
- - - - - - - - - - - - - - - - - . . . . . . - - -..........J
~orus-Preserving
pple
Procedure)
Operative Indications
Operative Technique
he operative procedure can be performed through either a bilatelal
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
v. and a.
Duodenum
<-'
,+ - ---4- - - ,
--J\
\
Pancreas
Tumor
Inferior
vena cava
Portal v.
Gal/bladder
'-'-_--'--C--,--_ Common
duct
__
Su~
mesen!alc
/
-T-- ~
r - -- -
Neck of
pancreas
Supe~ior
mesfJteriC
Duodenum---jhr-
1~_-1
C~p-+--- Superior
mesenteric a.
Superior
mesenteric v.
Inferior
Aorta
vena cava
Uncinate
process
paJJaE -
Rgash:a
FII"SI poI1Joo
oIduodenum _ _ __
----:,-::.~
StOlT\G
I
~I
Gallbladder
Portal v.
Hepalic a.
w;".- - - - liver
DMded first
porooo 01 duodenum
Divided
r. gastroeplpiotc
Divided
gastroduodenal a.
Cystic duct
Common duct
Commo n
hepatic duct _ __
/)
Ring catheter
""'"
Divided
common hepatic
duct
~'
Stomach
/
L
- ........
Duodenum _ _ _ _""""_ _ __ _
~
EtLV
393
.f
"-t"
-..: :. '"
~-;;-...,.
Po<1aJ v. _ __ _ -;:-
OuOOenum
Divided first
portion of
duodenum
l
process
Superior mesenteric
a and v.
Common - - -- -- -":
hepatic
duct
Mobilized
gallbladder _ _ _ --.::
', ~,.L-,-+->;----'----+--;c-~____
.' , ....L
,'-
ead of
pancreas
Jejunum
- 'a&:swase
Body o'
pancreas
Superior
mesenteric v.
~~~~------------ BOOd
pruueas
'--c-+- - - - -- - - - - - - Uncinate
process
Duodenum /
--:ll!:--'-'-+ - - - Proximal
Resection Specimen
jejunum
Gallbladder
Head and
neck of pancreas
Duodenum _ _ _ _ _ _ _ _ __
~---
and v.
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
j
Sutures
duct
__ - L __
________________
hepali~
End-la-side
Ring calheter
Jejunum
Posterior
row
sf
r
..., " Ii 'n"oosaa
If _ _ _......
-l---
Frn portion 0{
_ _ duodaraJrn
- _ Slomach
End-to-side duodenojejt.lnosb;ly
Inner lay", 0{
anterior
row
_-,,----=~_=_-
Pylorus
- --;-- - Stomach
..,
R....
End-Io-SIde
duodenojejunoslomy
_ .!-_ _
Prox jmal
jejunum
,1
Duodenum
Tumor
Pancreas
Reconstruction Alternatives
End-Io-slde
pancreabco,ejUI1OSalmy
Hemigaslreclomy
with gastrojejunostomy
hen the end of the pancreas is too large to be invaginated into the
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
!includes
duct)
Outer layer of
anterior row
Duodenum
Divided
greater omentum
Biliary
anastomosis
Transverse colon
Outer layer
Hemigastrectomy with
gastrojejunostomy
PeriampuIlary Cancer
Operative Indications
f a patient with a periampullary carcinoma is explored and is found to haw
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
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 nee'
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
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
portal v.
Obstructed
common duct ----!,+-n
--==-.!_ _ _
Superior
mesenteric v.
Pancreatic duct
Gastrotomy
r
Gallbladder
Stomach
,,
- ....
,,
,,
Outer layer of
posterior row
_--_ . . .. . . I
,
'-
---
,,
,,
Proximal ieilmum
lmerlayefol
postencr row
Inner Iayef
01 anlerior raw
.,
,.,
J'
---
\
Outer layer of
anterior
\~
I
JeplaI
loop
,
Stomach
Transverse mesocolon
tacked to stomach
,,
,,
,, ,,
, \
,
I
I
,
.,
,,
I'
,,
\
A
,,
,,
'I
/' !
"
,i , ,
,
r- _
I
I
,
- - -- ...
,
,,
---
I
I
/
I
_",' I
I'
,
,,
Retrocolic
jejunal
loop
\ ,. . ... '"
,,
"
I
I
Cholecystotomy
Inner layer
ofpostaD ...
Outer lay er of
posterior row
Enterotomy
19
20
Ou'.erlayerol"
an enor raN
Inner layer 01
anterior row
Relrocolic
jejunal loop
Hepatic
flexure 01_--''---_
colon
\
\
\
Opening in
transverse _ _ _ ---,;:-_ _ _
mesocolon
Outer layer
01 posterior _ _ __ __
row
+___
~*.
Enterotomies
Stomach
Gastrojejunostomy
Transverse
mesocolon
tacked to
stomach
~ ,
/
,
1/
,,
,, ' '
,, ,
,
\
\ ,
'\
p,
, ,1
"
,
I
,I
I"
A-
\
(
aizca
..... If
./
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
0ISIal
COi.M.Klfl duct _ __
Posterior row
Ou:xfenum
~r
Ring catheter
Enterotomy
Jejunal loop
Liver
Gallbladder fossa
~~-;:--;-7'T-";--~ End-to-side
hepaticojejunostomy
j.,
r - --
,,
,,
f ,~\
----,
...
"
,.
,,
,
''( ,
.t
,,
,,
,,
,,
.-
'I
,,
--
"
_J
,
,,
,
,,
,
,,
,' ....
,
,,
Operative Technique
.,..,...;.'----_ _ _ _ Spleen
_ _ _ _ _ _ Tail 01 pancreas
Divided
;",-_ _ _~----_ greater
omentum
Divided
vasa brevia
I
Transverse
colon
Stomach
Tumor
Pancreas
_ __ Spleen
1/
Tail of
pancreas
Splenic
flexure 01
colon
ligament
Splenic
flexure of colon
- - --f:- -:;ur-:;:-
Tai l of
V ';-""--pancreas
"'-:'';;:-_ _ Splenic v.
Tumor _ _ _ _ __ _
Head oj
Duodenum
nce the distal pancreas is mobilized over to the midline, the splenic
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
..
Tumor
In ericr
mesenteric v.
Overlapping
mattress
sutures
\~~~~;=:~~~~~
___
Uncinate process
I
Superior
. -::-::-_--''-_ _ mesen teric
v. and a.
Tail of
of
pancreas
Tumor
_ __
Retro peritoneal
bed
Superior
mesenteric a.
Inferior
pancreaticoduodenal
v. and a.
Superior
mesenteric v.
Head of
pancreas -----""\Ii::'~: '..~Jj:
v. anda
poocess
l4s of Surgery
LaparotoDlyforInsulinoDla
Operative Indications
nce the diagnosis of an insulinoma has been confirmed on the basis
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
Head of
pancreas
Duodenum
Body of
pancreas
jl~
7.~!iC~~~t~?=-"_::':_=
: _..jt--_-_-_-_-_Superior
mesenteric a
Superior mesenteric v.
Head of pancreas
Uncinate
process
Slomach
Divided
greater omenIlI::>
2.~_--;--;;~_-,- ;-___
Inferior
border of pancreas
Palpation of
body and
of pancreas
Cauterize vesse ls
on tumor
Clip~s
onpanoreas
Pancreatic bed of
islet ce ll tumor
Atlas of Surgery
Operative Technique
ither a long midline or a bilateral subcostal incision can be used .
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
Transverse
mesocolon
Proximal
jejunum
Retropentoneal
extensl()(\ cA abscess
:;
t is important to take down the hepatic flexure and mobilize the right colon
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
Root of transverse
mesocolon
Transverse
colon
L. colon
L. colon
ProXJmal I"Junum
It
Transverse
colon
Stomach
I~I
T~
colon
Stomach
Ptaremelll:
01
drains
of
pancreatic
abscess
Transverse colon
nother option for drainage is to pack the entire lesser sac and all
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 - - - --
Operative Technique
irtually all patients with blunt or penetrating trauma should be
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
of colon
Body of pancreas
Stellale injury
of pancreas
f the duodenal and pancreatic lesions are severe but repairable, one may
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.
'EOEX
Proxim al stomach
First
portIOn of
,
Antrum of
stomach
\\
Re paired
duodenal
Pancreatic
wounds
injury
DIvided
greater
omenn.m
Repaired
duodenal --lCL..~-!7Ii"
wounds
Transverse
colon
Pancreatic
injury
Body
of
pancreas
-tube in
common
duct
-~--
Hepatic
Ilexure 01
colon
Proximal
jejunum
Pancreatic injury
Repaired
duodenal
wounds
--
...-.
Operative Technique
ll abdominal trauma patients are explored through a midline incision.
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
Pylorus
Divided
cystic duct
Gallbladder
Gastrojejunostomy
I
T -tube in
common duct _ __
_ _ __ _ _ _ _ __ Common
duct
Repaired
duodena l -----L~-~-,~
wounds
,,
,,
.....,
,,
,,
-- --
,,
,
\
--
,,
,,
,
\....... ...
I
Transve rse mesocolon
Gastrotomy
closure
Stell ate
injury of
pancreas
Omentum
,,
\
\
I~F: NI.r.
'ANIlON t;.
,,
,
,, ,
,
Transverse colon
~y ~------~--~
Omentum --+----:1j
Transverse
colon
Small bowel
mesentery
Jejunal loop
Gastrojejunostomy
Index
and, 276
Arteriotomy, infusion catheter insertion
through, 204
Asci tes, 266
LeVeen shunt and, 312, 320, 321
portacaval shunt and, 282
Atria l anastomosis, mesoalrial shunt and, 306
Atriotomy, hepatic vein injury and, 248
B
Bakes dilators, 14 , 15
Silastic transhepatic biliary stent and , 46,
102
Balloon catheter
bilia,,-. 12. 13
ainety-fiy percent distal pancreatectomy
and. 362 -36-!
B : :u!"ca~ ion. hepatic duct. Sec Heparic due:
'='::'J:-ca: io::.
Biliary stricrure(s)
benign, resection of. 38-57
distal
secondary to sclerosing cholangitis.
108- 115
side-to-side choledochoduodenosromy and,
28
Biliary tree, 152
exploration of, instruments for, 12- 15
intrahepatic, dilatation of, 100, 101
retraction of, 276, 277
stones in, 10
transhepatic stenting of, 2
benign biliary stricture and, 44-47
Caroli's disease and, 128- 141
proximal cholangiocarcinoma and, 64-71 ,
82-83,84-89
sclerosing cholangitis and, 102, 103
Biliary tumor(s), proximal. See Proximal
cholangiocarcinoma
Bowel, small division of, 332, 333
Budd-C hiari syndrome, 252-254
inferior vena cava and, 298
C
Calculi,2
common duc t, 10
side-to-side choledochoduodenostomy and.
28
sphincteroplasty and. See Sphincteroplasty
Calot's triangle, dissection of, 4
Cannulation, accessory papilla, 366
Carcinoma_ See also Metastases; specific type
distal pancreatectomy for , 428-435
gall bladder, wedge resection of liver and
regional lymph node dissection for.
142- 149
periampu llary
pancreaticoduodenectomy for, 386
unresectable, 414-427
Caroli's disease, transhepat ic stenting for
indications for, 128
technique for , 128- 141
Catheter(s). See also Cholangiocatheter
balloon
biliary, 12, 13
ninetyfive percent distal pancreateCtomy
and,362-364
eoude. See Coude cathetelisl
French. biliary tree and. 14. 15
infusion. 204
:or ?Dnal pressure measurement. 276
!e::g. Sa Ring catheter> s ,
3:jas:r.:. liyer a~ and. 23t 235
C~:a:t :-:-:..:. e:d-:o-~id~ portacaval shunt
lor. 12- 15
technique f.... 10-1;
lIl5U WlitillS
272
Coude catheter(s)
benign biliary stricture and. -14.-15
Caroli 's disease and, 134
proximal cholangiocarcinoma and, 64. 65.
82,83,88, 89
sclerosing cholangitis and . 100, 101
Cyst(s). See also Pancreatic pseudocyst
choledochal
Caroli's disease and, 128
resection of, 116-127
hepatic
aspiration of, 206, 207
simple. 206-209
hydatid. 206
management of, 210-223
Cystadenocarcinomas, 208, 386
Cystadenomas, 386
Cystic artery
identification of, 4-6
ligation of, 6, 7
right hepatic lobectomy and , 182. I'
Cystic du ct
looping of, 4. 5
right hepatic lobectomy and. 182. 1
unresectable periampullary carcinoma
involving. 424, 425
Cystic duct stump. ligation of, 8. 9
Cystic neoplasms, distal pancreatectomy for.
428
Cystoduodenostomy, 384 -385
Cystogastrostomy, 370, 380-383
Cystogram. 372
Cystojejunostomy, 370-379
resection and
lateral segment of left lobe, 164. 165
wedge, 146. 147. 158
Closing cholangiography, 16
Colon, right. direct mesocaval shunt and, 292,
293
Colorectal metastases, to liver, 2
hepatic arrery infusion and. 200
Common duct
distal. di"ision of. 60-62. 120. 121
hepaticojejunosrorny anc. -!~t -t25
Idenri:ication or. nme::.-::',-c ;:.c:-,:r:,,_: ::3:a.~
. - -,
;>ar.c-ea:c.::c::::.' a.:::. :r._- :r.::
;>a.-;''::-fa:;.:-c':'.::~-c:-.'C"...-:_:-_:. l.::.: :.:;..-; ;"-:.;.
~- -
(_.::-.z:(.::
.::::...a..--6A~;:~:'- :.:.::c.
~:.;:('"~:_c
:"
D
Dacron prosthesis, interposition mesoca\'al
shunt and. 258-265
DeBakey clamp
direct mesoca\'al shunt and. 292. 293
distal splenorenal shunt and. 270
Debridement. pancreatic abscess drainage
and. -1-16--14
Deep stellate injury. oi Ii"er. 2-10. 241
De\-ascularization. of left hepaoc lobe. l:--t
D,"~hragm. nght hepatic lobectomy and. 1
D::a:or, . Bake;. 14. 15
O':i;;.,:x :rac.,ne;l3:lC ~)llia:o ;:em a.'ld. -16 .
:':'2
" - =0=: _
Ib hi
DisuI
-z
.....oIE'
--., 22II~"
.1'!IIIric ""rd'.....
~~nmu.~~~D~~~,
-435
entenllOmJ' and, 426" m
gastrotomy and, 380, 38J
pyloric exclusion and, 462, 463
longitudinal pancreaticojejunostnmy
DisW p;m<l!12:lJ0I""'f
f..- duunic .............. JSD.359
328,329
wedge resection and, 158
End-t<H!nd pancreatirojejlloostomy
45-1-461
Drain(s)
cholecystectomy and, 8, 9
choledochoduodenostomy and , 36
choledochotomy and, 16
distal pancreatectomy and, 360
duodenotomy and, 368
end-to-end pancreaticojejunostomy and , 348
hepaticojejunostomy and, 56
massive liver trauma and, 242, 243
pancreaticoduodenectomy and, 412
Drainage
of abscess
liver, 224-235
pancreatic, 442-453
pancreatic, trauma and, 454-461
pancreatic pseudocyst
into duodenum , 384-385
into Roux-en-Y jejunal loop, 370-379
into stomach , 380-383
Duodenal bypass, unresectable periampu llary
carcinoma and, 414-427
Duode nal C loop, ninety-five percent distal
pancreatectomy and, 362-365
Duodenojeju nostomy, end-to-side, 404
Duodenotomy, 20-22, 26, 27, 32, 33
clos ure of, 368
drainage of, 368
longitudinal, accessory duct papillotomy
and, 366, 367
Duodenum
dive rticularization of, trau ma and, 454-461
first portion of, division of, 390, 391
kocheri zation of, 108- 109,384-385
common duct exploration and, 10- 11
pancreaticoduodenectomy and, 386-389
side-to-side choledochod uodenostomy and,
30-31
mobilization of, portacaval shun t and, 278,
279
pancreatic pseudocyst drainage into,
384-385
trauma to, 454-461 , 462-467
DuVal procedure
indications for, 342
technique for, 342-349
E
Echinococcus granulosa. Sa H;-daod qs
disease
F
Faltiform liga ment, 152- 154
reattachment of, 166, 167
Fat necrosis, 448, 449
Figure-of-eight sutu res, distal pancreateClIlCJ
and,358,359, 434, 435
Forceps, Randall Stone, 12, 13
French catheter, biliary tree and,14,15
G
Gallbladder, 154
carcinoma of, wedge resection of ti,-er and
regional lymph node dissection 1..-,
142- 149
dissection of, 6, 7
hepatic lobectomy and
left, 170, 171
right, 182
lymphatic hypertension and, 2J6
pancreaticod uodenectomy and, ~,~i:J
trisegmentectomy and, 192
Gallstones, 2_ See also Calculi;
Cholecystectomy
Gast roduodena l artery
dissection of, pancrealti-arl':loClB:!=,,-and,390,391
.1 A, W
-.
f..- disIaI $Ilium"", .......mry to
sdaosillg. h .....gja is 108-115
end-1I>Side, 426
hepatic lobectomy and. proximal
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
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
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
"H" graft. interposition, 274, 286-287
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
L.,6ux
:~
2.."':c.
InP"'V,.".,-aJ
jndjcarjoos f.
32 .92
I;ngat:o:: . ;>ancre a~ic ab3ce~:s dral r.agt and.
+4.S . +t9
I31er cell t:.ImOfS. ..,- . Sa aL~o Insulinoma
technique for.
1:i6
1 ~ 161
K
Ki dney. See Renal entries
Klatskin tu mors, 58
Kling, packing with, massive liver trauma
and,246,247
Knit ted Dacron prosthesis, interposit ion
mesocaval shunt and, 258-265
Kocher clamps, Whipple procedure and,
410-413
Kocherization, duodenal. See Duodenum,
kocherization of
~h.~'~l~ . :a : . ~ .
~Co:~~a3 :-:::: .
.)?,
+49
Sri C2.!'cino:::la: !pi,-,{r.t llX41WII
()T
Pcor-..ac:avai shunt
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
and.~
p
Packing
246,247
'
pancreatic abscess drainage and, 452, 453
Pain, abdominal
pancreas divisum and, 366
pancreaticojejunostomy for
end-to-end,342
longitudinal,326
Pancreas
Shunt(s)
Prosthesis
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
258-265
mesoatrial shunt and , 302- 305
Proximal cholangiocarcinoma
palliation of, transhepatic stem ing and
hepaticojejunostom y in, 84 -93
bilateral,58- 71
hepatic lobectomy and, 72-
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
'
n ~ -fZ ~
a::.~
:::2
~nigr.
::r
::.:t:-?:J5:::'::::: :: ;:-1!;..';"_ ~
biliary
~:rk.t~ a.~"
-12_ -L1
1:l:~ :34
:-:::,~,:-:<c..a:
=:.-s: ;C.:
~.
;t:=.::.::eE.:t..:-xb:Ci'::a..-:,x:::: a::':.
~~2. 3~3.
~=r]
;:t!'(,x:::.:ai
c::ola::gE:~C::".o17la
a1".d. S-E-cil.
~ :? - ~ 5.~~
82-83, 90-93
sclerosing cholangitis and, 104
pancreaticojejunostomy and
endtoend,346
longitud inal,330-335
pancreatic pseudocyst drai nage into,
370-379,380
S
Saline, hypertonic, as scolecidal agent, 212
Satinsky clamp
interposit ion "H" graft and, 286, 287
interposition mesocaval shu nt and, 258, 259
Sclerosi ng cholangitis, 94- 107
di s tal strictu ring secondary to,
hepaticojejunostomy for, 108-115
Sclerotherapy, 266, 274
Scolecidal agents, 212
Scoops, for biliary tree exploration, 12 , 13
Sepsis, acute pancreatitis and, 442
Septotomy , sphincteroplasty and, 22, 23
Shun t(s)
Le Veen
indications fOT, 312
technique for, 312-323
mesoatrial
ind ications for, 298
technique for, 298-311
mesocaval
direct, 288-297
in terposition, 252-265
place men t of, hepatic vein injury and, 248
po rtacaval
endtoside, 275, 276- 281
" H," 286- 287
ind ica tions fo r, 274, 276
sidetoside, 282- 285
splenorenal, distal, 266-273
Sidetoside choledochoduodenostomy, 28- 37
Side to-side pancreaticojejunostomy ,
longitudinal. 336- 341
Side-ta-side ponacayai shunt. 2-; 4. ~~:2 - :?~;:;
5ilastic cuff. mesoatrial Jro5thesis c:::. :=':':2
5!ias::t: :!a:1Shepatic Ji::~:-: S:t:::::-.'
:-2:-.:g:: Jili2ry s:r1c:'''::-': ;:-.::. ~ -.;:
C.;. ~ :::S di3ec.x a:::. =~~<~:
Sphincteroplasty
incision length for. 22
indications for, 18
technique for, 18- 27
Sphincterotomy, 18, 22, 23
Splanchn icectomy, chemical, 422, 423
Spleen, mobilization of
distal pancreatectomy and, 352, 353
end to-end pancreaticojejunostomy and.
342, 343
Splenic artery
distal pancreatectomy and, 432, 433
end-toend pancreaticojejunostomy and,
344,345
Splenic vein
distal pancreatectomy and, 356, 357, 432,
433
distal splenorenal shunt and, 268- 273
end-to-end pancreaticojejunostomy and ,
344,345
Splenorenal shunt, distal
indications for, 266
technique for, 266-273
Stell ate injury
of liver, 238-249
of pancreas, 454, 455, 460
Stenting, transhepatic, of biliary tree. See
Transhepatic stenting of biliary tree
Sternocleidomastoid muscle, LeVeen shunt
and,312,313
Sternotomy, med ian
hepa tic vein injury and, 248
trisegmentectomy and, 190
Stomach, pancreatic pseudocyst drainage
into, 380-383
"Sump syndrome," 36
Superior mesenteric artery,
pancreaticoduodenectomy and , 394.
395
Superior mesenteric vein
mesoatrial shunt and, 300, 301
mesocaval shunt and
direct, 290, 291 , 294-297
interpos ition, 254-257
pancreaticoduodenectomy and, 388, 389
Suture(s)
cholecystojejunostomy and , 418- 421
cystoduodenostomy and , 384, 385
cystojejunostomy and, 376- 379
distal pancreatectomy and, 358- 361. 434,
435
end-to-end pancrea ticojejunostomy and.
348.349
gastrojejunostomv and. 414-41~. -I&I.-l65
hepaticojejunostomy and. 426. 42:matt ress
Caroli's disease and. 138
chromic catgu t. 1.,16. IC . l6-t 1';;;
ce?lEition me..'-0C3\al clam? and. 25e.
2':;~
type
u
Ultrasonic dissector, 160
Trau ma
accessory papilla cann ulation and , 366
38
Trisegmentectomy
indications for , 190
technique fo r, 190-199
272
Uncinate process, dissection of,
pancreaticod uoden ectomy and, 394.
395
v
Vagotomy, 464
Varices
esophageal
direct mesocaval shunt for. 288
portacaval shunt for , 274
gastroesophageal, distal s plenorenal shunt
for , 266
Vasa brevia, di vision of, 352, 353
Veins. See specl/ic veins
w
Wedge resection, of liver, 156, 158- 159
for carcinoma of gallbladder, 144- 147
Whipple procedure, 362, 406, 407, 410-413
pylorus-preserving
indications for, 386
tech nique fo r, 386-413