Table of Contents
- Winter JM, Cameron JL, Campbell KA, et al. 1423 Pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg. 2006;10(9):1199-1211. doi:10.1016/j.gassur.2006.08.018.
- Neoptolemos JP, Stocken DD, Friess H, et al. A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. N Engl J Med. 2004;350(12):1200-1210. doi:10.1056/NEJMoa032295.
- Kalser MH, Ellenberg SS. Pancreatic cancer: adjuvant combined radiation and chemotherapy following curative resection. Arch Surg. 1985;120(8):899-903. doi:10.1001/archsurg.1985.01390320023003.
- Oettle H, Post S, Neuhaus P, et al. Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA. 2007;297(3):267-277. doi:10.1001/jama.297.3.267.
- Abrams RA, Lowy AM, O'Reilly EM, Wolff RA, Picozzi VJ, Pisters PW. Combined modality treatment of resectable and borderline resectable pancreas cancer: expert consensus statement. Ann Surg Oncol. 2009;16(7):1751-1756. doi:10.1245/s10434-009-0413-9.
Table of Contents
- Exposure and Approach
- Inspection/Identification of Structures behind Duodenum
- Management of porta hepatis
- END of PART ONE (Part 2 Video to cover remaining steps)
- Mobilization and Division of Proximal Extent of Duodenum
- Mobilization and Division of Jejunum
- Mobilization and Division of Pancreas
- An epidural is placed for postoperative pain control in the operating room or pre-operative area.
- General Anesthesia is given in the operating room.
- Patient placed in supine position with all bony prominences well padded.
- Abdominal midline incision extending from xiphoid to just below umbilicus. An alternative is a right subcostal incision.
- Once abdomen entered, the entire peritoneum is inspected including the surface of the liver to insure no peritoneal metastasis. If found, procedure is aborted.
- Hepatic flexure of right colon mobilized and reflected medially.
- Duodenum identified.
- Kocher maneuver performed, where incision of peritoneum is made along right border of duodenum, allowing reflection of the duodenum and head of the pancreas medially, or to the left of the patient. This allows for mobilization as well as palpating involvement of the retroperitoneum and SMA.
- Determine if any lymphadenopathy is present.
- Inspection and palpation of superior mesenteric artery.
- Inspection of common bile duct.
- Inspection of transverse mesocolon with mobilization of omentum off of transverse mesocolon and colon.
- Lesser sac entered by incision of lesser omentum.
- Identify middle colic vein flowing into the superior mesenteric vein.
- Follow superior mesenteric vein under neck of pancreas to portal vein.
- Gallbladder mobilized in retrograde fashion.
- Cystic artery cauterized and alternativel clipped.
- Cystic duct mobilized to insertion into common bile duct.
- Incise peritoneum overlying porta hepatis.
- Identify hepatic artery and common hepatic duct as it joins with cystic duct to form common bile duct.
- Mobilize common bile duct and transect just proximal to the insertion of the cystic duct.
- Proline sutures placed on hepatic duct to prevent retraction into liver.
END of PART ONE (Part 2 Video to cover remaining steps)
- Mobilize Pylorus and and Perform Partial Omentectomy
- Gastroduodenal artery identified at its insertion into hepatic artery.
- After insuring good blood flow through common hepatic artery when occluded, gastroduodenal artery is divided using vascular stapling device. Alternatively, this may be done by suture ligation or clips.
- Divide Stomach 2 cm proximal to pyloric valve using gastro-intestinal stapling device.
- Divide Jejunum with GI Stapler.
- The Ligament of Treitz is identified and 10 – 15cm distal to this an appropriate vascular arcade is identified. The Ligament of Treitz is then mobilized with dissection of the 3rd and 4th portions of the duodenum. This is brought under the superior mesenteric vessels to the right upper quadrant.
- Suture ligate superior and inferior pancreaticoduodenal vessels used for vascular control and traction.
- Once under neck of pancreas, divide pancreas.
- Portal vein separated from uncinate process of pancreas via blunt and sharp dissection.
- Mobilize head and uncinate process off the portal and superior mesenteric vein. This includes taking the retroperitoneal tissue posterior to the superior mesenteric artery. Small branches of the vessels either clipped or cauterized.
- Once completely mobilized to the superior mesenteric artery, transect the remaining tissue with clips and electrocautery allowing en bloc resection of the pancreas and associated duodenum
- The pancreatic margin on the specimen is marked for a frozen section.
- Proximal end of jejunum is brought through defect in transverse mesocolon.
- Pancreatic duct identified.
- Enterotomy performed in jejunum.
- Pancreaticojejunostomy is performed by anastomosing duct to jejunum in a duct-to-mucosa fashion using 5-0 PDS suture for the mucosal anastomosis, and 3-0 Vicryl for a posterior layer and anterior. layer of pancreas to serosa for the second layer. A silastic stent is placed through the anastomosis prior to competion.
- Hepaticojejunostomy is performed distal to the pancreaticojejunostomy by creating another enterotomy and anastomosing the hepatic duct to the jejunum in an end-to-side fashion using 4-0 PDS suture.
- This loop is sutured to the mesenteric defect to prevent an internal hernia.
- A distal loop of jejunum approximately 20 cm distal to defect in the transverse mesocolon is brought either retrocoloic or antecolic.
- Small enterotomy in the jejunum and a gastrotomy on the posterior wall of the stomach are made.
- Gastrojejunostomy performed via the enterotomy and gastrotomy using a gastrointestinal stapler to create a common wall.
- Defect in gastrojejunostomy is oversewn with interrupted 3-0 Vicryl suture.
- Gastrojejunostomy tube, or separate Gastrostomy and jejunostomy tubes placed.
- Purstring of 3.0 Vicryl made on anterior wall of stomach close to great curve.
- Gastrotomy made.
- 5 mm incision made in left upper quadrant and G-J tube brought through.
- Place tube into stomach threading it through the distal loop of jejunum until the ballon is in the stomach.
- Tie down purstring.
- Blow up ballon and pull up to abdominal wall.
- Abdomen copiously irrigated.
- Fascia closed in running fashion using #1 PDS suture.
- Skin reapproximated using skin staples.
- Patient transported to either recovery room or ICU.
So we go up high. So come - just - you know, just - just stop there a second. Let's see if we can - what we can do. Let’s get the fascia. You know, even right now, people are doing so many things laparoscopically, that residents, when they get out of training - with certain cases - don’t know how to do some things open. You have to use your left hand too. Yep, it’s a little harder, I know. That’s okay. Just go here because falciform should be right there.
Feel the peritoneal surface - the rest of the peritoneal surface. Alright, now get cl - a little closer. Open your scissors more. There you go. It’s okay. Alright, I don’t think we have to take any more of that down because it’s just - this is all omentum. It’s just for the retraction. Okay, get the omentum down. That, yep. I just want to get this omentum off. Yeah, get all of this. Yeah. That’s bowel up on the abdominal wall. This is preperitoneal stuff. Trust me, I’ve made that mistake much - mul - multiple times. See, all this is where to go - just come right through this. That’s the wrong plane. See how that comes down like that? Yeah, this - I mean, this didn’t really look… No. That’s just because I’ve - oh, I see - I’ve done it. And this is stuck under that little cloaca right here, so just come across this. Let’s get this down with your Metz. Watch the loop underneath me.
So I always look in this spot. Are you looking for nodes? No, I’m looking for the retroperitoneal space because this is where the tumor’s going to erode through is right in this spot here a lot of times, and it looks okay. So right as the pancreas comes through right over here, and you can actually have tumor eroding through here - and that’ll preclude us - sometimes, of us – see, right here’s the SMA, right there. That’ll preclude us from taking the tumor out. The tumor’s right up here, right? Yeah, but usually - a lot of times you’ll see this dimpling where you’ll see tumor eroding through. Then that’s not - it’s - cat’s out already - already out. You’re not going to be able to remove that. That’s one of the places you’ll feel. So alright, let’s get the Bookie in.
That’s good. Let’s tighten that all the way. Let’s see. Where’s her falciform? Hold it up. Alright, let’s take - we need to take all this fat off. This I do because this stuff gets in the way. What’s that? Oh, because this gets in the way? Yeah, the fat - sometimes, it’s good to have it, but a lot of times, it’ll just get in the way. Get a little handle on it. Yeah. Alright, and just take this down a little bit more - right, so we don’t rip the liver. What’s this? Appendix. Appendix, right. Colon, hepatic flexure - what’s this underneath the hepatic flexure? Dude, the colon is the hepatic flexure, so the hepatic flexure of the colon is - oh, so it’s the colon. Right. You’ve to be right on the duodenum here.
Alright, you just - you just want to stay right - there you go. Alright. Let’s come this way with it. See the duodenum? Yeah, so it’s up here. You can come right through here. Yeah, lift that up. Lift it up more, right? Because - if - you’re going to go right through the - the… Come closer to me. Closer up here? Yeah, you’re going to go right through the cava if you get - so if you don’t lift it up.
So we’re Kocherizing the duodenum now. It’s a retroperitoneal structure. Right, we’re - we’re taking off the - those attachments. Careful, careful. You see those vessels on the cava coming through right there? Just be careful. So let’s not get that sucker. How often, when you come and try to do this on cancer case, is this really stuck? A good number of the time. So now it’s just not getting your hand in there? No, you can. You can. It’s just sometimes it’s just more stuck than others. You know, if it’s a - if it’s a uncinate process mass, if it’s a - right. Good.
Okay. We're all the way by the aorta already. See? Feel. Already? Feel that? Wow. That's a periaortic node. See that? This one right there. These are peri. So this is - take a feel. This is the aorta. Vena cava there. You can see that really well. Right? She has a nice small - and here's aorta, right? They sit right next to each other.
So I'm underneath the duodenum - underneath a bunch of stuff, so I'm trying to find where the SMA is. So you use the SMA as a landmark? To the left of - of the SMV - well, I'm trying to find the SMA, because if I feel tumor encroaching around it, then I know it's not resectable. So this is one of those times when you feel, but I don't really feel it too good. So I feel it way over here. You feel the SMA way over there? Yeah, so put your hand underneath. We'll keep mobilizing. It's going to be a little further over than you think, and you'll feel it anterior. Yeah, yeah - no, that's what I'm trying to feel for. You might have to more lat - more towards me even because it comes like this. The SMA comes in kind of this way.
Get a little bit - clo - no, no - get a little closer. Yeah, I want to get some of this stuff. You want to - this is all the lymph node stuff, yeah. Okay, good. So that we know is recyclable. What about - what about getting your hand in there between the portal vein and the - under it? Oh, we will. Isn't that - I mean, isn't that also - we will.
So that's the first thing, right? So we mobilize this so the duodenum is over here now. Alright, so we're just taking this omentum off so we can find that stuff there, but let's do a little bit more. Higher, higher - a little higher. Higher - yeah, right there. Right there. Go towards you along that line. Keep going. We got to get into that space. That up towards you. This is probably a middle colics there. This also a middle colic? Yeah, I think so. Just open this up here. Slow down one second. So these are just adhesions on the stomach along the mesentery of the colon. Good. Let's get this thing that's bleeding. This is the other side of that vessel probably. Take a ligature. Get this little bridge here. Okay. That's pylorus right over there. So I got to - okay, so there...
So I'm just doing - there's a bunch of ways to get into to find the middle colics. This is just one of them. So just go right on my finger. There's a vessel there. I'm trying to keep so you're not too close to there. Hold that up a second for me. Yeah, that's probably gastroepiploic. Such a pancreas - come this way just a little bit more with your ligature. You're trying to find middle colic - it's going to be in here - somewhere in there. See this - do you - you kind of pull up and look for the tenting of it, or? Yeah, if you can't tell, you can look on this side. What I usually do is - see that vessel there? So fall that one. You have Metz - just a second - for me? The long ones? Yeah, watch - just watch me get into it. Can I the DeBakey, Bill? Yeah, yeah. Hold the... Alright, let me see something. Let me see where the pancreas is. So we're right on the edge of pancreas too. It's right there, right? Yeah, so we're close.
Yeah just - so we're done with fat. Let me see the Bovie a second. I can feel the pancreas, and I see big vessels here - but I can't get the - so the pancreas is kind of right - right here, right? Yeah. Yeah, so the edge is there. Actually comes down a little bit here. There's a bit more down here, right? Yeah, it keeps - it's - it change - yeah, it's not like a - Bovie this stuff. It goes there. Here's - nah. Can I have a malleable for the Bookwalter? This is the mesentery of the transverse colon coming down. So we followed this, and we found this vessel here. So we went on the other side of it, and we found this vessel here. So this is the superior mesenteric vein there, so we should be able to just stay anterior to it all the way up to the portal vein. There shouldn't really be any branches because most of the branches come off on the side. Right in here? Yeah, see that? That's in - that's a - that's always big there. That could be positive because it looks a little off, but that's always a big node right there along - goes around the hepatic artery. And that - but that's just usually where the vein - portal vein comes underneath. And this is her pancreas.
You don't want to go into the liver, right? You just want to get this peritoneum off, so if you go in like that, you're going to get right into the liver, which you'll had - did a little bit, see? You just want to get in the peritoneum just like you normally do. And then peel it back? Yeah. See how it just goes like that? You don't have to go in through that. You just got to get through that first layer of the peritoneum, and then you should be okay. Nah, you're still doing it. Go right here. There you go. See? Stay off. See, this is all capsule liver that's being torn. Little bit more - so - you know, we're way up here, so it's just - no, I mean, you're fine if you come this way. Our tendency with these is to want to keep traveling this way. That's how you get in trouble. Eventually - because you have to march all the way down - yeah, eventually you're going to come back up - up and around. Alright, you can hold this. That's what I figure. Just keep coming - no. I think it's right here. Alright. I agree. I think it would be over here though - a little bit - just a little bit - I'm going to check the edge there. Right. So that's - Okay. Okay. Careful over here - just get the peritoneum now.
So all this should be able to go. See, because this is the duct there, so - that's right down there - yeah, see? Get - get lower, yeah. Really? Do you ever take the artery first when you're doing this? Well this - we're - we're going to take the artery anyway. No, I know - first and then we're going to go - and then we're going to strip down the bi - the cystic duct down to the bile duct. No, I - I - I guess my question is do you ever take the artery bef - before you start taking the gallbladder down. It's just the order. Oh, it depends. We got to get this peritoneum down - I would take it - just a little bit lower - just the peritoneum. Yeah, because I think that's the duct there, right?
So you'll take all that down. Can I have the clip, please.
Let's open that up. This is the lesser omentum that we're incising. This is - this - alright, so this way we can get into the - get that little bleeder. Keep coming this way a little bit. So I can see everything this way. Alright, so now this is all through the lesser omentum. Pulling the stomach down so that's why I'm able - we're able to see everything because that's where the pancreas lies - is in - in that spot, so there's that. So I'm around all this, so - the duct is all - is in here.
Okay. You can take all that. You have the DeBakey's? So I want you to do is - when you just - when you come through all this peritoneum - just to score it? Uh huh. She alright? Yeah. Her pressure is a little high. There's bile duct there. So go through that stuff. Yeah, these are all lymphatics, so we want to get out. Here, so stay up there, yep. Okay, hold up. All that's going to go. There's going to be little vessels in all that. There's the artery. I want to - I'm going to want to take this with us eventually, so we'll probably take that. Take the - the node down there, right? The node - so you want to come back and then - go ahead. That's going - might bleed. Just come through here. Like that? There you go. Woah, woah, woah - the hepatic artery is in - underneath us here, so just be careful.
Let's see. Good, good, good. Alright, that's a little better. So what we want to do is go up that way. Schnidt. Where do you see the bile duct? Well, the bile duct is here. Right, I don't know if the edge is there. It might not be - I'm not sure. I'm just - right, but that's why I - I would just keep taking this peritoneum down. Just keep coming up with it. Just a little bit more. Okay, good. Alright, so if this is the artery here, which we have to clean up just a little bit just because we got to be able to see the - the gastroduodenal. So this - what's that? Take a feel of it. Alright - keep running north out - let's go in from here, that way - so this funnel, then? The right hepatic artery goes anterior, medial, lateral, or posterior to the common bile ducts? Or the hepatic duct, I should say. Just here - it divides - you want it - soon divides - kind of have a common duct that goes like this. It goes over. That's so - that's - you know, majority of the time, but you can have a barren anatomy, which is why I'm always stealing underneath to feel - what am I feeling for when I feel underneath? Pulse. Do you know why I'm feeling for pulse posterior to the porta? It's a replaced right. Alright, so here's the junction.
So that's usually where you want to take it - is somewhere there, so let's - so - hang on. So this is the cystic? I just want to see the junction. So the junction is right here, right? Somewhere in there, yeah. It's - you don't see exactly, but I'm trying to get it as good as I can. Take some of this off a little more too. Yeah, there's a vessel in there. Go ahead. Okay, so where are we going to take this sucker? Alright, so this comes down here like that. Going this way now? Yeah, but you got to be careful on this side - because you got to get that stuff up. Yeah, right, but you got to be careful on that side because, you know, the portal vein could be more lateral than you think and stuff. That's always the bigger issue, so that's why I always have my hand back here. I'm peeling, and I want to see where that goes. Take it higher - higher. So we can pull all this down with this. Okay, so that's the bottom edge of it. So the bottom edge of the duct? Yeah, right here. Yeah. Okay. So - okay, Bovie what you've got. Okay.
Ready to see what we're looking at? So this is our artery here. That's our bile duct, which is huge because of the obstruction. This is the cystic duct going into the bile duct here. These are these lymph nodes that we've been working on back here. We were pulling up with our specimen. So we're going to - well, we're going to trans - we're going to - we're going to transect. Right, and then see it underneath? The bile duct - see it underneath and then we can to follow it. We could also find it over here, but we're not quite there yet. Sticky. Is that usual? Just because of the inflammation from the stent and everything . That's a big duct. Very big. Go straight. Keep coming. Alright, hold up. Okay. Okay, good. Good. And this way. All the way to here. Good. Okay. stop.
Can you put a stitch? Do you have a - put Prolene on each side now? 3-0 Prolene. One over here, one over here. Helps with the outcomes? Yeah, we're just - we're just - we're just just tagging it, yeah. You don't even have to tie it down. Hemostat scissor. Keep going. Don't go too - like, go deep, but just be careful because we don't know where the portal vein is. Yeah. Just a little bit more. Okay, good. It's probably going to be far away and more medial than we are, but I don't - we're really not. Right. And this side - go ahead. Using Coag, right? Yep. Okay. Alright, see the stent? It's in there. Keep going. Kind of just right here - I don't know how far over we got. Let's do my side first. Just over here? Yeah, because I'm - I'm not on the other side yet. You're good. Here's portal vein right there. See it? Yeah, now we grab the edge of it? Yeah, right there. Go ahead. That? Yep, try not to - just don't touch me. Yep. Oh, you see the vein, right? Yes. Okay. Watch. So we've taken all the lymph nodes off the portal vein laterally and posterior to it over there. Right, so here's our bile duct here. Alright, we took - these are all these lymph nodes that are here. This is the bile duct here, so here's our artery. Come up around. We're just trying to find her gastroduodenal artery. Once we find that, we'll tie that off. Then we should be looking right on top of the portal vein.
And there's usually sometimes two branches coming off of this thing. Oh really? Yeah. it's like maybe there's something there. Yeah, I don't think there's anything in this. Yeah, and all this should be able to come down. We're right near - this - this is the hepatic artery here. This is the bile duct, which we transected already, and this is the - probably the gastroduodenal artery - wow - right here - is that coming off. I'm going to test it, but then there's this aberrant vein, which is here. Are you on the solar plexus right now? No, no - on the celiac? No, no, that's way - that's over here. So that - the hepatic comes off of that over here. So this is just a branch that comes off of it, but the portal vein just lies right underneath that. We got to take all that off. Gotcha. And all this other tissue is all lymph nodes that we're taking off - that we have to take down. Good.
Alright, so you've got to clamp this because we've got make sure we're not getting the actual hepatic artery, so you clamp it so you make sure that you're okay. So that always causes an injury to it, which always makes me a little nervous. Yeah, you should take a vessel loop really. Wait, that's really simple, but that's really a cool idea. Yeah, I know. Take a feel and make sure we're still - have a pulse in it. Yeah, there's still pulse in it. Alright. Can you hold the instrument for me, so I don't - you got it? Yep, I got it. Okay. Now we're going to divide stomach. Yeah, just - let's do something - make some progress.