Open Antrectomy, Duodenal Resection, and Gastrojejunostomy for a Multiple Endocrine Neoplasia Tumor
Having monitored the growth of the patient’s neuroendocrine tumor in the first portion of her duodenum, the patient’s oncologist suggests she get it removed. Consequently, Dr. David Berger identifies the small tumor tattooed from a previous endoscopy and then performs a duodenal and gastric resection and reconstructs with a gastrojejunostomy.
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After adequate general endotracheal anesthesia was obtained, the patient was sterilely prepped and draped in standard fashion.
- Midline abdominal incision, enter peritoneum
- Entry of Lesser Sac using Wide Kocher Maneuver
- Evaluation of Pylorus and Duodenum
- Ligation of right gastroepiploic artery and right gastric artery
- Examine Pylorus and Duodenum for tumor
- Division of Duodenum
- Mobilization of stomach and division of short vessels along the lesser and greater curvature
- Resection of Antrum and send specimen for pathology
- Mobilization of Jejunum to stomach in retrocolic fashion
- Two layer anastomosis
- Interrupted 3-0 silk (outer layer)
- Running 3-0 Vicryl (inner layer)
- Lembert Sutures
- Bring anastomosis through trap and suture in place
- Abdominal Fascia closed with #1 Running Prolene
- Skin closed with staples
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarentee their complete accuracy
This case is a woman who has a neuroendocrine tumor in the first portion of her duodenum. This is a tumor that we've been following. It has slowly grown, and she and her oncologist decided they would like to have it removed.
There are two issues really with this case, one is identifying the tumor. The tumor’s been marked endoscopically with a tattoo. If I can remove just a small segment of the first portion of the duodenum I'll do that, otherwise if I have to do a resection I will probably proceed with a resection of the first portion of the duodenum. If I can save the pylorus I will, but more likely than not I'll have to resect a little bit of the stomach as well and then will reconstruct with the gastrojejunostomy. So the operation will unfold by entering the abdomen and will then proceed with a wide Kocher maneuver and free up the duodenum. At that point I'll try and identify where the tumor is, if necessary I’ll perform an endoscopy to see if I can see the tumor; however, I know the tumor is small enough that the endoscopist couldn't see it without a endoscopic ultrasound. Consequently I'll have to use the tattoo marks that were placed endoscopically. Once I establish where the tumor is I'll do my best to try and figure out what kind of operation I'll proceed with. If I can do a local resection I will if not I'll have to proceed with resecting the duodenum and primarily the pylorus and a little bit of stomach, in which case I'll do a retrocolic gastrojejunostomy as a reconstruction.
So I think that the big issue for us in this case is going to be what are we going to do right. There’s the tattoo. That’s good. Let's do a Kocher. We're going to do a wide Coker right? Oh for lymph nodes? No, not even for lymph nodes, just to get Mobility so that we can do.
Okay, so the next thing to do is to take this down. Then we'll just end up taking a little bit of stomach? I don't know what we're going to take yet honestly. We can even do a wedge if I can feel it. We want to do as little as possible she's young girl and this is small tumor. I mean ideally I'd like to do pretty minimal amount. The big issue for us to try not to miss it right? Yeah.Well they couldn't see it on a scope. It was only on the ultrasound? Yeah. Yeah.
No, that's the right. You guys are great. Yup, slide it up. Scissors. Tie please. So there's our pancreas and the problem of course with this is trying to figure out. Surtsey that nothing. I can't feel it. That’s a huge bummer right for her. Well see the problem is though if it's on the underside.Go through here. Hold that. That take this right here. Hello. The Snips.
So we just entered the Lesser sac in the greater the Lesser sac and now we're going to try and come on underneath this duodenum and then we're going to have to make a decision about whether or not we need to take it out. I can't feel that we're going to end up having to do it like a you know duodenal resection and then. Catch Cod right. Now pickups. Up here. So this comes down, here. Lift up for the spot lap pad. Come right down on me. Turn right there. Right there.
So now we're coming underneath the first portion of the duodenum on top of the head of the pancreas. See right there. You can see that you're underneath it right there right. Take that there. So I see we’re completely under the mark now. Of course all I feel is the pylorus. Anything any different. Okay Schnitz. Cut.
Now what we're going to do is we're going to isolate the head of the pancreas. We are going to take this down here. You can take that. This is the right chronic vein right there. Here you go. Stay right there. So we haven't done anything yet to limit ourselves. We haven't taken any vessels that are problem yet. Thank you.
Alright so there’s the mark.We are usually like this. We’re pretty much under it. I can't feel it. So if we're under it and I can't feel it then we're going to have to do a resection to get it out because you know what I mean.
Hold that up there. Hold you cauterizer in your other hand. Come right here. Isolating the gastroepiploic right? So now, we're going to take the gastroepiploic right. That’s the right gastroepiploic coming off of the GTA. Current time? Cautery. We're going to end up having to resect. The first portion of the duodenum right?
Have the in the room ti-55 4.8 please. Don't open. Just it in here to make a pretty picture.
That's the head of the pancreas. That's the first portion of the duodenum. See how we've isolated the head of the bulb. Now we can take a little more back will that up there cuz we've got to get. Schnitz. You got to get to beyond the mark right.So we're going to do schnitz right there. 3-0.
Cutting the first portion of the duodenum off of where it is attached on the pancreas right? So we still got this right here, this last little bit. See where you got to put your hand got to pull there and you got to slide that that way see the difference in the angle. Okay, cut.
Hold that retractor for me please. Ok, tie that. Oh that's what I'm saying Hold that for one second. Can you hold that for me? Just like that, sorry. Is it ok to just cut that little graft. Just go around. It keep coming in the way. Push against. This way bring it that way. Don't go and lift up on this that one pull. Cut. Just pull like that.
So now do you see how you've got the entire first portion of the duodenum and duodenal bulb up there's the pylorus there's the bulb, and I still can't feel the tumor but it's up high enough now that we can do what we need to do so hold that like that. Give her a cautery.
Now the question is. Hold it there. Alright. So now we're way beyond it I think now we're obligated to take it. I can't, I can't for the life of me feel the tumor. That is here. I mean that's way down there your way up you're not taking anything right you're not taking anything that's coming in. Okay, can we have the ti 55 4.8 please? I feel the pylorus. Let's give them a good video shot.
The legion. The tattoo. So you want to bring that in. You want to reticulate it. Now you want to slide it down, no. Hold that with one hand. This needs to be all the way down there right? Think about what we're trying to do. We're trying to take this as far down. Okay you can take that. Okay. No, no , no. Now do it. Right here. Knife please. Got a lock it right.
Okay I see that that's stapled off really into the second portion. Find frozen into say we can fight it. What else we going to do I can't take that anymore I'm not going to do a whipple. Thank you. Let's go right here.
Schnitz. Schnitz. So I'm going to want this to go to path, and I'm going to want them to see if they can find this. For the life of me I can't find it, huh.
Okay let's take this little bitty vessel here.3-0.Yeah. Then we're going to want an ILA 100. We resected into the second portion of the duodenum. I said we resected it into the second portion of the duodenum. Wait we could do some feel that. Well the pylorus is here. We resected the whole first portion. We resected the entire tattoo. Bovie right here. Score this one. How many millimeters is it supposed to be? 7 millimeters. Schnitz.
So I need it walked over to path and then I need someone to call from path when they get it and they look at it. Alright, it's Antrim and first portion of the duodenum and there’s supposed to be a neuroendocrine tumor in the duodenal bulb by the tattoo, and I resected the whole tattoo. Highway 100. So you want the Frozen? I want it as them to find the tumor I don't care that they do a frozen I just want them to confirm that the tumor is in there. Take it. I need one. Okay, so here is the specimen. Antrim and duodenal bulb. We resected this. All the way back you can't take anymore it's a Whipple or bust. I'm not going to do a Whipple for several days.
Okay so now what we need to do is bring up or gastrojejunostomy. She is doing well. Window’s right there. This way up and down. So now we're making a retrocolic window for a gastrojejunostomy. There’s our window. Now they’re going to try it, which is there. We're going to go down. And then we're going to bring up a limb through our hole. Hold that. Okay. Stitches please. Just buzz that right there. Grab that right there. Pickups. Grab that. Buzz me. Okay so let's go right here. Let's go right through here. Stop. Do you have a stitch? So you were here, so right go right about there. Go right through that, lower. Snap. No more snaps after this. Stitch. Fire up the silks. 100 powered pickups to me. In right here. Up right here. Here. Here.
I am certainly not going to do a Whipple on here without. Another packages of 3-0 silk please. Is she paralyzed you think? That’s too close. Hold these this way. Right there. Right there. Towards me. Good. Now blue. Hold that over that way. Better over there. Okay, go ahead. Stay up high. Always stay high right. Stay high.
Okay. Vicryls. 3-0 Vicryl runners. So now what we're going to do is so the stomach to the duodenum, which is set it up right here. So you start here right you're going to run to me we're going to do just what we did yesterday right. Transfer right here. This is a Singer sewing machine right. Now you hold that. Pull that towards you. What torture. So we're doing our anastomosis this is our inner layer of running 3-0 vicryl. By pulling towards herself, she is setting herself up to put the next stitch in. Push down turn your rest there you go that's a good knot. Turn towards you. I like that you help yourself. You are too far back on the Stitch where you're pulling. Get lower on the stitch where you are pulling. Call Best Buy Snellville. The angles all wrong. Everything about it was wrong. Put it in there. Pull towards you. Pull towards you. Pull towards you. Angle.
Was that my suture. Can I come over? Do you mind checking this? Bring it into the corner. Right in the corner. Right here. Now. Get a pick ups in your hand. 45 out. Grab right here. Now going to come in here and out here. Now you going to go 90 right. You are going to go straight out right here. Now you are going to go straight in. Now you are going to go 45. Well you're hurting yourself just push that in with the tip turn it up. Now 45 that way. 45 out. 45 in. That turns your corner. Now backhanded and bring it out here. Snap your stitch. Hold these up. Hold them up to help you get under there. Push this down. After this we're going to use interrupted 3-0 silks. Taking way too big bite, look how much mucosa you got. You're moving your feet which is good you're setting yourself to get your stitches in more perpendicular. Good better.
So I haven't heard from the pathology people. Weren’t they going to call us? Oh you told him great. Thanks. thank you.
Right under here. On this side? Yup then loaded back hand and you're going to come in here and out here. In hear, out here. That's a canal Stitch to lock the last one just on the last one right cause all we're trying to do is bury the last one so we go that way and then we take this this way. Tie. Yup tie them. Cool. So you can see it looks like you don't even need to have any silks on the top right, if you've done it right. We're still going to put in the second layer but you can see it looks like you're done. All right. Start right here little bite and right into there. Good that was nice bite. Excellent. Stitch. Get a perpendicular bite turn your wrist. Don't get too close. Okay that's fine. If you get to close you rolled. Good and now right here just fire them right across. Doesn’t need to be that close together.
So we're in pretty good shape cause I don't have much more I can do. If I can't do this if it's not it out he didn't she needs a Whipple and I can't really do a Whipple. That’s way too much for this.
There. Just one more. Yup. It’s going right in there right. Pull that over that way. Go right in that space. Now that was nice. That was good. So if you're not retracting which is you're trying to do the inner layer this way like if you were retracting funny then I won't imbricate this nicely right? Right if you don't put your stitches in properly symmetrically then it doesn't imitate in right. Or like if you pull up between the wrong? Yeah that won’t work either. It won’t rotate over.
I don't need a frozen. I just need to know that well I'd like to know that the specimen is there. Yes sir. Brilliant. Thank you. No sir. Thank you very much. Awesome.
Turn right there. Yup. Alright guys that's good news. So wanted to be right. See it right there they're in there and do that. Cut edge. Heading straight there. Tie that. Number 1 Proline next. Cut those 3 please.
It’s amazing. I couldn't see that thing couldn't. I couldn’t feel it. It's because it was up against the pylorus right. Well it was up against the pylorus that makes a ton of sense.
Alright if there's a break in the table will you please take it out. Number 1 Proline.
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