PREOPERATIVE DIAGNOSES: Common bile duct stricture, history of chronic pancreatitis, and chronic pain.
POSTOPERATIVE DIAGNOSES: Common bile duct stricture, history of chronic pancreatitis, chronic pain, and infiltrative pancreatic cancer.
OPERATIONS PERFORMED: Pancreaticoduodenectomy, pancreaticojejunostomy, choledochojejunostomy, and gastrojejunostomy.
SURGEON: Bradford Doe, MD
ASSISTANT: John Doe, MD
ANESTHESIA: General endotracheal tube anesthesia.
COMPLICATIONS: None.
BLOOD LOSS: 100 mL.
SPECIMENS OBTAINED:
1. Distal bile duct margin.
2. Pancreaticoduodenectomy.
DRAINS: One JP drain to bulb suction.
INTRAOPERATIVE FROZEN PATHOLOGY RESULTS:
1. Common bile duct margin negative for malignancy.
2. Uncinate margin of the pancreas positive for adenocarcinoma consistent with pancreatic cancer. Neck of pancreas, positive adenocarcinoma consistent with pancreatic cancer, infiltrative type.
DESCRIPTION OF OPERATION: The patient was placed supine on the operating table after adequate IV access and IV sedation for pancreaticoduodenectomy, pancreaticojejunostomy, choledochojejunostomy and gastrojejunostomy. Central venous access and Foley catheterization were obtained by Anesthesiology and nursing staff respectively.
The abdomen was prepped with Betadine solution and draped with sterile linen and sterile drapes. An incision was created with a 10 blade scalpel and carried down through the peritoneum with electrocautery. Falciform ligament was taken between clamps and ligated with 0 silk ligatures.
The right colon was now mobilized at the hepatic flexure. The duodenum and pancreatic head were elevated out of the retroperitoneum. The lesser sac was entered. The top of the pancreas was palpated and found to be quite hard and calcific. The head was generous. There was no dominant mass.
The superior mesenteric vein was now followed up and dissected to the pancreatic tunnel with the superior mesenteric artery. The pancreas was elevated off of the vessels and found to be nonadherent and no evidence of cancer invading within vessels. The gastroduodenal artery was circumferentially dissected and looped with a vessel loop. The common bile duct was identified.
Previous laparoscopic cholecystectomy clips were identified on the cystic duct. At the head of the pancreas, the common bile duct and cystic duct remnant were circumferentially dissected and looped. The stent within the bile duct was palpated and could be felt. The common bile duct was transected and a margin sent for frozen pathology to rule out cancer. Frozen pathology results came back with no evidence of cancer. The stent was removed. The pancreatic duct portion was oversewn with 2-0 Prolene suture. The proximal portion was left to drain within the abdomen.
The gastroduodenal artery was now ligated and divided between ligatures. The duodenum was transected at the pylorus with a GIA 75 blue load stapler. The stomach and pylorus were elevated up and out of the surgical field. A vessel loop was placed through the mesenteric tunnel under the neck of the pancreas for identification and retraction. Mobilization of the duodenum was now performed completely out of the retroperitoneum. The first portion of the jejunum was now identified at the ligament of Treitz. The bowel was divided just distal to the ligament of Treitz.
The mesentery of the third portion of the duodenum was taken down between ligatures and the third portion was slipped underneath the mesenteric tunnel back to the right side of the abdomen. The pancreas was now divided at its surgical neck after placing two vascular Heaney sutures for hemostasis of 2-0 Prolene suture.
The pancreatic head was now dissected off of the portal vein. This was quite adherent, had multiple tributaries, but also had a large adherent reaction with numerous thromboses and radicles going into the portal vein. Each one of these were ligated with silk ligatures and then oversewn with Prolene figure-of-eight sutures. The adherence was quite suspicious for adenocarcinoma.
All periportal lymph nodes were taken with the specimen. The uncinate pancreas was now dissected from underneath the portal vein removing all uncinate and head of the pancreas tissues with the specimen en bloc. The specimen was sent to pathology for frozen evaluation of margins and identification of whether there was cancer within the pancreas or not.
Intraoperative frozen pathology results indicated that uncinate had adenocarcinoma at its capsule, that there was adenocarcinoma at the surgical neck transection site, but bile duct was free of cancer. Considering the chronic pancreatitis, the fact that the uncinate had positive margins through its capsule, as well as having diffuse infiltrating adenocarcinoma at the surgical neck, further resection of the pancreas was deemed to be not in the patient’s best interest.
The preparation for reconstruction was now made. The retroperitoneum was evaluated and found to be hemostatic. A portal vein tributary on the back wall was found to require a figure-of-eight 4-0 Prolene suture for hemostasis. The abdomen was irrigated and aspirated dry.
The stomach was now transected at the crow’s foot landmarks with a GIA-75 blue stapler and the pylorus was excised. The proximal portion of the jejunum was now mobilized taking another 3 cm from the jejunum to mobilize the mesentery so that the limb could be brought up into the hilum of the liver and the pancreas body.
A tunnel was made through the mesentery of the colon to the right of the middle mesenteric vessels. The staple line of the jejunum was oversewn with Lembert 3-0 silk sutures. An antimesenteric enterotomy was created in the jejunum after bringing the jejunum through the tunnel and up to the pancreatic body.
A pancreaticojejunostomy was performed in two-layer fashion with mucosa-to-mucosa technique with the first layer being 3-0 silk Lembert sutures and a full thickness interrupted 5-0 Maxon pancreatic duct to mucosa of the jejunum.
With the pancreaticojejunostomy now complete, the choledochojejunostomy was performed and enterotomy was made on the antimesenteric surface at the appropriate length in a mucosa-mucosa technique with a running 5-0 Maxon suture performed completing a choledochojejunostomy. The jejunum was now run 50 cm from the choledochojejunostomy, was brought through the colonic mesentery to the left of the middle colic vessels up to the stomach staple line.
A 5 cm gastrostomy was created by removing the staple line of the dependent most portion of the stomach. A gastrojejunostomy end-to-side anastomosis was performed in a two-layer fashion with 3-0 silk sutures in Lembert style and a full thickness running 3-0 Maxon suture. The remaining staple line was oversewn with Lembert 3-0 silk ligatures. The stomach was now brought down through the mesentery of the colon.
The mesenteric rent was closed around the edge of the stomach with interrupted 3-0 silk sutures to prevent herniation and slippage. This allowed the small bowel to drain well and have normal motility.
The rent within the mesentery of the colon to the right of the middle vessels was closed with individual 3-0 silk ligatures. The abdomen was irrigated with copious amounts of sterile saline and aspirated dry.
All dissection planes were evaluated for hemostasis and found to be hemostatic. The anastomoses were all evaluated and found to be intact and with good vascularity. CoSeal fibrin glue was now used to cover the anastomoses between the pancreas, the common bile duct, and the stomach. The defunctionalized oversewn staple line of the jejunum was also covered with CoSeal fibrin glue.
A 10 French flat JP drain was brought through a separate stab incision and placed in a retropancreatic, retrohepatic space to bulb suction. The retracting system was removed. The abdomen was closed in a one-layer fashion with looped PDS suture. The subcutaneous tissues were irrigated with sterile saline and the skin was reapproximated with sterile staples.
The patient was hemodynamically stable, tolerated the pancreaticoduodenectomy and rest of procedures very well, and was taken to the recovery room in awake and stable condition.
