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Basic Techniques in Pancreatic Surgery
Basic Techniques in Pancreatic Surgery KENNETH W. WARREN RICHARD B. CATTELL
considerable progress has been made in pancreatic surgery during the last quarter century, much confusion still remains in this field. This confusion is apparent in the frequent failure of physicians and surgeons alike to suspect or to detect pancreatic disease when adequate historical, physical and laboratory data are available to justify such a diagnosis. It is more apparent still in the multiplicity of surgical procedures which are recommended in the treatment of several pathological conditions which affect the pancreas. The complicated anatomic relationships, the multiple physiologic functions of the pancreas and the difficulties of suturing the gland contrive to make this a hazardous area of surgical endeavor. It is worth while therefore to consider some of the basic features in the technical approach to pancreatic problems.
ALTHOUGH
INCISION
The choice of an incision in approaching the pancreas, aside from personal preference, should be guided by the location, nature, and extent of the known or suspected pancreatic pathology. In evaluating these features preoperatively, consideration should be given to the prospect of finding associated disease in the biliary tract, stomach or duodenum which might influence materially the type and location of the incision. The transverse epigastric incision provides adequate exposure of the gland if it is extended sufficiently in both directions but it gives very little flexibility for maneuvering in the extreme right upper abdominal quadrant. This incision is time-consuming to make and to close. A right paramedian incision, reflecting the rectus muscle laterally, gives excellent exposure of the biliary tract and head and neck of the pancreas. Since it is easier to manipulate the distal segment of the gland a right paramedian incision is preferable even though it may be necessary to resect the tail and body of the pancreas. If the gallbladder 707
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is presumed to be normal an epigastric midline incision, extending from the xiphoid process to a point 1 to 2 inches below the umbilicus, permits excellent access to the head and neck of the pancreas and to the common bile duct. In general, this incision should be avoided when it appears likely that the gallbladder should be removed. Regardless of the type of incision selected in extensive pancreatic operations it is important that the incision be generous, for the nature of the dissection is such that additional hazards will be invited if the surgeon is limited by a small incision. EVALUATION OF THE PANCREAS DURING ABDOMINAL EXPLORATION
The pancreas, resting as it does in the retroperitoneal space within the lesser peritoneal sac and hidden almost entirely by the stomach, is easily ignored during a cursory exploration of the abdominal viscera. It is wise to acquire the habit of palpating the pancreas throughout its entire length during every abdominal exploration, for it is only by cultivating such a habit that some of the lesser changes which occur in the gland can be discerned and some of the gross pathological conditions commonly encountered are distinguished. If any palpable pathologic disease is found in this manner it is necessary to expose the gland for direct inspection and more precise palpation. This exposure can be obtained by dividing the gastrohepatic or the gastrocolic ligament, or both. The normal pancreas is a soft, yellowish tan structure. A cross section through the neck or proximal body is roughly triangular in shape. The distal body and tail of the normal gland are thin and flat and the tail frequently insinuates itself among the ramifications of the splenic vein at the hilus of the spleen. The edges of the gland are distinct except in the presence of marked obesity. Despite the retroperitoneal position of the pancreas and the absence of a mesentery, the neck or proximal body of the normal gland can almost be encircled with the thumb and index finger. The diffusely diseased pancreas is enlarged, pale and indurated in the presence of chronic inflammation or malignant tumors arising in the head of the gland. The neck and body and, to a Jesser extent, the tail become rounded in cross section. The edges of the gland appear indistinct by inspection, but are readily discernible by palpation. The tail is blunted and slightly withdrawn from the hilus of the spleen. Obstruction of the duct of Wirsung should be determined at this point in the abdominal exploration. This obstruction occurs most commonly in primary ductal carcinoma arising in the head of the pancreas, but may also be found in the presence of chronic relapsing pancreatitis. The degree of dilatation of the main pancreatic duct is greater in the presence of a proximal malignant tumor than in chronic relapsing pancreatitis. The dilated duct can usually be identified by the palpating finger in the neck
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and body of the gland at the junction of the upper and middle thirds of the pancreas. In order to evaluate pathologic changes in the head of the pancreas it is necessary to mobilize thoroughly the duodenum and the head of the pancreas along with the uncinate process (Fig. 221). Mobilization of the head of the pancreas is facilitated by dropping the hepatic flexure. If the hepatic flexure is freed widely and retracted inferiorly, the peritoneal leaflet at the right extremity of the duodenum can be incised and the duodenum and the head of the pancreas elevated from their bed. A
Fig. 221. Mobilization of duodenum and head of pancreas. The hepatic flexure of the colon has been freed and displaced downward. The parietal peritoneum and fascia propria lateral to the duodenum have been incised widely and the entire duodenum and head of the pancreas have been elevated from the inferior vena cava and aorta.
common error in mobilization of the duodenum and head of the pancreas results from failure to incise the fascia propria immediately after incising the peritoneum and failure to pursue this line of dissection as close to the duodenum and head of the pancreas as possible. If this cleavage plane is entered properly no significant vascularity is encountered unless the tumor has spread across the cleavage line. This dissection should be carried generously under the entire head of the pancreas and uncinate until these structures along with the duodenum are elevated completely from the inferior vena cava and aorta. The first venous structure observed upon entering the retroperitoneal space lateral to the duo-
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denum will be the spermatic or ovarian vein. If the proper cleavage plane is entered, this dissection can easily be followed up to the common duct. LOCATION OF ISLET CELL ADENOMAS
One of the most trying experiences in pancreatic surgery can be the search for a pancreatic adenoma in a patient with well established clinical and laboratory criteria for the diagnosis of hyperinsulinism. These adenomas may occur in any portion of the pancreas and they may be exceedingly small and still give rise to dramatic symptoms. They can appear as ectopic masses. They may be multiple. The diagnosis of hyperinsulinism should be reasonably well founded before exploration is attempted. The patient should have attacks which come on during periods of fasting or after extreme physical exertion. The attacks should be of such severity as to cause stupor or convulsions; they should be relieved immediately by the ingestion or intravenous administration of glucose, and it should be demonstrated that upon one or more occasions the blood sugar concentration during a seizure is below 50 mg. per 100 cc. Serial determination of blood sugar value during prolonged fasting is more reliable than the glucose tolerance test in detecting organic hyperinsulinism. In addition, the possibility of other diseases being responsible for the attacks or for the hypoglycemia should be ruled out, and the self administration of insulin excluded. If these criteria are met, abdominal exploration is warranted. Since it is easier to expose and to examine the tail and body of the gland, it is best to proceed immediately with wide division of the gastrocolic omentum in order that the anterior surface of this segment of the gland can be inspected and palpated. Again, it should be remembered that the tail of the pancreas is intimately associated with the primary tributaries of the splenic vein at the hilus of the spleen and this area should be searched very carefully. If no tumor is found in the tailor the body of the gland, the hepatic flexure should be dropped and the duodenum and entire head of the pancreas mobilized. It is important to divide the gastrocolic omentum completely in its right extremity to facilitate inspection along the course of the superior mesenteric vein as it disappears under the neck of the pancreas. One of the most inaccessible areas of the pancreas is the inferior aspect of the uncinate process as it sweeps behind the superior mesenteric vein and extends to within a few millimeters of the superior mesenteric artery. If no tumor is detected after these maneuvers the tail and body of the pancreas should be mobilized. If the adenoma is not detected, the gastrocolic and the splenocolic ligaments and the paraduodenal tissue should be searched carefully for an ectopic adenoma. If the adenoma is found in the pancreas it should be excised with some normal surrounding pancreatic tissue and submitted to frozen section
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analysis. Ten per cent of these are unquestionably malignant, and an additional 10 to 12 per cent show microscopic evidences of malignant change, although clinically they may behave in a benign fashion. If the adenoma involves the tail of the pancreas it is better perhaps to resect this portion of the gland in order to get around the tumor completely and to minimize the prospect of undetected injury to the duct of Wirsung. When the tumor is deep 'within the substance of the head of the pancreas, which it rarely is, an approach to the tumor with the least prospect of
Fig. 222. The gastrocolic and gastrosplenic ligaments have been divided, as have the splenic artery and vein. The mobilization of the distal segment of the pancreas is carried to the superior mesenteric and portal veins. The pancreas is transected in the region of the neck of the gland and the distal end of the remnant is closed with he:wy silk mattress sutures (inset).
injuring the major pancreatic duct should be pursued. If no adenoma is found, it is wise to remove the distal portion of the gland. This should be accomplished by removing the spleen along with generous portions of the gastrocolic omentum and carrying the mobilization of the distal segment of the gland to the level of the portal vein where the gland is transected as it crosses over the superior mesenteric and portal veins (Fig. 222). The transected neck of the pancreatic remnant should be closed with mattress sutures of heavy silk. The duct of Wirsung should be precisely identified and ligated with an encircling or "figure 8" transfixion suture.
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Kenneth W. Warren, Richard B. Cattell PANCREATIC CYSTS
Pancreatic cysts vary in size, location, etiology, anatomic relations, associated inflammation, and the presence or absence of neoplastic elements. They may be single or multiple, unilocular or multilocular, and they may be a reflection of a more profound pathologic state involving the pancreas such as chronic relapsing pancreatitis or cystic dilatation secondary to a proximal malignant tumor. Finally, they occur in individuals who in turn vary in their physical abilities to withstand major surgical procedures. With this knowledge of the variations in the pancreatic cysts, it appears unwise to have a preconceived single method of
Fig. 223. a, The contents of the cyst have been aspirated and the cavity carefully inspected. A de Pezzer catheter is inserted into the cyst and (b) the opening into the cyst wall is closed around the catheter with interrupted sutures. The other end of the catheter is brought out through a stab wound.
treating all pancreatic cysts. It is better to consider several surgical procedures and to apply these according to the nature of the cysts encountered and in accord with the ability of the patient to withstand a given procedure. A desperately ill patient with a pancreatic pseudocyst and acute pancreatic necrosis should have simple drainage of the cyst, and if the cyst points in the flank, it should be drained in this location without traversing the peritoneal cavity. It is probable that the classical operation of marsupialization of pancreatic cysts need no longer be employed, for external drainage can be achieved by aspirating the fluid contents of the cyst after which the cystic cavity or cavities can be inspected for the possible
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presence of neoplastic elements. If none is found, a de Pezzer catheter can be sutured into the opening which has been made into the cystic cavity and brought out through a stab wound (Fig. 223). By doing this, one of the main objections to marsupialization can be avoided, namely, the irritation of the skin by the escaping pancreatic ferments. This procedure has been employed in the clinic in a number of cases of pancreatic cysts with excellent results and without any pancreatic digestion of the skin. While internal drainage of pancreatic cysts is rarely employed
Fig. 224. Transgastric internal drainage of pancreatic cyst. The cyst has been exposed by dividing the gastrocolic ligament. Firm adherence of the posterior wall of the stomach to the anterior surface of the cyst is demonstrated. An incision is made in the anterior wall of the stomach. A trocar and cannula are inserted into the cyst through the adherent posterior gastric wall and the fluid contents removed. The opening is enlarged sufficiently to permit inspection of the cystic cavity. If no neoplastic elements are found, the edge of the opening into the cyst is encircled with a continuous interlocking catgut suture. The opening in the anterior gastric wall (not shown in drawing) is closed with a Connell suture of chromic catgut, reinforced with interrupted silk sutures.
at the clinic as a primary procedure since most of them can be excised, resected or drained externally in the fashion described above, it is true that internal drainage has some merit and has become increasingly popular. Several patients with recurrent pancreatic cysts following internal drainage have been referred to the clinic. No stoma has been found at reoperation in any of these patients. If internal drainage is to be employed, it frequently can be accomplished by transgastric cystogastrostomy since the posterior wall of the stomach is frequently adherent to the cyst wall. This method was first described by
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Jurasz. 3 An incision is made in the anterior wall of the stomach overlying the dome of the cyst and its contents are aspirated through the adherent posterior wall of the stomach. After the contents have been evacuated, the opening in the cyst should be sufficiently enlarged to insure that there are no neoplastic components and that smaller locules are not overlooked. The edge of the opening between the cyst and the adherent posterior wall of the stomach should be sutured with a continuous interlocking stitch of chromic catgut which serves to keep the opening patent and to control any hemorrhage (Fig. 224). Fatalities have been reported from massive hemorrhage following the internal drainage of pancreatic cysts. One patient at the clinic treated by internal drainage of a pancreatic cyst died suddenly from exsanguination shortly after discharge from the hospital. After the edges of the opening have been sutured, the opening in the anterior wall of the stomach is then closed, first with a continuous Connell suture of chromic catgut followed by a row of interrupted silk sutures. Retention cysts which are commonly devoid of any significant inflammatory reaction, with the exception of those associated with chronic relapsing pancreatitis, are best treated by enucleation or if they are located in the distal half of the pancreas, by distal pancreatectomy. Pancreatic cysts of traumatic origin should be treated initially by external drainage after the manner described above and if they persist or recur, should ultimately be treated by distal pancreatectomy, since they result primarily from transection of the duct of Wirsung and the body of the gland as it traverses the vertebral column. Cysts associated with chronic relapsing pancreatitis are frequently multiple. They are usually retention cysts with very firm walls and they result from obstruction of the pancreatic ducts. The treatment may be very complicated, some of them requiring resection of the head of the pancreas. Occasionally they may be drained by transduodenal exploration and probing of the pancreatic ducts. CHRONIC RELAPSING PANCREATITIS
Numerous surgical procedures have been employed in the management of chronic relapsing pancreatitis. Many of these, including choledochos. tomy, sphincterotomy and choledochoduodenostomy, are directed primarily toward the biliary tract. Others concern gastrointestinal diversionary operations such as gastroenterostomy, pyloric exclusion and partial gastrectomy. Increasing experience with chronic relapsing pancreatitis has demonstrated to usl the necessity for direct surgical attack upon the pancreas in most instances of this disease. This conviction is based upon the demonstration of partial or complete obstruction of the duct of Wirsung or the duct of Santorini, or both, in a large majority of patients with advanced chronic pancreatitis. We usually employ one or a combination of the following procedures in this condition: (1) trans-
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duodenal sphincterotomy and exploration and dilatation of the duct of Wirsung and the duct of Santorini, (2) distal pancreatectomy, (3) anastomosis of the duct of Wirsung to the stomach or jejunum, and (4) pancreatoduodenal resection. TECHNIQUE OF TRANSDUODENAL EXPLORATION AND DILATATION OF THE PANCREATIC DUCTS
This procedure is elected in two instances: first, in those patients with mild to moderate degrees of chronic pancreatitis in whom it is felt that more radical procedures are neither necessary nor justifiable, and second, when there is so much associated peripancreatitis that resection, although preferable, is too difficult and hazardous to employ. In the latter situation some consideration must be given to the possibility that duodenostomy in the presence of marked edema and loss of flexibility of the duodenum may be an extremely difficult and dangerous maneuver. We have, upon rare occasion, chosen pancreatoduodenectomy because the anterior wall of the duodenum was so edematous and inflexible that the more radical resection seemed safer than transduodenal manipulation of the pancreatic ducts. Generous mobilization of the duodenum and head of the pancreas, achieved by dropping the hepatic flexure and incising widely the peritoneum and fascia propria along the entire duodenal convexity (Fig. 221), will permit inspection and palpation of the head of the pancreas, and will facilitate and add to the safety of duodenostomy. In most instances of chronic relapsing pancreatitis the surgeon will wish to perform a choledochostomy in order to evaluate the common duct, and in some instances, to insert a long limb T tube. The level of the major duodenal papilla can be readily identified by inserting a uterine sound or Bakes dilator through the opening made into the common duct and directing the tip to or through the orifice. The anterior wall of the duodenum is opened longitudinally for a distance of approximately 4 cm. directly opposite the site of the major duodenal papilla. The tip of the metal sound emerging from the duodenal papilla can be grasped and by gentle traction can be utilized to elevate the papilla to a position where it can be easily manipulated. With the papilla securely in view the tip of a right angle clamp is gently inserted into the ampulla of Vater as the metal sound is retracted from the common bile duct. The clamp is then gently spread and an incision, measuring 0.5 to 1 cm. in length, is made at approximately the 10 o'clock position on the circumference of the sphincter of Oddi (Fig. 225). Hemorrhage of any consequence is rarely observed when the incision is made in this manner and in this position. After the sphincterotomy has been accomplished, attention is directed toward the opening of the duct of Wirsung. The ostium of the duct of Wirsung can be readily identified in most
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instances. It is commonly located in the ampUlla of Vater within 2 or 3 mm. of the summit of the major papilla and at approximately the 5 o'clock position. We have found the opening of the duct of Wirsung on the medio-inferior aspect of the summit of the papilla in about 15 per cent of the cases analyzed. In this position there is no common pancreatobiliary channel.
Fig. 225. Transduodenal sphincterotomy and exploration of the pancreatic ducts. A duodenotomy has been made in the longitudinal axis, exposing the papilla of Vater. Division of the sphincter of Oddi is made after a curved or right angle hemostat has been inserted into the ampulla of Vater from below. The tip of a 2 mm. Bakes dilator is shown entering the duct of Santorini. Inset, The sphincterotomy permits identification of the ostium of the duct of Wirsung, shown here with a Bakes dilator being inserted into the main pancreatic duct. Obstruction at or near the opening of the duct of Santorini or Wirsung is relieved by incising the ostium, probing and dilating the stenosed segment of the duct and by removing obstructing pancreatic calculi when present.
If any difficulty is encountered in idantifying the opening of the duct of Wirsung, secretin is administered intravenously. Within 60 to 120 seconds there will be some escape of external pancreatic juice from the ostium even in the presence of obstruction of the duct since this obstruction is rarely at the ampullary termination of the duct. This procedure is particularly helpful in identifying the minor papilla. We have observed submucosal pouting of the lesser papilla under secretin stimulation when
Basic Techniques in Pancreatic Surgery the ostium of this duct was obstructed. When such an obstructed duct is probed the initial pancreatic fluid which escapes is turbid and contains characteristic chalky flecks of material. A fine probe is inserted into the opening of the main pancreatic duct and if obstruction -is encountered, the ostium is incised to permit more generous intraductal manipulation. The point of obstruction may be overcome by forceful dilatation with a small Bakes dilator. In a majority of cases with this type of obstruction pancreatic stones will be encountered distal to the obstruction. The most proximal stone immediately adjacent to the point of obstruction usually is relatively large, and once it has been removed it is possible to remove with a small common duct scoop or forceps the larger stones in the major duct. Some of the smaller stones can be flushed out by irrigating the duct with saline solution introduced through a small catheter. It is neither possible nor necessary to remove all of the pancreatic stones to obtain a satisfactory result. It is important to explore the duct of Santorini in most instances and particularly in those cases in which there is obvious pancreatic obstruction but no demonstrable obstruction of the duct of Wirsung. We have encountered at least six cases of severe chronic relapsing pancreatitis in which the duct of Santorini was the main pancreatic duct and was obstructed, while the duct of Wirsung drained only a small portion of the head of the pancreas and was unobstructed. In diffuse calcification of the head of the pancreas both major ducts are obstructed. Multiple points of obstruction of the major ducts occur and may necessitate a more varied approach. In a recent instance the body and tail of the gland were resected because of obstruction of the duct of Wirsung in the mid body of the pancreas with spontaneous erosion of the duct against the posterior wall of the stomach. Proximal obstruction of the duct of Wirsung and of Santorini. was relieved by transduodenal dilatation of the ducts with removal of numerous pancreatic calculi. If there is considerable fibrosis in the region of the strictured area of the pancreatic ducts a short segment of rubber or polyethylene tubing is anchored in the ducts with the free end of the tubing resting in the lumen of the duodenum. ANASTOMOSIS OF THE DUCT OF WIRSUNG TO THE GASTROINTESTINAL TRACT
Indications for anastomosis of the duct of Wirsung to the gastrointestinal tract include: (1) certain instances of chronic relapsing pancreatitis; (2) inoperable carcinoma of the head of the pancreas; (3) pancreatic fistulas following drainage of pancreatic cysts, or surgicaJ injury to the main pancreatic duct, and (4) reconstruction following pancreatoduodenal resection. In chronic relapsing pancreatitis obstruction of the duct of Wirsung
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may be relieved by anastomosis of the duct to the stomach or jejunum. This procedure is employed in the clinic in those patients who are too ill or have too much peripancreatitis to permit transduodenal exploration of the pancreatic ducts or pancreatoduodenal resection and as an adjunctive measure when multiple areas of ductal obstruction are present. It is not necessary to divide the pancreatic duct proximally, as described by Wangensteen,4 or to resect the tail of the pancreas as advocated by Zollinger et al. 5 and by DuVaP in order to decompress the obstructed duct. The latter procedure, however, may be more useful when the duct is obstructed but not greatly dilated (Fig. 226).
Fig. 226. Distal pancreatectomy and retrograde pancreatojejunostomy (described by Zollinger et al. and by DuVal). The distal end of the pancreas has been excised and the dilated duct of Wirsung anastomosed to a loop of proximal jejunum. Note the careful mucosal approximation of the duct to the jejunum.
When the stomach is to be utilized for the anastomosis, the posterior gastric wall is approximated for a distance of 3 or 4 cm. to the body of the pancreas superior to the dilated duct with a row of interrupted silk sutures. An opening is made into the duct of Wirsung and into the stomach, and the edges of the stoma are approximated with interrupted sutures of fine silk. A final row of interruptpd silk sutures reinforces the inferior border of the anastomosis. The pancreatic duct is anastomosed to a loop of proximal jejunum in a similar fashion with the exception that the first row of sutures approximat-
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ing the jejunum to the body of the pancreas is made along the inferior border of the dilated duct. A diverting jejunojejunostomy is routinely employed. When this anastomosis is performed for inoperable carcinoma of the head of the pancreas the surgeon may prefer to utilize a small T tube, inserting the horizontal limb into the duct of Wirsung and directing the shortened vertical limb into the lumen of the stomach or jejunum. This procedure does not necessarily prolong life in cases of inoperable carcinoma of the head of the pancreas, but it frequently will relieve pain and improve nutrition by returning the pancreatic enzymes to the intestinal tract. Persistent external pancreatic fistulas following drainage of pancreatic cysts or surgical division of the duct of Wirsung during gastrectomy may require anastomosis of the duct of Wirsung. The essential technical requirement for success under these circumstances is to excise the fistulous tract completely so that the anastomosis can be performed directly between the duct and a segment of the gastrointestinal tract which seems mpst appropriate to the particular situation encountered. The detailed description of the technique of pancreatoduodenal resection is not included in this discussion. The method employed at the clinic has been recorded elsewhere. The elevation of the neck of the pancreas from the superior mesenteric and portal vein and the anastomosis of the duct of Wirsung of the pancreatic remnant to the jejunum constitute two of the most significant and treacherous details of the operation. Since it is necessary to demonstrate that the neck of the pancreas can be freed from the superior mesenteric and portal veins in determining operability, this manipulation should be accomplished before the stomach is divided. A generous division of the gastrocolic and gastrohepatic ligaments will facilitate this dissection. The neck of the pancreas may be elevated from the portal vein from above downward or from below upward. Only rarely will any venous tributaries join the anterior surface of the segment of the superior mesenteric or portal vein which lies behind the neck of the pancreas. The landmark for the emergence of the portal vein superior to the neck of the pancreas is a point immediately to the left of the pancreatoduodenal artery as it reaches the superior border of the pancreas. The superior pancreatic lymph node roughly marks this point. This node is frequently enlarged in pancreatic disease. When the portal vein has been visualized in this location the index finger of the left hand can be gently insinuated between the neck of the pancreas anteriorly and the portal vein posteriorly and gradually advanced in this cleavage plane until the tip of the finger emerges inferiorly. The inferior approach is begun by identifying the course of the superior mesenteric vein where it disappears beneath the neck of the pancreas. It is easier when using this approach to separate the neck of the gland from the vein by wiping the anterior surface of the
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vein from the posterior surface of the pancreas with a small moistened gauze pledget grasped in the tip of a right angle clamp. When the neck of the pancreas has been freed from the portal vein a right angle clamp is passed under the pancreas at this level (Fig. 227). Transfixing silk sutures are placed proximally and distally at the superior and inferior border of the pancreas to control the superior and inferior longitudinal pancreatic arteries. The neck of pancreas is then divided and the duct of Wirsung identified.
Fig. 227. The neck of the pancreas has been freed from the anterior surface of the portal vein and a right angle clamp has been inserted under the neck of the gland to facilitate subsequent division of the pancreas at this level.
During pancreatoduodenal resection the duct of Wirsung can be anastomosed directly to the jejunum in almost every instance, regardless of the caliber of the pancreatic duct. This anastomosis is facilitated by the employment of carefully placed paired hemostatic mattress sutures of silk at the superior and inferior borders of the pancreas before the gland is divided. When the duct is unobstructed, as in most instances of carcinoma of the ampulla of Vater and in malignant tumors of the distal common bile duct, particular attention is directed toward the identification of the duct of Wirsung as it is transected. If the caliber of the duct is small, four fine silk sutures are inserted into the respective quadrants of the circumference of the divided duct as it is transected. A small
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catheter or segment of polyethylene tubing is inserted into the duct and the four sutures are tagged with a fine hemostat and reserved for future use when the reconstruction is performed (Fig. 228). After the head of the pancreas has been removed the posterior surface of the transected end of the pancreas is approximated to the side of a proximal loop of the jejunum with interrupted silk sutures. A small stab wound is then made into the jejunum opposite the duct of Wirsung. The previously placed silk sutures are successively rethreaded on a small curved French needle and the end of the duct is approximated to the opening in the jejunum. If the pancreatic duct is dilated additional interrupted sutures are employed in
Fig. 228. a, Silk sutures on a small French needle have been inserted into each quadrant of the divided duct of Wirsung, and are to be utilized later, (b) during the pancreatojejunostomy. The duct of Wirsung is sutured to an opening in the jejunum.
approximating the duct to the jejunal stoma. Before the anterior suture is placed in the jejunum the segment of catheter or polyethylene tubing is anchored in the duct of Wirsung and the free end is directed into the lumen of the jejunum. The anterior surface of the pancreatic remnant is approximated to the jejunum with interrupted silk sutures. TOTAL PANCREATECTOMY
The high mortality and the profound physiologic disturbances combined with the discouraging long term results following this operation limit the indications for this procedure. Total pancreatectomy may be justified in carefully selected cases of diffuse cystadenocarcinoma, in an
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occasional case of chronic relapsing pancreatitis, or in the patient with obvious organic hyperinsulinism in whom no adenoma is found in the pancreas or in the usual anatomical locations for aberrant pancreatic tissue, and who had not been relieved by distal pancreatectomy. Total pancreatectomy has been performed in seven cases at the clinic. The indications for the operation are listed in Table 1. The only postoperative Table 1 TOTAL PANCREATECTOMY
CASES
Carcinoma of head of pancreas. . . . . . Living 1 year 1 patient Diffuse cystadenocarcinoma. . . . . . . Living 372 years 1 patient Chronic relapsing pancreatitis. . . . Living 4 years 1 patient *HyperinsuJinism. . . . . . . . . . . . . . . . . TOTAL. . . . . . . . . . . .
Subsequent deaths. . . . . . . . . . . .
3 2 1 1 7 3
*Postoperative death, 1 (14%)
death in this group occurred in a patient with uncontrolled hyperinsulinism. This patient had had three previous operations for this condition, including distal pancreatectomy. At the final operation the pancreatic remnant and the common sites of pancreatic heterotopia were searched without revealing an adenoma. At one point in the operation bleeding was encountered near the celiac axis. The hemorrhage was readily controlled with a transfixing silk suture. A pancreatoduodenectomy was performed. Despite the fact that no adenoma was found in the specimen, the patient was immediately relieved of her attacks and required 20 units of insulin daily to maintain the blood sugar level within normal range. On the sixth postoperative day dehiscence of the abdominal wound occurred. The wound was resutured, but the patient died the following day. At necropsy, an almost completely infarcted aberrant islet cell adenoma was found at the site near the celiac axis where the hemorrhage had occurred during the operation. The arterial supply to the adenoma presumably had been ligated in arresting this hemorrhage. The detailed technique of total pancreatectomy is not included in this discussion, but certain features of the procedure merit some attention. A careful appraisal of the indications for the procedure must be made. If the lesion is malignant it must be determined, in so far as possible, that no direct extension or metastatic spread of the disease beyond the limits of resection has occurred. If the disease is benign it should be agreed that
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any procedure of lesser magnitude offers little or no prospect of relieving the condition. Once it has been determined that total pancreatectomy is indicated and technically feasible, it is best to mobilize the distal segment of the gland before the common bile duct or jejunum has been divided. The entire gastrocolic and gastrosplenic ligaments are severed. The splenic artery
Fig. 229. The tail and body of the pancreas with the spleen attached has been mobilized from left to right beyond the portal and superior mesenteric veins. The stomach is transected beforl' the distal portion of the pancreas is mobilized, but the jejunum and common bile ducts are divided after this portion of thl' gland is freed. Note that the jejunum has been divided to the left of the ligament of Treitz and that the proximal jejunum which is to be removed has been withdrawn from beneath the superior mesenteric vessels. The opening in the mesocolon at the ligament of Treitz is closed with a continuous suture. Inset, Reconstruction of the gastrointestinal tract is accomplished by an end-toend gastrojejunostomy and an end-to-side choledochojejunostomy. A jejunojejunostomy diverts the gastrointestinal- contents around the choledochojejunostomy.
is divided along the superior border of the pancreas close to the hilus of the spleen. The splenic flexure of the colon is reflected caudally. The peritoneal reflection lateral to the spleen is incised and the spleen and tail of the pancreas are mobilized medially and to the right. The small venous tributaries of the splenic vein along the inferior border of the pancreas and the inferior mesenteric vein are divided. Care must be taken during
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this distal mobilization to identify the site of the superior mesenteric and portal veins so that the splenic vein can be divided without encroaching upon the lumen of the portal vein. Recent experience with distal pancreatectomy has demonstrated the value of elevating the neck of the pancreas from the superior mesenteric and portal veins before the distal dissection is begun. A small Penrose drain can be passed around the neck of the pancreas and thus serve as a guide to the location of this strategic point. It is easier to mobilize the body and tail of the pancreas with the splenic vein until the approximate junction of the splenic and superior mesenteric veins is reached. The splenic vein is then divided. Following division of the jejunum and the common bile duct, the spleen, pancreas, duodenum, and distal segment of stomach and proximal segment of the jejunum can be removed (Fig. 229) by clamping and dividing the branches of the superior mesenteric artery and vein which supply the duodenum and uncinate process. The reconstruction of the gastrointestinal tract following total pancreatectomy is accomplished by end-to-end gastrojejunostomy, end-toside choledochojejunostomy and a diversionary jejunojejunostomy (Fig. 229, inset). SUMMARY
Some basic considerations in pancreatic surgery are discussed. Isolated technical details which frequently prove decisive in this field of surgery are described. REFERENCES 1. Cattell, R. B. and Warren, K. W.: Surgery of the Pancreas. Philadelphia, W. B. Saunders Co., 1953, pp. 301-317. 2. DuVal, M. K. Jr.: Caudal pancreaticojejunostomy for chronic relapsing pancreatitis. Ann. Surg. 14-0: 775-785 (Dec.) 1954. 3. Jurasz, A.: Zur Frage der operativen Behandlung der Pankreacysten. Arch. f. klin. Chir. 164-: 272-279, 1931. 4. Wangensteen, O. H.: Discussion. Ann. Surg. 132: 797 (Oct.) 1950. 5. Zollinger, R. M., Keith, L. M. and Ellison, E. H.: Pancreatitis. New England J. Med. 251: 497-502 (Sept. 23) 1954.
considerable progress has been made in pancreatic surgery during the last quarter century, much confusion still remains in this field. This confusion is apparent in the frequent failure of physicians and surgeons alike to suspect or to detect pancreatic disease when adequate historical, physical and laboratory data are available to justify such a diagnosis. It is more apparent still in the multiplicity of surgical procedures which are recommended in the treatment of several pathological conditions which affect the pancreas. The complicated anatomic relationships, the multiple physiologic functions of the pancreas and the difficulties of suturing the gland contrive to make this a hazardous area of surgical endeavor. It is worth while therefore to consider some of the basic features in the technical approach to pancreatic problems.
ALTHOUGH
INCISION
The choice of an incision in approaching the pancreas, aside from personal preference, should be guided by the location, nature, and extent of the known or suspected pancreatic pathology. In evaluating these features preoperatively, consideration should be given to the prospect of finding associated disease in the biliary tract, stomach or duodenum which might influence materially the type and location of the incision. The transverse epigastric incision provides adequate exposure of the gland if it is extended sufficiently in both directions but it gives very little flexibility for maneuvering in the extreme right upper abdominal quadrant. This incision is time-consuming to make and to close. A right paramedian incision, reflecting the rectus muscle laterally, gives excellent exposure of the biliary tract and head and neck of the pancreas. Since it is easier to manipulate the distal segment of the gland a right paramedian incision is preferable even though it may be necessary to resect the tail and body of the pancreas. If the gallbladder 707
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is presumed to be normal an epigastric midline incision, extending from the xiphoid process to a point 1 to 2 inches below the umbilicus, permits excellent access to the head and neck of the pancreas and to the common bile duct. In general, this incision should be avoided when it appears likely that the gallbladder should be removed. Regardless of the type of incision selected in extensive pancreatic operations it is important that the incision be generous, for the nature of the dissection is such that additional hazards will be invited if the surgeon is limited by a small incision. EVALUATION OF THE PANCREAS DURING ABDOMINAL EXPLORATION
The pancreas, resting as it does in the retroperitoneal space within the lesser peritoneal sac and hidden almost entirely by the stomach, is easily ignored during a cursory exploration of the abdominal viscera. It is wise to acquire the habit of palpating the pancreas throughout its entire length during every abdominal exploration, for it is only by cultivating such a habit that some of the lesser changes which occur in the gland can be discerned and some of the gross pathological conditions commonly encountered are distinguished. If any palpable pathologic disease is found in this manner it is necessary to expose the gland for direct inspection and more precise palpation. This exposure can be obtained by dividing the gastrohepatic or the gastrocolic ligament, or both. The normal pancreas is a soft, yellowish tan structure. A cross section through the neck or proximal body is roughly triangular in shape. The distal body and tail of the normal gland are thin and flat and the tail frequently insinuates itself among the ramifications of the splenic vein at the hilus of the spleen. The edges of the gland are distinct except in the presence of marked obesity. Despite the retroperitoneal position of the pancreas and the absence of a mesentery, the neck or proximal body of the normal gland can almost be encircled with the thumb and index finger. The diffusely diseased pancreas is enlarged, pale and indurated in the presence of chronic inflammation or malignant tumors arising in the head of the gland. The neck and body and, to a Jesser extent, the tail become rounded in cross section. The edges of the gland appear indistinct by inspection, but are readily discernible by palpation. The tail is blunted and slightly withdrawn from the hilus of the spleen. Obstruction of the duct of Wirsung should be determined at this point in the abdominal exploration. This obstruction occurs most commonly in primary ductal carcinoma arising in the head of the pancreas, but may also be found in the presence of chronic relapsing pancreatitis. The degree of dilatation of the main pancreatic duct is greater in the presence of a proximal malignant tumor than in chronic relapsing pancreatitis. The dilated duct can usually be identified by the palpating finger in the neck
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and body of the gland at the junction of the upper and middle thirds of the pancreas. In order to evaluate pathologic changes in the head of the pancreas it is necessary to mobilize thoroughly the duodenum and the head of the pancreas along with the uncinate process (Fig. 221). Mobilization of the head of the pancreas is facilitated by dropping the hepatic flexure. If the hepatic flexure is freed widely and retracted inferiorly, the peritoneal leaflet at the right extremity of the duodenum can be incised and the duodenum and the head of the pancreas elevated from their bed. A
Fig. 221. Mobilization of duodenum and head of pancreas. The hepatic flexure of the colon has been freed and displaced downward. The parietal peritoneum and fascia propria lateral to the duodenum have been incised widely and the entire duodenum and head of the pancreas have been elevated from the inferior vena cava and aorta.
common error in mobilization of the duodenum and head of the pancreas results from failure to incise the fascia propria immediately after incising the peritoneum and failure to pursue this line of dissection as close to the duodenum and head of the pancreas as possible. If this cleavage plane is entered properly no significant vascularity is encountered unless the tumor has spread across the cleavage line. This dissection should be carried generously under the entire head of the pancreas and uncinate until these structures along with the duodenum are elevated completely from the inferior vena cava and aorta. The first venous structure observed upon entering the retroperitoneal space lateral to the duo-
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denum will be the spermatic or ovarian vein. If the proper cleavage plane is entered, this dissection can easily be followed up to the common duct. LOCATION OF ISLET CELL ADENOMAS
One of the most trying experiences in pancreatic surgery can be the search for a pancreatic adenoma in a patient with well established clinical and laboratory criteria for the diagnosis of hyperinsulinism. These adenomas may occur in any portion of the pancreas and they may be exceedingly small and still give rise to dramatic symptoms. They can appear as ectopic masses. They may be multiple. The diagnosis of hyperinsulinism should be reasonably well founded before exploration is attempted. The patient should have attacks which come on during periods of fasting or after extreme physical exertion. The attacks should be of such severity as to cause stupor or convulsions; they should be relieved immediately by the ingestion or intravenous administration of glucose, and it should be demonstrated that upon one or more occasions the blood sugar concentration during a seizure is below 50 mg. per 100 cc. Serial determination of blood sugar value during prolonged fasting is more reliable than the glucose tolerance test in detecting organic hyperinsulinism. In addition, the possibility of other diseases being responsible for the attacks or for the hypoglycemia should be ruled out, and the self administration of insulin excluded. If these criteria are met, abdominal exploration is warranted. Since it is easier to expose and to examine the tail and body of the gland, it is best to proceed immediately with wide division of the gastrocolic omentum in order that the anterior surface of this segment of the gland can be inspected and palpated. Again, it should be remembered that the tail of the pancreas is intimately associated with the primary tributaries of the splenic vein at the hilus of the spleen and this area should be searched very carefully. If no tumor is found in the tailor the body of the gland, the hepatic flexure should be dropped and the duodenum and entire head of the pancreas mobilized. It is important to divide the gastrocolic omentum completely in its right extremity to facilitate inspection along the course of the superior mesenteric vein as it disappears under the neck of the pancreas. One of the most inaccessible areas of the pancreas is the inferior aspect of the uncinate process as it sweeps behind the superior mesenteric vein and extends to within a few millimeters of the superior mesenteric artery. If no tumor is detected after these maneuvers the tail and body of the pancreas should be mobilized. If the adenoma is not detected, the gastrocolic and the splenocolic ligaments and the paraduodenal tissue should be searched carefully for an ectopic adenoma. If the adenoma is found in the pancreas it should be excised with some normal surrounding pancreatic tissue and submitted to frozen section
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analysis. Ten per cent of these are unquestionably malignant, and an additional 10 to 12 per cent show microscopic evidences of malignant change, although clinically they may behave in a benign fashion. If the adenoma involves the tail of the pancreas it is better perhaps to resect this portion of the gland in order to get around the tumor completely and to minimize the prospect of undetected injury to the duct of Wirsung. When the tumor is deep 'within the substance of the head of the pancreas, which it rarely is, an approach to the tumor with the least prospect of
Fig. 222. The gastrocolic and gastrosplenic ligaments have been divided, as have the splenic artery and vein. The mobilization of the distal segment of the pancreas is carried to the superior mesenteric and portal veins. The pancreas is transected in the region of the neck of the gland and the distal end of the remnant is closed with he:wy silk mattress sutures (inset).
injuring the major pancreatic duct should be pursued. If no adenoma is found, it is wise to remove the distal portion of the gland. This should be accomplished by removing the spleen along with generous portions of the gastrocolic omentum and carrying the mobilization of the distal segment of the gland to the level of the portal vein where the gland is transected as it crosses over the superior mesenteric and portal veins (Fig. 222). The transected neck of the pancreatic remnant should be closed with mattress sutures of heavy silk. The duct of Wirsung should be precisely identified and ligated with an encircling or "figure 8" transfixion suture.
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Kenneth W. Warren, Richard B. Cattell PANCREATIC CYSTS
Pancreatic cysts vary in size, location, etiology, anatomic relations, associated inflammation, and the presence or absence of neoplastic elements. They may be single or multiple, unilocular or multilocular, and they may be a reflection of a more profound pathologic state involving the pancreas such as chronic relapsing pancreatitis or cystic dilatation secondary to a proximal malignant tumor. Finally, they occur in individuals who in turn vary in their physical abilities to withstand major surgical procedures. With this knowledge of the variations in the pancreatic cysts, it appears unwise to have a preconceived single method of
Fig. 223. a, The contents of the cyst have been aspirated and the cavity carefully inspected. A de Pezzer catheter is inserted into the cyst and (b) the opening into the cyst wall is closed around the catheter with interrupted sutures. The other end of the catheter is brought out through a stab wound.
treating all pancreatic cysts. It is better to consider several surgical procedures and to apply these according to the nature of the cysts encountered and in accord with the ability of the patient to withstand a given procedure. A desperately ill patient with a pancreatic pseudocyst and acute pancreatic necrosis should have simple drainage of the cyst, and if the cyst points in the flank, it should be drained in this location without traversing the peritoneal cavity. It is probable that the classical operation of marsupialization of pancreatic cysts need no longer be employed, for external drainage can be achieved by aspirating the fluid contents of the cyst after which the cystic cavity or cavities can be inspected for the possible
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presence of neoplastic elements. If none is found, a de Pezzer catheter can be sutured into the opening which has been made into the cystic cavity and brought out through a stab wound (Fig. 223). By doing this, one of the main objections to marsupialization can be avoided, namely, the irritation of the skin by the escaping pancreatic ferments. This procedure has been employed in the clinic in a number of cases of pancreatic cysts with excellent results and without any pancreatic digestion of the skin. While internal drainage of pancreatic cysts is rarely employed
Fig. 224. Transgastric internal drainage of pancreatic cyst. The cyst has been exposed by dividing the gastrocolic ligament. Firm adherence of the posterior wall of the stomach to the anterior surface of the cyst is demonstrated. An incision is made in the anterior wall of the stomach. A trocar and cannula are inserted into the cyst through the adherent posterior gastric wall and the fluid contents removed. The opening is enlarged sufficiently to permit inspection of the cystic cavity. If no neoplastic elements are found, the edge of the opening into the cyst is encircled with a continuous interlocking catgut suture. The opening in the anterior gastric wall (not shown in drawing) is closed with a Connell suture of chromic catgut, reinforced with interrupted silk sutures.
at the clinic as a primary procedure since most of them can be excised, resected or drained externally in the fashion described above, it is true that internal drainage has some merit and has become increasingly popular. Several patients with recurrent pancreatic cysts following internal drainage have been referred to the clinic. No stoma has been found at reoperation in any of these patients. If internal drainage is to be employed, it frequently can be accomplished by transgastric cystogastrostomy since the posterior wall of the stomach is frequently adherent to the cyst wall. This method was first described by
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Kenneth W. Warren, Richard B. Cattell
Jurasz. 3 An incision is made in the anterior wall of the stomach overlying the dome of the cyst and its contents are aspirated through the adherent posterior wall of the stomach. After the contents have been evacuated, the opening in the cyst should be sufficiently enlarged to insure that there are no neoplastic components and that smaller locules are not overlooked. The edge of the opening between the cyst and the adherent posterior wall of the stomach should be sutured with a continuous interlocking stitch of chromic catgut which serves to keep the opening patent and to control any hemorrhage (Fig. 224). Fatalities have been reported from massive hemorrhage following the internal drainage of pancreatic cysts. One patient at the clinic treated by internal drainage of a pancreatic cyst died suddenly from exsanguination shortly after discharge from the hospital. After the edges of the opening have been sutured, the opening in the anterior wall of the stomach is then closed, first with a continuous Connell suture of chromic catgut followed by a row of interrupted silk sutures. Retention cysts which are commonly devoid of any significant inflammatory reaction, with the exception of those associated with chronic relapsing pancreatitis, are best treated by enucleation or if they are located in the distal half of the pancreas, by distal pancreatectomy. Pancreatic cysts of traumatic origin should be treated initially by external drainage after the manner described above and if they persist or recur, should ultimately be treated by distal pancreatectomy, since they result primarily from transection of the duct of Wirsung and the body of the gland as it traverses the vertebral column. Cysts associated with chronic relapsing pancreatitis are frequently multiple. They are usually retention cysts with very firm walls and they result from obstruction of the pancreatic ducts. The treatment may be very complicated, some of them requiring resection of the head of the pancreas. Occasionally they may be drained by transduodenal exploration and probing of the pancreatic ducts. CHRONIC RELAPSING PANCREATITIS
Numerous surgical procedures have been employed in the management of chronic relapsing pancreatitis. Many of these, including choledochos. tomy, sphincterotomy and choledochoduodenostomy, are directed primarily toward the biliary tract. Others concern gastrointestinal diversionary operations such as gastroenterostomy, pyloric exclusion and partial gastrectomy. Increasing experience with chronic relapsing pancreatitis has demonstrated to usl the necessity for direct surgical attack upon the pancreas in most instances of this disease. This conviction is based upon the demonstration of partial or complete obstruction of the duct of Wirsung or the duct of Santorini, or both, in a large majority of patients with advanced chronic pancreatitis. We usually employ one or a combination of the following procedures in this condition: (1) trans-
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duodenal sphincterotomy and exploration and dilatation of the duct of Wirsung and the duct of Santorini, (2) distal pancreatectomy, (3) anastomosis of the duct of Wirsung to the stomach or jejunum, and (4) pancreatoduodenal resection. TECHNIQUE OF TRANSDUODENAL EXPLORATION AND DILATATION OF THE PANCREATIC DUCTS
This procedure is elected in two instances: first, in those patients with mild to moderate degrees of chronic pancreatitis in whom it is felt that more radical procedures are neither necessary nor justifiable, and second, when there is so much associated peripancreatitis that resection, although preferable, is too difficult and hazardous to employ. In the latter situation some consideration must be given to the possibility that duodenostomy in the presence of marked edema and loss of flexibility of the duodenum may be an extremely difficult and dangerous maneuver. We have, upon rare occasion, chosen pancreatoduodenectomy because the anterior wall of the duodenum was so edematous and inflexible that the more radical resection seemed safer than transduodenal manipulation of the pancreatic ducts. Generous mobilization of the duodenum and head of the pancreas, achieved by dropping the hepatic flexure and incising widely the peritoneum and fascia propria along the entire duodenal convexity (Fig. 221), will permit inspection and palpation of the head of the pancreas, and will facilitate and add to the safety of duodenostomy. In most instances of chronic relapsing pancreatitis the surgeon will wish to perform a choledochostomy in order to evaluate the common duct, and in some instances, to insert a long limb T tube. The level of the major duodenal papilla can be readily identified by inserting a uterine sound or Bakes dilator through the opening made into the common duct and directing the tip to or through the orifice. The anterior wall of the duodenum is opened longitudinally for a distance of approximately 4 cm. directly opposite the site of the major duodenal papilla. The tip of the metal sound emerging from the duodenal papilla can be grasped and by gentle traction can be utilized to elevate the papilla to a position where it can be easily manipulated. With the papilla securely in view the tip of a right angle clamp is gently inserted into the ampulla of Vater as the metal sound is retracted from the common bile duct. The clamp is then gently spread and an incision, measuring 0.5 to 1 cm. in length, is made at approximately the 10 o'clock position on the circumference of the sphincter of Oddi (Fig. 225). Hemorrhage of any consequence is rarely observed when the incision is made in this manner and in this position. After the sphincterotomy has been accomplished, attention is directed toward the opening of the duct of Wirsung. The ostium of the duct of Wirsung can be readily identified in most
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Kenneth W. Warren, Richard B. Cattell
instances. It is commonly located in the ampUlla of Vater within 2 or 3 mm. of the summit of the major papilla and at approximately the 5 o'clock position. We have found the opening of the duct of Wirsung on the medio-inferior aspect of the summit of the papilla in about 15 per cent of the cases analyzed. In this position there is no common pancreatobiliary channel.
Fig. 225. Transduodenal sphincterotomy and exploration of the pancreatic ducts. A duodenotomy has been made in the longitudinal axis, exposing the papilla of Vater. Division of the sphincter of Oddi is made after a curved or right angle hemostat has been inserted into the ampulla of Vater from below. The tip of a 2 mm. Bakes dilator is shown entering the duct of Santorini. Inset, The sphincterotomy permits identification of the ostium of the duct of Wirsung, shown here with a Bakes dilator being inserted into the main pancreatic duct. Obstruction at or near the opening of the duct of Santorini or Wirsung is relieved by incising the ostium, probing and dilating the stenosed segment of the duct and by removing obstructing pancreatic calculi when present.
If any difficulty is encountered in idantifying the opening of the duct of Wirsung, secretin is administered intravenously. Within 60 to 120 seconds there will be some escape of external pancreatic juice from the ostium even in the presence of obstruction of the duct since this obstruction is rarely at the ampullary termination of the duct. This procedure is particularly helpful in identifying the minor papilla. We have observed submucosal pouting of the lesser papilla under secretin stimulation when
Basic Techniques in Pancreatic Surgery the ostium of this duct was obstructed. When such an obstructed duct is probed the initial pancreatic fluid which escapes is turbid and contains characteristic chalky flecks of material. A fine probe is inserted into the opening of the main pancreatic duct and if obstruction -is encountered, the ostium is incised to permit more generous intraductal manipulation. The point of obstruction may be overcome by forceful dilatation with a small Bakes dilator. In a majority of cases with this type of obstruction pancreatic stones will be encountered distal to the obstruction. The most proximal stone immediately adjacent to the point of obstruction usually is relatively large, and once it has been removed it is possible to remove with a small common duct scoop or forceps the larger stones in the major duct. Some of the smaller stones can be flushed out by irrigating the duct with saline solution introduced through a small catheter. It is neither possible nor necessary to remove all of the pancreatic stones to obtain a satisfactory result. It is important to explore the duct of Santorini in most instances and particularly in those cases in which there is obvious pancreatic obstruction but no demonstrable obstruction of the duct of Wirsung. We have encountered at least six cases of severe chronic relapsing pancreatitis in which the duct of Santorini was the main pancreatic duct and was obstructed, while the duct of Wirsung drained only a small portion of the head of the pancreas and was unobstructed. In diffuse calcification of the head of the pancreas both major ducts are obstructed. Multiple points of obstruction of the major ducts occur and may necessitate a more varied approach. In a recent instance the body and tail of the gland were resected because of obstruction of the duct of Wirsung in the mid body of the pancreas with spontaneous erosion of the duct against the posterior wall of the stomach. Proximal obstruction of the duct of Wirsung and of Santorini. was relieved by transduodenal dilatation of the ducts with removal of numerous pancreatic calculi. If there is considerable fibrosis in the region of the strictured area of the pancreatic ducts a short segment of rubber or polyethylene tubing is anchored in the ducts with the free end of the tubing resting in the lumen of the duodenum. ANASTOMOSIS OF THE DUCT OF WIRSUNG TO THE GASTROINTESTINAL TRACT
Indications for anastomosis of the duct of Wirsung to the gastrointestinal tract include: (1) certain instances of chronic relapsing pancreatitis; (2) inoperable carcinoma of the head of the pancreas; (3) pancreatic fistulas following drainage of pancreatic cysts, or surgicaJ injury to the main pancreatic duct, and (4) reconstruction following pancreatoduodenal resection. In chronic relapsing pancreatitis obstruction of the duct of Wirsung
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may be relieved by anastomosis of the duct to the stomach or jejunum. This procedure is employed in the clinic in those patients who are too ill or have too much peripancreatitis to permit transduodenal exploration of the pancreatic ducts or pancreatoduodenal resection and as an adjunctive measure when multiple areas of ductal obstruction are present. It is not necessary to divide the pancreatic duct proximally, as described by Wangensteen,4 or to resect the tail of the pancreas as advocated by Zollinger et al. 5 and by DuVaP in order to decompress the obstructed duct. The latter procedure, however, may be more useful when the duct is obstructed but not greatly dilated (Fig. 226).
Fig. 226. Distal pancreatectomy and retrograde pancreatojejunostomy (described by Zollinger et al. and by DuVal). The distal end of the pancreas has been excised and the dilated duct of Wirsung anastomosed to a loop of proximal jejunum. Note the careful mucosal approximation of the duct to the jejunum.
When the stomach is to be utilized for the anastomosis, the posterior gastric wall is approximated for a distance of 3 or 4 cm. to the body of the pancreas superior to the dilated duct with a row of interrupted silk sutures. An opening is made into the duct of Wirsung and into the stomach, and the edges of the stoma are approximated with interrupted sutures of fine silk. A final row of interruptpd silk sutures reinforces the inferior border of the anastomosis. The pancreatic duct is anastomosed to a loop of proximal jejunum in a similar fashion with the exception that the first row of sutures approximat-
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ing the jejunum to the body of the pancreas is made along the inferior border of the dilated duct. A diverting jejunojejunostomy is routinely employed. When this anastomosis is performed for inoperable carcinoma of the head of the pancreas the surgeon may prefer to utilize a small T tube, inserting the horizontal limb into the duct of Wirsung and directing the shortened vertical limb into the lumen of the stomach or jejunum. This procedure does not necessarily prolong life in cases of inoperable carcinoma of the head of the pancreas, but it frequently will relieve pain and improve nutrition by returning the pancreatic enzymes to the intestinal tract. Persistent external pancreatic fistulas following drainage of pancreatic cysts or surgical division of the duct of Wirsung during gastrectomy may require anastomosis of the duct of Wirsung. The essential technical requirement for success under these circumstances is to excise the fistulous tract completely so that the anastomosis can be performed directly between the duct and a segment of the gastrointestinal tract which seems mpst appropriate to the particular situation encountered. The detailed description of the technique of pancreatoduodenal resection is not included in this discussion. The method employed at the clinic has been recorded elsewhere. The elevation of the neck of the pancreas from the superior mesenteric and portal vein and the anastomosis of the duct of Wirsung of the pancreatic remnant to the jejunum constitute two of the most significant and treacherous details of the operation. Since it is necessary to demonstrate that the neck of the pancreas can be freed from the superior mesenteric and portal veins in determining operability, this manipulation should be accomplished before the stomach is divided. A generous division of the gastrocolic and gastrohepatic ligaments will facilitate this dissection. The neck of the pancreas may be elevated from the portal vein from above downward or from below upward. Only rarely will any venous tributaries join the anterior surface of the segment of the superior mesenteric or portal vein which lies behind the neck of the pancreas. The landmark for the emergence of the portal vein superior to the neck of the pancreas is a point immediately to the left of the pancreatoduodenal artery as it reaches the superior border of the pancreas. The superior pancreatic lymph node roughly marks this point. This node is frequently enlarged in pancreatic disease. When the portal vein has been visualized in this location the index finger of the left hand can be gently insinuated between the neck of the pancreas anteriorly and the portal vein posteriorly and gradually advanced in this cleavage plane until the tip of the finger emerges inferiorly. The inferior approach is begun by identifying the course of the superior mesenteric vein where it disappears beneath the neck of the pancreas. It is easier when using this approach to separate the neck of the gland from the vein by wiping the anterior surface of the
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Kenneth W. Warren, Richard B. Cattell
vein from the posterior surface of the pancreas with a small moistened gauze pledget grasped in the tip of a right angle clamp. When the neck of the pancreas has been freed from the portal vein a right angle clamp is passed under the pancreas at this level (Fig. 227). Transfixing silk sutures are placed proximally and distally at the superior and inferior border of the pancreas to control the superior and inferior longitudinal pancreatic arteries. The neck of pancreas is then divided and the duct of Wirsung identified.
Fig. 227. The neck of the pancreas has been freed from the anterior surface of the portal vein and a right angle clamp has been inserted under the neck of the gland to facilitate subsequent division of the pancreas at this level.
During pancreatoduodenal resection the duct of Wirsung can be anastomosed directly to the jejunum in almost every instance, regardless of the caliber of the pancreatic duct. This anastomosis is facilitated by the employment of carefully placed paired hemostatic mattress sutures of silk at the superior and inferior borders of the pancreas before the gland is divided. When the duct is unobstructed, as in most instances of carcinoma of the ampulla of Vater and in malignant tumors of the distal common bile duct, particular attention is directed toward the identification of the duct of Wirsung as it is transected. If the caliber of the duct is small, four fine silk sutures are inserted into the respective quadrants of the circumference of the divided duct as it is transected. A small
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catheter or segment of polyethylene tubing is inserted into the duct and the four sutures are tagged with a fine hemostat and reserved for future use when the reconstruction is performed (Fig. 228). After the head of the pancreas has been removed the posterior surface of the transected end of the pancreas is approximated to the side of a proximal loop of the jejunum with interrupted silk sutures. A small stab wound is then made into the jejunum opposite the duct of Wirsung. The previously placed silk sutures are successively rethreaded on a small curved French needle and the end of the duct is approximated to the opening in the jejunum. If the pancreatic duct is dilated additional interrupted sutures are employed in
Fig. 228. a, Silk sutures on a small French needle have been inserted into each quadrant of the divided duct of Wirsung, and are to be utilized later, (b) during the pancreatojejunostomy. The duct of Wirsung is sutured to an opening in the jejunum.
approximating the duct to the jejunal stoma. Before the anterior suture is placed in the jejunum the segment of catheter or polyethylene tubing is anchored in the duct of Wirsung and the free end is directed into the lumen of the jejunum. The anterior surface of the pancreatic remnant is approximated to the jejunum with interrupted silk sutures. TOTAL PANCREATECTOMY
The high mortality and the profound physiologic disturbances combined with the discouraging long term results following this operation limit the indications for this procedure. Total pancreatectomy may be justified in carefully selected cases of diffuse cystadenocarcinoma, in an
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Kenneth W. Warren, Richard B. Cattell
occasional case of chronic relapsing pancreatitis, or in the patient with obvious organic hyperinsulinism in whom no adenoma is found in the pancreas or in the usual anatomical locations for aberrant pancreatic tissue, and who had not been relieved by distal pancreatectomy. Total pancreatectomy has been performed in seven cases at the clinic. The indications for the operation are listed in Table 1. The only postoperative Table 1 TOTAL PANCREATECTOMY
CASES
Carcinoma of head of pancreas. . . . . . Living 1 year 1 patient Diffuse cystadenocarcinoma. . . . . . . Living 372 years 1 patient Chronic relapsing pancreatitis. . . . Living 4 years 1 patient *HyperinsuJinism. . . . . . . . . . . . . . . . . TOTAL. . . . . . . . . . . .
Subsequent deaths. . . . . . . . . . . .
3 2 1 1 7 3
*Postoperative death, 1 (14%)
death in this group occurred in a patient with uncontrolled hyperinsulinism. This patient had had three previous operations for this condition, including distal pancreatectomy. At the final operation the pancreatic remnant and the common sites of pancreatic heterotopia were searched without revealing an adenoma. At one point in the operation bleeding was encountered near the celiac axis. The hemorrhage was readily controlled with a transfixing silk suture. A pancreatoduodenectomy was performed. Despite the fact that no adenoma was found in the specimen, the patient was immediately relieved of her attacks and required 20 units of insulin daily to maintain the blood sugar level within normal range. On the sixth postoperative day dehiscence of the abdominal wound occurred. The wound was resutured, but the patient died the following day. At necropsy, an almost completely infarcted aberrant islet cell adenoma was found at the site near the celiac axis where the hemorrhage had occurred during the operation. The arterial supply to the adenoma presumably had been ligated in arresting this hemorrhage. The detailed technique of total pancreatectomy is not included in this discussion, but certain features of the procedure merit some attention. A careful appraisal of the indications for the procedure must be made. If the lesion is malignant it must be determined, in so far as possible, that no direct extension or metastatic spread of the disease beyond the limits of resection has occurred. If the disease is benign it should be agreed that
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any procedure of lesser magnitude offers little or no prospect of relieving the condition. Once it has been determined that total pancreatectomy is indicated and technically feasible, it is best to mobilize the distal segment of the gland before the common bile duct or jejunum has been divided. The entire gastrocolic and gastrosplenic ligaments are severed. The splenic artery
Fig. 229. The tail and body of the pancreas with the spleen attached has been mobilized from left to right beyond the portal and superior mesenteric veins. The stomach is transected beforl' the distal portion of the pancreas is mobilized, but the jejunum and common bile ducts are divided after this portion of thl' gland is freed. Note that the jejunum has been divided to the left of the ligament of Treitz and that the proximal jejunum which is to be removed has been withdrawn from beneath the superior mesenteric vessels. The opening in the mesocolon at the ligament of Treitz is closed with a continuous suture. Inset, Reconstruction of the gastrointestinal tract is accomplished by an end-toend gastrojejunostomy and an end-to-side choledochojejunostomy. A jejunojejunostomy diverts the gastrointestinal- contents around the choledochojejunostomy.
is divided along the superior border of the pancreas close to the hilus of the spleen. The splenic flexure of the colon is reflected caudally. The peritoneal reflection lateral to the spleen is incised and the spleen and tail of the pancreas are mobilized medially and to the right. The small venous tributaries of the splenic vein along the inferior border of the pancreas and the inferior mesenteric vein are divided. Care must be taken during
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Kenneth W. Warren, Richard B. Cattell
this distal mobilization to identify the site of the superior mesenteric and portal veins so that the splenic vein can be divided without encroaching upon the lumen of the portal vein. Recent experience with distal pancreatectomy has demonstrated the value of elevating the neck of the pancreas from the superior mesenteric and portal veins before the distal dissection is begun. A small Penrose drain can be passed around the neck of the pancreas and thus serve as a guide to the location of this strategic point. It is easier to mobilize the body and tail of the pancreas with the splenic vein until the approximate junction of the splenic and superior mesenteric veins is reached. The splenic vein is then divided. Following division of the jejunum and the common bile duct, the spleen, pancreas, duodenum, and distal segment of stomach and proximal segment of the jejunum can be removed (Fig. 229) by clamping and dividing the branches of the superior mesenteric artery and vein which supply the duodenum and uncinate process. The reconstruction of the gastrointestinal tract following total pancreatectomy is accomplished by end-to-end gastrojejunostomy, end-toside choledochojejunostomy and a diversionary jejunojejunostomy (Fig. 229, inset). SUMMARY
Some basic considerations in pancreatic surgery are discussed. Isolated technical details which frequently prove decisive in this field of surgery are described. REFERENCES 1. Cattell, R. B. and Warren, K. W.: Surgery of the Pancreas. Philadelphia, W. B. Saunders Co., 1953, pp. 301-317. 2. DuVal, M. K. Jr.: Caudal pancreaticojejunostomy for chronic relapsing pancreatitis. Ann. Surg. 14-0: 775-785 (Dec.) 1954. 3. Jurasz, A.: Zur Frage der operativen Behandlung der Pankreacysten. Arch. f. klin. Chir. 164-: 272-279, 1931. 4. Wangensteen, O. H.: Discussion. Ann. Surg. 132: 797 (Oct.) 1950. 5. Zollinger, R. M., Keith, L. M. and Ellison, E. H.: Pancreatitis. New England J. Med. 251: 497-502 (Sept. 23) 1954.