HOW I DO IT
Pancreaticoduodenectomy Larry C. Carey, MD, Tampa,Florida
Few m a j o r abdominal operations have undergone the extent of dramatic change as that associated with pancreaticoduodenectomy in the last 2 0 years. The precipitous drop in the mortality rate most likely has a muhifaeeted explanation. Possibilities include the concentration of the operations at specialized centers, the improvement in the quality of critical care and anesthesia, and the improvement in the skill and experience of surgeons performing t h e procedure. Concomitant with the drop in the morality rate has been an inerease in the reseetability rate, along with the early encouraging evidence of improved long-term survival. However, many aspects of the technical portion of the procedure, particularly the pancreaticojejunostomy, need to be evaluated in prospective trials. The changes in the mortality and resectability rates make the operation more widely available to a larger n u m b e r of patients, and the effectiveness of pancreaticoduodenectomy even for palliation is now well established.
Fromthe Departmentof Surgery,Universityof South Florida,Tampa, Florida. Requests for reprintsshouldbe addressedto Larry C. Carey,MD, Harbourside Medical Tower, 4 Columbia Drive, Suite 430, Tampa, Florida 33606. ManuscriptsubmittedNovember21, 1991,and acceptedin revised form January 27, 1992.
ince Whipple's original description of pancreaticoduodenectomy, the operation has undergone a steady evolution [1]. From a technical standpoint, nearly all of the variations were first tried by Whipple [2,3]. From an acceptance standpoint, the recent decrease in mortality has rekindled an interest in the application of the procedure for periampullary disease. Not long ago, the operative mortality rate associated with pancreaticoduodenectomy was 20% in most reported series. Whereas notable exceptions were reported, they were, in fact, exceptions. Furthermore, the curability of pancreatic cancer, the disease for which the operation is most often performed, was less than 10%. These data in combination produce a cure rate that was considerably lower than the operative mortality. In concert with a dramatic fall in operative deaths, there has been a sharp increase in resectability as well as encouraging improvement in 5-year survival. The following description of the technique of pancreaticoduodenectomy is intended to benefit those who are interested in the challenge of the procedure. Although many variations are possible, the described procedure can be performed comfortably in under 4 hours and frequently in under 3 hours (mean time: 3 hours 22 minutes). Unless there has been a previous exploration, blood transfusion is often not necessary. Anastomotic leaks occur in fewer than 10% of patients and have not prolonged hospitalization in the last 65 patients. Three deaths were unrelated to operative complications. Two patients died of perforated sigmoid diverticulitis, and one of myocardial infarction a week after discharge from the hospital. Seventy-five percent of the patients have returned to their preoperative activity and regained their weight.
S
REFERENCES 1. Whipple AO, Parsons WB, Mullins CR. Treatment of carcinoma of the ampulla Vater. Ann Surg 1935; 102: 763-79. 2. Whipple AO. Observationson radical surgery for lesions of the pancreas. Surg Gyneeol Obstet 1946; 82: 623-31. 3. Whipple AO. A reminiscence:pancreaticoduodenectomy.Rev Surg 1963; 20: 221-4.
THE AMERICAN JOURNAL OF SURGERY VOLUME164 AUGUST1992 153
CAREY
Figure 1A. Bilateral subcostal or midline incision provides adequate exposure. The lesser sac is opened by separating the omentum from the transverse colon. This is a plane of minimal vasculadty. The stomach is reflected superiorly, and the transverse colon and hepaUc flexure inferiorly. When combined with a generous Kocher maneuver, ~is allows visualization as well as palpation of the head of the gland.
154
THE AMERICAN JOURNAL OF SURGERY
VOLUME 164
AUGUST 1992
PANCREATICODUODENECTOMY
J J
/"
VENA
/'
/ /
l
v:/
Figure 1B, A clamp Is shown between the portal vein and ~ neck of ~ e pancreas. A small incision at the inferior and superior margins of the gland helps with the placement of this clamp. A blunt right angle is a safe instrument with which to accomplish this dissection. It is important to stay in t ~ area exactly vertical on the portal vein to avoid troublesome bleeding from smell branches that enter the vein on Its right lateral aspect. The liver is palpated, and nodes are sought adjacent to the superior mesenteric artery and along the celiac axis. The large predictable node, posterior to the common duct, is rarely involved. The area of the ligament of Treitz should also be examined for evidence of metastasis. After the clamp is removed from the space between the pancreas and the portal vein, an attempt is made to determlne portal vein invasion. This may be difficult since the uncinate process may be extended posterior to the vein, making the extent of invasion of the right lateral aspect of the vein difficult to assess.
THE AMERICAN JOURNAL OFSURGERY
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AUGUST 1992
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CAREY
Figure 2, This autopsy specimen shows a portal vein surrounded by the pancreas anteriorly, posteriorly, and to the right. A small tumor invading the portal vein may be difficult to assess until after the pancreas is divided. Intraoperative ultrasonography may be helpful in making the determination of portal vein invasion.
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THE AMERICAN JOURNAL OF SURGERY
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PANCREATICODUODENECTOMY
f t /
I
J
:,,: 'Y
:
9
.'Lhy~.:./.:,::~
/
I
A"
ARTERY
\ GASTRO[ ARTERY %
Rgure 3A, The hepatic artery Is identified superiorly and parallel to the distal lesser curvature of the stomach. Its first branch is the gastroduodenal artery, which Is found perpendicular to the hepatic artery coursing infariorly. The gastroduodenal vessel is divided close to its origin from the hepatic artery. This dissection allows for examination of the superior extent of the tumor and its relationship to the hepatic artery. The insert shows the superior and inferior pancreaticoduodenal arterial arcade from hepatic and mesenteric origins.
THE AMERICAN JOURNAL O F S U R G E R Y
VOLUME 164
AUGUST 1992
157
CAREY
/
PYLORUS
Flgure 3B. The duodenum is easily encircled 189to 2 cm distal to the pylorus and is divided with a stapler. Using the staple device obviates the use of large clamps in the operative field and minimizes spill from ~ open duodenum. Although there is a suggestion that pyIoric preservation may compromise the treatment of cancer, most investigators have not seen sufficient evidence of recurrence in the residual duodenum to avoid this technique. The common duct is divided above the entry of this cystic duct, and the distal duct and its adjacent lymphatics are separated from the portal vein,
158
THE AMERICAN JOURNAL OF SURGERY
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PANCREATICODUODENECTOMY
\
Flgure 4, Top and Bottom. The transverse colon Is reflected superiorly, exposing •e proximal jejunum. The ligament of Tmitz is divided. The jejunum distal to the ligament of Treitz is divided with a stapler. Dissection along the antlmesenterlc aspect of the duodenum is avascular and can be extended from left to right behind the superior mesenterlc vessels. Control of the blood supply to the distal duodenum and proximal jejunum requires very careful dissection and division of the vessels close to the wall of the bowel. These vessels may be quite short, and one must be mindful of the Iocetlon of the superior rnesenteric artery. Upon completion of the dissection, the duodenum is rotated under the superior mesontarlc vessel so that the entire specimen is to the right of the vessels.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 164
AUGUST 1992
159
CAREY
RTERIES FROM S.M.A. EINS TO PORTAL VEIN PLENIC VEIN
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THE AMERICAN JOURNAL OF SURGERY
VOLUME 164
AUGUST 1992
Figure 5, Top and Bottom. With the right angle clamp between the pancreas and the portal vein, the pancreas is divided just to the left of the clamp. As the gland is divided, there ere usually two small arteries in the cut surface of the gland, These ere managed with 4-0 silk suture ligature. I prefer not to cross-clamp the pancreatic parenchyma. Division of the pancreas exposes the portal vein. The branches from the head of the gland and uncinate process ere taken under direct vision. Holding the specimen in the left hand with traction toward the patient's right facilitates this dissection since, as previously noted, the uncinate process may extend posterior to the portal vein. It may be quite close to the superior mesenteric artery (SMA). Branches from the artery courseposterior to the portal vein and, if divided without control, tend to retract undemeath the portal vein, making retrieval both troublesome and dangerous. This portion of the operation is critical and requires patience.
PANCREATICODUODENECTOMY
,-,
/
Figure 6. The specimen has been removed, and the jejunum advanced into ~ r hilum of the liver. The jejunum is usually brought through a small opening in the transverse mesocolon just to the right of and anterior to the inferior mesenteric vein. The small Inset shows inversion of the staple line across the jejunum. This may not be necessary but is a precaution that I prefer. The r is accomplished with interrupted suture of 4-0 polyyglycollc acid suture; in large ducts, running suture technique is quite acceptable. Great care needs to be taken to assure the creation of a water-tight anastomosis.
Figure 7. A small stab wound Is made in the jejunum to accommodate the pancreatic duct. A row of 3-0 silk sutures approximates the posterior pancreatic parenchyma to the jejunum. There is no "capsule" on the postedor aapect of the pancreas so the sutures are simply In the paranchyma of the gland. The pancreatic duct is then anastomosed directty to ~ jejunum mucosa with interrupted absorbable sutures. A small 89 curved needle is quite helpful. A 4-0 or 5-0 suture is used for which absorbable monofllament works well. After completing the ductal anastomosis, the pancreaticojejunostomy is finished by sewing the anterior and surface of the pancrees to the serosa of the jejunum. This technique serves the two useful purposes of minimizing leak and presarvlng ductal patency. The duodenum distal to the pylorus Is anastomosed to the jejunum a comfortable distance from the pancreaticojejunostomy, using a single layer of 3-0 silk sutures placed through and through the bowel postaricrly with intraluminal knots and in a Lembert fashion anteriorly. If running suture is preferred, I have no criticism.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 164
AUGUST 1992
161
CAREY
Figure 8. This diagram shows the completed mconstrucUon. A single closed suction drain is placed through a right upper-quadrant stab wound and adjacent to the biliary and pancreatic anastomosis. With this technique, there has not been an anastomotic leak of clinical significance in the last 75 patients, and postoperative gastrointestinal function allows good nutri' tion without medication.
162
THE AMERICAN JOURNAL OF SURGERY
VOLUME 164 AUGUST 1992
Pancreaticoduodenectomy Larry C. Carey, MD, Tampa,Florida
Few m a j o r abdominal operations have undergone the extent of dramatic change as that associated with pancreaticoduodenectomy in the last 2 0 years. The precipitous drop in the mortality rate most likely has a muhifaeeted explanation. Possibilities include the concentration of the operations at specialized centers, the improvement in the quality of critical care and anesthesia, and the improvement in the skill and experience of surgeons performing t h e procedure. Concomitant with the drop in the morality rate has been an inerease in the reseetability rate, along with the early encouraging evidence of improved long-term survival. However, many aspects of the technical portion of the procedure, particularly the pancreaticojejunostomy, need to be evaluated in prospective trials. The changes in the mortality and resectability rates make the operation more widely available to a larger n u m b e r of patients, and the effectiveness of pancreaticoduodenectomy even for palliation is now well established.
Fromthe Departmentof Surgery,Universityof South Florida,Tampa, Florida. Requests for reprintsshouldbe addressedto Larry C. Carey,MD, Harbourside Medical Tower, 4 Columbia Drive, Suite 430, Tampa, Florida 33606. ManuscriptsubmittedNovember21, 1991,and acceptedin revised form January 27, 1992.
ince Whipple's original description of pancreaticoduodenectomy, the operation has undergone a steady evolution [1]. From a technical standpoint, nearly all of the variations were first tried by Whipple [2,3]. From an acceptance standpoint, the recent decrease in mortality has rekindled an interest in the application of the procedure for periampullary disease. Not long ago, the operative mortality rate associated with pancreaticoduodenectomy was 20% in most reported series. Whereas notable exceptions were reported, they were, in fact, exceptions. Furthermore, the curability of pancreatic cancer, the disease for which the operation is most often performed, was less than 10%. These data in combination produce a cure rate that was considerably lower than the operative mortality. In concert with a dramatic fall in operative deaths, there has been a sharp increase in resectability as well as encouraging improvement in 5-year survival. The following description of the technique of pancreaticoduodenectomy is intended to benefit those who are interested in the challenge of the procedure. Although many variations are possible, the described procedure can be performed comfortably in under 4 hours and frequently in under 3 hours (mean time: 3 hours 22 minutes). Unless there has been a previous exploration, blood transfusion is often not necessary. Anastomotic leaks occur in fewer than 10% of patients and have not prolonged hospitalization in the last 65 patients. Three deaths were unrelated to operative complications. Two patients died of perforated sigmoid diverticulitis, and one of myocardial infarction a week after discharge from the hospital. Seventy-five percent of the patients have returned to their preoperative activity and regained their weight.
S
REFERENCES 1. Whipple AO, Parsons WB, Mullins CR. Treatment of carcinoma of the ampulla Vater. Ann Surg 1935; 102: 763-79. 2. Whipple AO. Observationson radical surgery for lesions of the pancreas. Surg Gyneeol Obstet 1946; 82: 623-31. 3. Whipple AO. A reminiscence:pancreaticoduodenectomy.Rev Surg 1963; 20: 221-4.
THE AMERICAN JOURNAL OF SURGERY VOLUME164 AUGUST1992 153
CAREY
Figure 1A. Bilateral subcostal or midline incision provides adequate exposure. The lesser sac is opened by separating the omentum from the transverse colon. This is a plane of minimal vasculadty. The stomach is reflected superiorly, and the transverse colon and hepaUc flexure inferiorly. When combined with a generous Kocher maneuver, ~is allows visualization as well as palpation of the head of the gland.
154
THE AMERICAN JOURNAL OF SURGERY
VOLUME 164
AUGUST 1992
PANCREATICODUODENECTOMY
J J
/"
VENA
/'
/ /
l
v:/
Figure 1B, A clamp Is shown between the portal vein and ~ neck of ~ e pancreas. A small incision at the inferior and superior margins of the gland helps with the placement of this clamp. A blunt right angle is a safe instrument with which to accomplish this dissection. It is important to stay in t ~ area exactly vertical on the portal vein to avoid troublesome bleeding from smell branches that enter the vein on Its right lateral aspect. The liver is palpated, and nodes are sought adjacent to the superior mesenteric artery and along the celiac axis. The large predictable node, posterior to the common duct, is rarely involved. The area of the ligament of Treitz should also be examined for evidence of metastasis. After the clamp is removed from the space between the pancreas and the portal vein, an attempt is made to determlne portal vein invasion. This may be difficult since the uncinate process may be extended posterior to the vein, making the extent of invasion of the right lateral aspect of the vein difficult to assess.
THE AMERICAN JOURNAL OFSURGERY
VOLUME 164
AUGUST 1992
155
CAREY
Figure 2, This autopsy specimen shows a portal vein surrounded by the pancreas anteriorly, posteriorly, and to the right. A small tumor invading the portal vein may be difficult to assess until after the pancreas is divided. Intraoperative ultrasonography may be helpful in making the determination of portal vein invasion.
156
THE AMERICAN JOURNAL OF SURGERY
VOLUME 164 AUGUST 1992
PANCREATICODUODENECTOMY
f t /
I
J
:,,: 'Y
:
9
.'Lhy~.:./.:,::~
/
I
A"
ARTERY
\ GASTRO[ ARTERY %
Rgure 3A, The hepatic artery Is identified superiorly and parallel to the distal lesser curvature of the stomach. Its first branch is the gastroduodenal artery, which Is found perpendicular to the hepatic artery coursing infariorly. The gastroduodenal vessel is divided close to its origin from the hepatic artery. This dissection allows for examination of the superior extent of the tumor and its relationship to the hepatic artery. The insert shows the superior and inferior pancreaticoduodenal arterial arcade from hepatic and mesenteric origins.
THE AMERICAN JOURNAL O F S U R G E R Y
VOLUME 164
AUGUST 1992
157
CAREY
/
PYLORUS
Flgure 3B. The duodenum is easily encircled 189to 2 cm distal to the pylorus and is divided with a stapler. Using the staple device obviates the use of large clamps in the operative field and minimizes spill from ~ open duodenum. Although there is a suggestion that pyIoric preservation may compromise the treatment of cancer, most investigators have not seen sufficient evidence of recurrence in the residual duodenum to avoid this technique. The common duct is divided above the entry of this cystic duct, and the distal duct and its adjacent lymphatics are separated from the portal vein,
158
THE AMERICAN JOURNAL OF SURGERY
VOLUME 164 AUGUST 1992
PANCREATICODUODENECTOMY
\
Flgure 4, Top and Bottom. The transverse colon Is reflected superiorly, exposing •e proximal jejunum. The ligament of Tmitz is divided. The jejunum distal to the ligament of Treitz is divided with a stapler. Dissection along the antlmesenterlc aspect of the duodenum is avascular and can be extended from left to right behind the superior mesenterlc vessels. Control of the blood supply to the distal duodenum and proximal jejunum requires very careful dissection and division of the vessels close to the wall of the bowel. These vessels may be quite short, and one must be mindful of the Iocetlon of the superior rnesenteric artery. Upon completion of the dissection, the duodenum is rotated under the superior mesontarlc vessel so that the entire specimen is to the right of the vessels.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 164
AUGUST 1992
159
CAREY
RTERIES FROM S.M.A. EINS TO PORTAL VEIN PLENIC VEIN
160
THE AMERICAN JOURNAL OF SURGERY
VOLUME 164
AUGUST 1992
Figure 5, Top and Bottom. With the right angle clamp between the pancreas and the portal vein, the pancreas is divided just to the left of the clamp. As the gland is divided, there ere usually two small arteries in the cut surface of the gland, These ere managed with 4-0 silk suture ligature. I prefer not to cross-clamp the pancreatic parenchyma. Division of the pancreas exposes the portal vein. The branches from the head of the gland and uncinate process ere taken under direct vision. Holding the specimen in the left hand with traction toward the patient's right facilitates this dissection since, as previously noted, the uncinate process may extend posterior to the portal vein. It may be quite close to the superior mesenteric artery (SMA). Branches from the artery courseposterior to the portal vein and, if divided without control, tend to retract undemeath the portal vein, making retrieval both troublesome and dangerous. This portion of the operation is critical and requires patience.
PANCREATICODUODENECTOMY
,-,
/
Figure 6. The specimen has been removed, and the jejunum advanced into ~ r hilum of the liver. The jejunum is usually brought through a small opening in the transverse mesocolon just to the right of and anterior to the inferior mesenteric vein. The small Inset shows inversion of the staple line across the jejunum. This may not be necessary but is a precaution that I prefer. The r is accomplished with interrupted suture of 4-0 polyyglycollc acid suture; in large ducts, running suture technique is quite acceptable. Great care needs to be taken to assure the creation of a water-tight anastomosis.
Figure 7. A small stab wound Is made in the jejunum to accommodate the pancreatic duct. A row of 3-0 silk sutures approximates the posterior pancreatic parenchyma to the jejunum. There is no "capsule" on the postedor aapect of the pancreas so the sutures are simply In the paranchyma of the gland. The pancreatic duct is then anastomosed directty to ~ jejunum mucosa with interrupted absorbable sutures. A small 89 curved needle is quite helpful. A 4-0 or 5-0 suture is used for which absorbable monofllament works well. After completing the ductal anastomosis, the pancreaticojejunostomy is finished by sewing the anterior and surface of the pancrees to the serosa of the jejunum. This technique serves the two useful purposes of minimizing leak and presarvlng ductal patency. The duodenum distal to the pylorus Is anastomosed to the jejunum a comfortable distance from the pancreaticojejunostomy, using a single layer of 3-0 silk sutures placed through and through the bowel postaricrly with intraluminal knots and in a Lembert fashion anteriorly. If running suture is preferred, I have no criticism.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 164
AUGUST 1992
161
CAREY
Figure 8. This diagram shows the completed mconstrucUon. A single closed suction drain is placed through a right upper-quadrant stab wound and adjacent to the biliary and pancreatic anastomosis. With this technique, there has not been an anastomotic leak of clinical significance in the last 75 patients, and postoperative gastrointestinal function allows good nutri' tion without medication.
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