Pancreatic surgery

Surgical approaches to the pancreas

Several routes are used to expose the organ after laparotomy:

• Through the gastrocolic ligament (lig. gastrocolicum). Considered the most convenient option. The ligament is dissected in the avascular area closer to the greater curvature. The stomach is retracted upward, and the transverse colon is displaced downward.
• Through the transverse mesocolon (mesocolon transversum). This route is used when other approaches are impossible. It is often utilized for internal drainage of cysts (e.g., when creating a cystojejunostomy).
• Through the lesser omentum. Involves dissection of the hepatogastric ligament. This option is especially convenient in cases of marked gastroptosis.
• Additional route. Performed by separating the greater omentum directly from the transverse colon.

Interventions for acute destructive pancreatitis

The indication for surgery is acute destructive pancreatitis complicated by peritonitis. The intervention is performed in the supine position under endotracheal anesthesia, using an upper midline laparotomy.

The surgeon's main goals are to halt enzymatic tissue destruction, ensure the outflow of secretions and sequestra, and manage inflammation in the biliary tract. Manipulations on the pancreas itself should be minimal.

Transperitoneal drainage method:

1. The approach is performed through the lig. gastrocolicum.
2. A novocaine blockade (0.25% solution) of the transverse mesocolon and hepatoduodenal ligament is performed. In cases of trauma and generalized process, the anesthetic with the addition of 50,000 IU of Trasylol is injected into the surrounding tissues and beneath the parietal peritoneum.
3. 5–6 gauze packs and rubber drains are loosely placed near the pancreas.
4. To isolate the focus from the free peritoneal cavity, the edges of the gastrocolic ligament are sutured to the parietal peritoneum and with separate stitches to the packs. The abdominal wall wound is closed in layers down to the packs.

In case of concomitant destructive cholecystitis, cholecystectomy with external biliary drainage is additionally performed. To improve outflow from the pancreatic bed, a counter-incision in the lumbar region may be created.

Extraperitoneal approach: The skin incision is made on the left along the lower border of the 12th rib. The tissues of the lumbar region are dissected in layers, and the retroperitoneal adipose tissue is separated down to the lesion, where drains are placed. This method provides excellent outflow, prevents infection of the peritoneal cavity, and reduces the risk of postoperative adhesions.

Surgeries for tumors

Two types of interventions are performed for malignant neoplasms of the pancreatic head and periampullary zone:

• Palliative. Aimed at restoring bile outflow. Consist in creating an anastomosis between the extrahepatic bile ducts and the gastrointestinal tract (stomach or jejunum).
• Radical. The main procedure is pancreatoduodenal resection (PDT). This is an extremely complex and traumatic procedure.

Stages of PDT:

1. Mobilization of the duodenum, distal stomach, and pancreatic head.
2. Transection of the duodenum and common bile duct.
3. En bloc removal of the pancreatic head, proximal duodenum, and part of the stomach.
4. Reconstruction. Includes creating a series of anastomoses: between the jejunum, the pancreatic stump, and the common bile duct; between the jejunum and the remaining part of the stomach; as well as forming an enteroenterostomy.

Catheterization of the right gastroepiploic artery

Intraarterial administration is used for regional infusion of medications (Contrycal, Trasylol, etc.).

Execution Technique:

• Near the pylorus in the tissues of the greater omentum, the trunk of the right gastroepiploic artery is isolated.
• A 1-mm diameter polyethylene catheter is inserted into its lumen in the central direction (up to the level of the gastroduodenal artery).
• The artery is ligated at its origin from the hepatic artery, thereby securely fixing the catheter.
• The distal end of the tube is brought out through the skin wound.

To check correct placement, 2–3 ml of indigocarmine is injected into the catheter. If the position is correct, the pancreatic tissues will change color.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Technique of cystojejunostomy for pancreatic cysts
• Features of novocaine blockades in pancreatic trauma
• Options for palliative surgery in unresectable cancer of the pancreatic head
• Concomitant biliary interventions in destructive cholecystitis

Other topics in the "Abdominal Surgery" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.