Duodenopancreatectomy
As duodenopancreatectomy is defined as the total or partial removal of the pancreas (pancreas) together with the duodenum (duodenal) v. a. in the case of pathological changes in the area of the pancreatic head. In addition, various neighboring organs are often resected .
Classification
A distinction is made between partial duodenopancreatectomy and total duodenopancreatectomy . Another resection procedure is the left pancreatic resection, which is used in processes involving the body and tail of the pancreas.
Partial duodenopancreatectomy
In partial duodenopancreatectomy , the so-called Kausch - Whipple operation ( Whipple-Op. For short ), the gallbladder , the distal bile duct and the gastric antrum are removed in addition to the head of the pancreas and the duodenum . In addition, the regional lymph nodes are resected . The intervention is indicated for malignant processes in the area of the pancreatic head, such as pancreatic head carcinoma , papillary carcinoma or distal bile duct carcinoma , as well as benign inflammatory or stenotic processes. In recent years, the partial duodenopancreatectomy according to Traverso-Longmire (so-called pylorus-preserving partial duodenopancreatectomy = PPPD, English: Pylorus-Preserving Pancreaticoduodenectomy), in which the stomach including the pylorus and a narrow duodenal cuff is completely preserved. Originally, the stomach was partially dissected on the assumption that this would reduce the incidence of small intestinal ulcers . In fact, there is no significant difference between the two methods in this regard.
Action
The operation begins with an arched transverse upper abdominal laparotomy . First, organs such as the liver and peritoneum that are potentially at risk of metastasis are explored. Resection is usually contraindicated in cases of proven peritoneal carcinosis and liver metastasis. The omental bursa is then opened by severing the gastrocolic ligament , exposing the pancreas and exposing the celiac trunk and the hepatoduodenal ligament . Next, the Kocher duodenum is mobilized and the mobility of the pancreatic head is checked. If this is not the case or if there is tumor infiltration to the arteria and the superior mesenteric vein , the tumor may be irresectable. In individual cases, however, the portal vein or the mesenteric artery are resected and reconstructed. The lesser omentum is split and the common hepatic artery and common bile duct are shown , both of which are looped around with a rubber strap, as well as the portal vein by exposing the upper edge of the pancreas by means of fine dissection ligatures and by blunt detachment of the head of the pancreas from the vein cava inferior . Now the pancreas is tunneled under the head and body with an Overholt clamp and a rein is put on over this tunnel. Now at the latest, the hepatic duct is severed above the cystic duct , the gall bladder remains on the resected material. If necessary, the stomach is now resected or the postpyloric duodenum is severed. Subsequently, the pancreas is severed over the previously inserted rein or in a Kocher groove and thus the head of the pancreas is separated from the rest of the pancreas. The head of the pancreas is then detached from the portal vein using numerous ligatures and the duodenum is separated from the jejunum . The resected material, consisting of the head of the pancreas, the duodenum, and the main bile duct , ductus common bile duct with the gall bladder and possibly from the distal stomach, can be removed. The restoration of the food passage is carried out by a terminal-terminal or a terminal-lateral pancreatojejunostomy , a terminal-lateral biliodigestive anastomosis and a gastroenterostomy . Alternatively, the pancreatic anastomosis to the posterior wall of the stomach is performed as a terminal lateral pancreatogastrostomy.
Total duodenopancreatectomy
In the more radical total duodenopancreatectomy , the spleen as well as the pancreatic body and tail are also removed. This procedure is only indicated for carcinomas that cannot be curatively resected in any other way. The reconstruction is carried out with a Y-Roux loop and biliodigestive anastomosis.
Left pancreatic resection
This intervention is indicated u. a. in total necrosis of the pancreas, diffuse sclerosing pancreatitis and pancreatic tail carcinoma.
Action
After a transverse upper abdominal laparotomy and exploration, the spleen is mobilized by severing the vasa gastrica brevia and the ligamentum gastrocolicum. The splenic vein and splenic artery are ligated proximally and severed. Subsequently, the spleen and pancreas are detached from the retroperitoneal connections with gradual dissection ligatures. The pancreas is divided about 2 cm from the duodenum.
Preoperative measures
An upper abdominal sonography and a computed tomography of the abdomen are mandatory . The lipase , alkaline phosphatase , gamma-glutamyltransferase and bilirubin in the serum should be determined using laboratory values . Not to be forgotten is the determination of the blood group in order to have blood reserves ready in the event of major intraoperative blood loss. Optionally, an ERCP or an MRCP can be performed.
Post-operative complications
Particular mention should be made of secondary bleeding , pancreatitis , bile fistulas, pancreatic fistulas, anastomotic leakage , exocrine pancreatic insufficiency and diabetes mellitus . The latter is unavoidable with total pancreatectomy and very likely with left pancreatic resection, since the islets of Langerhans with the insulin- producing beta cells are located in the pancreatic body and tail . Thus, in addition to controls of the blood count and the inflammation parameters , close-knit controls of the blood sugar level must be carried out.
See also
literature
- Jürgen Durst and Johannes W. Rohen : Surgical operation theory . 2nd edition, 1996, Schattauer-Verlag
- Markus Müller: Surgery: for studies and practice . 8th edition, 2006/2007, Medical Publishing and Information Services
Web links
- Resection of the head of the pancreas , pancreas center of the Ruhr University Bochum
