Pancreaticoduodenectomy

As a pancreaticoduodenectomy is defined as the total or partial removal of the pancreas ( pancreatic ) together with the duodenum ( duodenum) esp. in pathological changes in the pancreatic head. In addition, it often comes to the resection of various neighboring organs.

Classification

A distinction is made between the partial pancreaticoduodenectomy and total pancreaticoduodenectomy. A further resection is the pancreatectomy, which is used in processes in the field of pancreatic body and tail of the pancreas.

Partial pancreaticoduodenectomy

In Partial pancreaticoduodenectomy, the so-called OP after Kausch - Whipple (short Whipple procedure ) is also removed the gall bladder, the distal bile duct and the gastric antrum adjacent to the pancreatic head and the duodenum. In addition, it comes to the resection of the regional lymph nodes. The procedure is indicated in malignant processes in the area of the pancreatic head, such as the pancreatic head carcinoma, the papillary or the distal bile duct carcinoma as well as benign inflammatory or stenotic processes. In recent years, the partial pancreaticoduodenectomy has increasingly enforced by Traverso - Longmire (so-called pylorus-preserving partial pancreaticoduodenectomy = PPPD ), in which the stomach including the pylorus and a narrow Duodenalmanschette remains completely intact. Originally, the partially resected stomach was on the assumption that it leads to a lower incidence of small intestinal ulcers. Actually, however, in this respect, there is no significant difference between the two methods.

Procedure

The operation begins with an arcuate cross laparotomy. First, potentially threatened by metastasis organs such as liver and peritoneum are explored. Then the lesser sac is opened by transection of the gastrocolic ligament, causing hepatoduodenale to expose the pancreas and to display the celiac trunk and the ligament. Next, the duodenum is mobilized by Kocher and analyzed the mobility of the pancreatic head. Should this not be given or there is a tumor invasion to the superior mesenteric artery and vein, the irresectability the tumor may exist. In some cases, however, the portal vein or the mesenteric artery is resected and reconstructed. With a proven peritoneal carcinomatosis and liver metastasis usually the resection is contraindicated. It continues with the cleavage of the lesser omentum and the representation of common hepatic artery and the common bile duct, both of which are snared with a rubber reins, and the portal vein by exposing the pancreatic top by means of fine Dissektionsligaturen and by blunt separation of the pancreatic head of the inferior vena cava inferior. Now the pancreas between the head and body is tunneled with a Overholt clamp and created a rein over this tunnel. At least now done the transection of the common hepatic duct above the cystic duct, the gallbladder remains on the resected specimen. If necessary, the stomach is now resected or the duodenum postpylorische severed. Thereafter, the pancreas is cut over the previously engaged rein or a cooker 's channel, and thus the head of the pancreas separated from the remaining pancreas. Subsequently, the head of the pancreas of the vena porta is replaced by means of numerous ligatures and isolated from the duodenum jejunum. This allows the resected specimen, consisting be removed from the head of pancreas, duodenum, bile main course common bile duct with the gall bladder and possibly the distal stomach. The restoration of the passage of food is done by terminoterminale or terminolateral Pankreatojejunostomie, terminolateral biliodigestive anastomosis and gastrojejunostomy. Alternatively, the pancreatic anastomosis is performed to the posterior gastric wall as terminolateral pancreatogastrostomy.

Total pancreaticoduodenectomy

In the more radical pancreaticoduodenectomy shots addition, the spleen and the pancreatic body and tail of the pancreas are removed. This procedure is only indicated in a different way not curative resectable tumors. The reconstruction is performed with Roux- Y loop and biliodigestive anastomosis.

Pancreatectomy

Indexed this intervention is, inter alia, in total necrosis of the pancreas, diffuse sclerosing pancreatitis and pancreatic tail carcinoma.

Procedure

After querer laparotomy and exploration, the spleen is mobilized under dissection of the Vasa gastric brevia and the ligamentum gastrocolicum. The splenic vein and splenic artery are ligated proximally and divided. Subsequently, spleen and pancreas are released under gradual Dissektionsligaturen from the retroperitoneal connections. The transection of the pancreas occurs approximately 2 cm from the duodenum.

Preoperative measures

Obligate are an upper abdominal sonography and computed tomography of the abdomen. At laboratory values ​​necessarily the lipase, alkaline phosphatase, gamma -glutamyltransferase, and bilirubin should be measured in serum. Not to be forgotten is to determine the blood group to have blood supplies in the event of greater intraoperative blood loss in readiness. Optionally, an ERCP or MRCP can be performed.

Postoperative Complications

Particular mention postoperative hemorrhage, pancreatitis, biliary or pancreatic fistula, anastomotic leakage and diabetes mellitus. The latter is inevitable with total pancreatectomy and very likely with pancreatic resection, since they are located in the pancreatic body and tail of the pancreas, the islets of Langerhans, the insulin-producing beta cells. Thus, in addition to checks of the blood count and inflammatory markers may also close monitoring of blood glucose levels should be carried out.