Cephalic pancreatoduodenectomy with Blumgart anastomosis and biliopancreatic separation (Merheim technique) - general and visceral surgery

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  • Laparotomy

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    Surgical access is gained via a standard transverse incision. Follow this with inspection and palpation of the entire abdomen to rule out distant metastases and signs of local unresectability.

    After inserting a wound edge protector mount the cable winch retractor system.

    Note:

    In patients with a sharply angled costal arch perform a midline laparotomy.

  • Opening the lesser sac

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    Enter the omental bursa by detaching the omentum from the right colic flexure to the left third of the transverse colon. Now that the pancreas can be examined in detail from the left too, look for any infiltration of the stomach or postpyloric duodenum. Take down any adhesions between the pancreas and posterior gastric wall.

    Note:

    The duodenum should be preserved over a distance of 2–3 cm. If this is not possible, perform partial gastric resection.

  • Kocher maneuver

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    First, detach the right colic flexure from the anterior aspect of the duodenum and pancreatic head. Then mobilize the duodenum with the Kocher maneuver. Transpose the mobilized colon section to the left, and after incising along the outer margin of the duodenum release the duodenum together with the head of the pancreas from its retroperitoneal attachments. Continue mobilizing the head of the pancreas across the aortic plane up to the ligament of Treitz until the pancreatic head can be completely enclosed and palpated from posterior.

    Next, palpate the mobilized pancreatic head to rule out retroperitoneal infiltration and also palpate the lymphatic pathways and large vessels.

  • Cholecystectomy

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    Start the resection phase with cholecystectomy:  Grasp the gallbladder and perform antegrade subserous dissection from the liver bed using bipolar forceps, expose the bile duct and cystic artery, which for now are left attached to the specimen later resected.

    Note:

    To prevent ascending cholangitis following bilioenteric anastomosis, cholecystectomy is mandatory for functional reasons when performing pancreatic head resection.

  • Dissecting the hepatoduodenal ligament and transecting the right gastric artery

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    Dissection of the hepatoduodenal ligament includes exposure of the common hepatic artery, proper hepatic artery, and gastroduodenal artery, portal vein, and common bile duct.

    The case presented here has an anatomical variant of the blood supply to the liver. An atypical right hepatic artery from the superior mesenteric artery crosses the common bile duct posteriorly.

    In this case, perform the lymphadenectomy along the left hepatic artery in a central direction towards the celiac trunk, exposing the bifurcation of the gastroduodenal artery.

    Begin mobilizing the pylorus by dividing the right gastric artery between ligatures.

    Before this, complete ligament dissection by exposing the suprapancreatic portal vein until posterior to the pancreas.

  • Transecting the postpyloric duodenum and gastroduodenal artery

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    Now expose and transect the duodenum with a linear stapler 3 cm distal to the pylorus.  Next, transect the gastroepiploic arcade and then the gastroduodenal artery. Secure the central stump with a suture ligature.

    Tip:

    Before transecting the gastroduodenal artery, first clamp it temporarily to rule out any significant stenosis of the celiac trunk.

  • Transecting and skeletonizing the first jejunal loop

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    After locating the first jejunal loop distal to the ligament of Treitz, identify the arterial and venous arcades and then transect the jejunum with the linear stapler. Next, divide the mesentery of the proximal limb of the jejunal loop close to the intestine up to the duodenojejunal transition at the level of the ligament of Treitz.

    Note:

    In the case presented here, the mesentery is dissected between ligatures; this can be done much easier and faster using a diathermy or ultrasonic sealing instrument.

  • Pulling through the jejunal limb / dissecting the superior mesenteric vein

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    Transpose the dissected jejunal loop through an opening in the mesocolon into the upper abdomen. Then identify the mesenteric vein on the inferior aspect of the pancreatic head. Follow the superior mesenteric vein until below the pancreas.

    Note:

    In case of unclear resectability, first dissect the superior mesenteric vein since this is the critical location for best assessing resectability.

  • Transecting the pancreas and CBD

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    Carefully tunnel the pancreas with Overholt dissecting forceps and raise the pancreas slightly off the superior mesenteric vein with a vessel loop. The latter protects the superior mesenteric vein when next transecting the pancreas with a scalpel.  Obtain hemostasis of bleeding vessels on the distal resection surface with suture ligation (4/0 monofilament, delayed absorbable). Then prepare the pancreatic stump for anastomosis.

    Now close off the common bile duct distally with a suture and then transect proximal to the confluence of the cystic duct with the common bile duct.

    Take a swab.  Close the common bile duct temporarily with a bulldog clamp.

    Tip:

    To assure unhindered perfusion, transect the common hepatic bile duct proximal to its confluence with the cystic duct, as close as possible to the hepatic hilum.

  • Detaching the pancreatic head

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    Completely detach the pancreatic head by transecting the afferent branches of the portal vein.

    This completes the resection phase and the resected specimen is handed over.

    Intraoperative frozen section study of the pancreatic resection margin should confirm tumor-free resection margins. If invasive cancer or high-grade epithelial dysplasia is present at the resection margin, further resection or even total pancreatectomy is indicated.

    Note:

    Ensure meticulous dissection at the posterior retroperitoneal resection margin since this is the region most likely to show advanced tumor invasion (R1).

  • Sealing the retroperitoneal resection area with HaemoCer PLUS

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  • Oversewing and pulling up the jejunal limb retrocolically

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  • Pancreatojejunostomy I (posterior wall)

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  • Pancreatojejunostomy II (anterior wall)

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  • Fashioning the Roux-en Y limb

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  • Bilioenteric anastomosis

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  • Anastomosing the stomach

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  • Terminolateral jejunojejunostomy (Roux-en-Y)

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  • Closing the abdominal wall

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