Pylorus-preserving pancreaticoduodenectomy (pp Whipple) with T-drain (PPPD)

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  • MVZ St. Marien Köln - Ärztliche Leiterin

    Edith Leisten

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  • Surgical anatomy of the pancreas

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    The pancreas is made up of lobules, has a reddish-gray color, is 14 - 18 cm long, and weighs 65 - 80 grams. It is located at the level of the first and second lumbar vertebra, and its wedge shape extends from the epigastric region to the left hypochondrium. Embryologically, the organ is in close relation with the upper abdominal organs and vessels.

    The pancreas is invested by capsule-like connective and fatty tissue and is divided into three sections: Head, body and tail (caput, corpus and cauda) While there is a somewhat coarser plate of connective tissue along the posterior aspect of the head, otherwise the posterior connection of the gland with the adjacent connective tissue is loose. Since it is a retroperitoneal organ, the anterior aspect of the gland is overlaid with peritoneum.

    The gland is widest at the head, which nestles within the curve of the duodenum just to the right of the second lumbar vertebra. Both the anterior and posterior aspect of the duodenum may be overlaid to varying degrees by glandular tissue. The inferior (uncinate) process the head reaches behind the superior mesenteric vein and sometimes even behind the accompanying artery. The notch in the uncinate process extending along the junction of the left half of the pancreatic head and the neck of the pancreas is known as incisura pancreatis.

    With a width of approx. 2 cm, the region of the pancreas at the level of the first lumbar vertebra constitutes the transition between the head and tail of the organ and is located craniad to the superior mesenteric vessels. From a surgical point of view, this is also known as the neck of the pancreas.

    The elongated pancreatic body extends caudocephalad anterior to the first and second lumbar vertebra, protruding anteriorly into the lesser sac and arcing toward the splenic hilum; anatomically, the body of the pancreas is not clearly delimited from the tail. The aorta, inferior vena cava, and superior mesenteric artery and vein are posterior to the pancreas and adjacent to the spinal column

    The pancreatic tail constitutes the tapered continuation of the body and extends to the splenorenal ligament or may even enter it.

    The pancreatic anlage may take various shapes – oblique, S-shaped, transverse, and L-shaped. Horseshoe and inverted V-variants have also been described. The transition between these variant shapes is fluid.

  • Relations with other organs and pathways

    Pancreatic topography comprises the following relations with neighboring organs and retroperitoneal pathways:

    • Anteriad, the lesser sac and posterior aspect of the stomach
    • To the right, a close relation between the head of the pancreas and the curve of the duodenum
    • To the left, a close relation with the splenic hilum
    • At the level of the head, the posterior aspect of the pancreas touches the portal vein, superior mesenteric artery and vein, and common bile duct., while at the level of the body it touches the splenic artery and vein, inferior mesenteric vein, and abdominal aorta. At the level of the tail the posterior aspect is in contact with the left kidney.
  • Pancreatic duct system

    The pancreatic duct is approximately 2 mm wide and traverses the organ in its longitudinal direction close to the posterior aspect. Along its path, numerous short glandular ducts terminate in the pancreatic duct at right angles. In about 77% of cases, the duct together with the common bile duct terminates in the major duodenal papilla at the posterior wall of the descending duodenum; in the remaining cases, both ducts terminate separately but close together. Quite often the accessory pancreatic duct, ductus pancreaticus accessorius, is only rudimentary or completely absent. If present, it terminates at the minor duodenal papilla.

  • Blood supply

    Arterial blood to the pancreas is supplied by the superior pancreaticoduodenal artery, which arises from the common hepatic artery; the pancreatic head is also supplied by the inferior pancreaticoduodenal artery, a branch of the superior mesenteric artery. While the blood supply to the head is rather constant, the body and tail display a more variable arterial supply: Via short arteries arising from the splenic artery and branches of the transverse pancreatic artery.

    The superior mesenteric vein drains the pancreatic head, while body and tail are part of the catchment area of the splenic vein.

  • Lymphatic drainage

    The lymphatic vessels of the pancreas parallel the blood vessels to all the lymph nodes in the immediate vicinity of the pancreas. The peripancreatic lymph nodes (station 1) are in close relation with the gland, sometimes even superficially embedded in the gland parenchyma. There is a chain of lymph nodes along the upper aspect of the organ extending from the splenic hilum to the hepatoduodenal ligament. Other lymph nodes are located anteriorly and posteriorly between the pancreatic head and the duodenum, along the inferior aspect of the pancreas and around the tail. Additional relevant lymph nodes are situated near the celiac trunk, superior mesenteric artery and vein as well as on both sides of the aorta (station 2 or collecting lymph nodes).

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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  • Bucket-handle incision

    116-4

    Open the abdomen through a bucket-handle incision about 3-4 fingers below the costal arches with transection of skin, subcutaneous tissue, anterior fascial lamina, rectus muscle and posterior fascial lamina/peritoneum. Divide the round ligament of the liver between clamps and secure the stumps with suture ligatures (Vicryl® 2-0). Free the falciform ligament with monopolar electrocautery far over the anterior aspect of the liver. After draping the margins of the incision with damp lap towels install the retractor system comprising a frame and a cable winch system such as the Ulrich retractor. This is followed by systematic exploration of the abdominal cavity: Liver (metastases?), stomach (tumor? position of gastric tube), small intestine (adhesions? peritoneal carcinomatosis?), large bowel (tumor?), greater omentum (adhesions? carcinomatosis of peritoneal cavity?)

  • Antegrade cholecystectomy

    116-5

    The resection phase starts with the antegrade cholecystectomy: After clamping the fundus of the gallbladder release it from the liver bed using bipolar forceps and scissors. Expose the cystic duct and cystic artery, and after clamping each with an Overholt forceps, divide them and secure each central remnant with a suture ligature (Prolene® 3-0). Once the gallbladder has been taken down and handed over for histology, take a swab of the bile secretion for microbiology.

  • Mobilizing the hepatic flexure/Kocher maneuver

    116-6

    Mobilize the right colic flexure by incising the peritoneal reflection lateral to the ascending colon and carry the incision around the hepatic flexure. Gentle traction on the colon will tauten the avascular tissue plane posterior to the colon, and the mesocolon may be released from the retroperitoneal space, anterior aspect of the duodenum and the head of the pancreas.

    Mobilize the duodenum with the Kocher maneuver: Pull the mobilized colon section over to the left, and after incising along the outer margin of the duodenum with bipolar forceps and dissecting scissors 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 so that the head of the pancreas can be completely enclosed and palpated from posterior (tumor size? consistency?)

  • Opening the lesser sac

    116-7

    Enter the lesser sac by freeing the greater omentum from the hepatic flexure to the left third of the transverse colon. Although the lesser sac displays minor adhesions, it can be easily freed and exposed with the bipolar forceps. This allows pancreatic exploration on the left side as well.

  • Exposing the inferior aspect of the pancreas and the mesenterico-portalvenous vascular axis

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    Continue the dissection along the inferior aspect of the pancreas by exposing the superior mesenteric and portal vein. To this end, divide the veins of the pancreatic head with the LigaSure® or between suture ligatures (Prolene® 4-0 or 5-0). Starting in the plane of the superior mesenteric / portal vein now tunnel the pancreas from inferior and place stay sutures at its inferior aspect to the left and right of the portal vein.

    Caution: Bleeding from the portal vein! - put as little traction on the tissue as possible!

  • Dissecting the hepatoduodenal ligament

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    After opening the lesser omentum and exposing the common hepatic artery at the superior aspect of the pancreas, dissect the lymph nodes and then divide the gastroduodenal and right gastric arteries and secure their central stumps with suture ligatures (Prolene® 4-0 or 3-0).

    Note: Before transecting the gastroduodenal artery, assess the blood flow in the hepatic artery proper at the hepatic portal.

    Dissect the common bile duct (CBD) and tape it with a vessel loop. After exposing the portal vein at the superior aspect of the pancreas, now tunnel the pancreas starting superiorly and place stay sutures at its superior aspect to the left and right of the portal vein. Once both dissection planes have been joined, tape the completely tunneled pancreas with a vessel loop as well.

  • Transecting the common bile duct

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    Gently lift the CBD by its tape, transect the duct, take a swab for microbiology, flush the hepatic stump with 100-300 mL of saline, and temporarily occlude the hepatic remnant with a bulldog clamp. Follow the CBD toward the duodenum and with a suture ligature (Vicryl® or Prolene® 2-0) close it and the cystic duct just before the CBD enters the duodenum.

  • Transecting the postpyloric duodenum

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    After freeing the postpyloric duodenum and dividing the right gastroepiploic artery, transect the duodenum with a stapler (GIA 60) about 3 cm distad to the pylorus. The view for the next steps is improved by covering the staple line of the transected stomach with a moist lap strip and retracting the stomach into the left upper quadrant for the time being.

  • Transecting the jejunum

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    After locating the first jejunal loop distal to the ligament of Treitz, identify the arterial and venous arcades under transillumination and dissect them with the LigaSure®. Once the jejunum has been transected with the stapler, 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 and retract the intestinal loop into the upper abdomen. Close the newly created opening at the ligament of Treitz (Prolene® 5-0).

  • Mobilizing the "Whipple specimen" and dividing the pancreas

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    Do not divide the pancreas in the plane of the portal vein yet. Instead, mobilize the head of the pancreas with the uncinate process from the right step-by-step and free it, including the surrounding lymph nodes, down to the level of the portal vein. Suture ligate and divide the vessels with Prolene 4-0 or 5-0 or the LigaSure®.

    Divide the pancreas at the level of the neck with a scalpel (posteriad with scissors). With a scalpel obtain a specimen of the transected left margin of the pancreas and hand it off for frozen section.

    Secure hemostasis of the left pancreas with Prolene® 5-0 sutures. In case of confirmed or suspected cancer, complete the lymphadenectomy around the celiac trunk and between the aorta and vena cava.

    Note:

    • In case of suspected cancer of the CHD, a specimen of the transected margin must also be obtained and handed off for frozen section.
    • It is also possible to divide the pancreas before it has been completely mobilized because at times this might technically be easier.
    • From an oncological point of view intraoperative frozen section of the pancreatic resection margin is always recommended. If invasive cancer or high-grade epithelial dysplasia is present at the resection margin, further resection is indicated. Total pancreatectomy should be considered in those cases where two additional resection steps do not yield an unremarkable resection margin.
  • End-to-side retrocolic pancreatojejunostomy

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  • End-to-side hepaticojejunostomy

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  • End-to-side antecolic duodenojejunostomy

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  • Irrigation and drains

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  • Closing the abdominal wall

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  • Prevention and management of intraoperative complications

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  • Prevention and management of intraoperative complications

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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • literature search

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