霍普金斯手术记录：胰十二指肠切除 Whipple

Title of Operation:

Classic pancreaticoduodenectomy.

Indications for Surgery:

福建省立医院基本外科黄东航

Obstructive jaundice.

Preoperative Diagnosis:

Carcinoma of the head of the pancreas.

Postoperative Diagnosis:

Carcinoma of the head of the pancreas.

Anesthesia:

General.

Specimen (Bacteriological, Pathological or other):

Classic pancreaticoduodenectomy specimen.

Prosthetic Device/Implant:

A 6-cm length of #5-French pediatric feeding tube used as pancreatic duct stent.

Surgeons Narrative:

The patient was brought to the operating room and placed on the table in the supine position.  General anesthesia was induced and he was intubated. His abdomen was prepped with Betadine and draped appropriately.  His peritoneal cavity was entered through an upper midline incision.  Upon entering his peritoneal cavity his abdomen was explored.  He had a sizable mass in the head of his pancreas that kocherized out of the retroperitoneum with a great deal of difficulty.  This difficulty was secondary to the neoadjuvant therapy of chemotherapy and radiotherapy that he had gone through previously.  It was not because of tumor.  There was no evidence of tumor spread to the liver or to peritoneal surfaces.  The third portion of the duodenum was kocherized and the superior mesenteric vein was identified.  The anterior surface was cleaned up under the neck of the pancreas.  The gallbladder was removed.  The common hepatic duct was divided.  A wall stent was removed from the biliary tree.  The portal vein was identified and an attempt was made to clean the anterior surface off of the undersurface of the first portion of the duodenum and the neck of the pancreas, but this was not possible because of the reaction from the radiotherapy and chemotherapy. The gastroduodenal artery was identified and doubly ligated with zero silks.  It was suture ligated on the hepatic artery side with a 2-0 silk and then divided.  The antrum of the stomach was cleaned along the greater and lesser curvatures by doubly clamping with Kelly clamps, dividing, and ligating with 2-0 black silks. The antrum of the stomach was divided with a GIA stapler. At this point, working mostly from below, the superior mesenteric vein was slowly cleared from the undersurface of the neck of the pancreas.  We would divided a little bit of the neck of the pancreas, and then clear some more superior mesenteric vein off of the undersurface.  This was a very tedious slow procedure, but eventually we were able to divide the entire neck of the pancreas without injury to the portal or superior mesenteric veins.  We then cleaned the portal and superior mesenteric veins off of the uncinate process.  The portal vein in the area of the radiotherapy was clearly thickened and white in appearance, but I think it was desmoplastic reaction and not tumor.  The uncinate process was then separated from the superior mesenteric artery and doubly clamped with Reinhoff clamps, divided, and ligated with 2-0 black silks.  The specimen was passed under the vessels to the left side of the abdomen.  The proximal jejunum was divided with a GIA stapler.  The mesentery to the proximal jejunum and fourth and third portions of the duodenum was doubly clamped with Kelly clamps, divided, and ligated with 2-0 black silks.  The specimen was removed from the operative field.  The end of the jejunum was inverted with a layer of 3-0 silk Lembert sutures.  The defect in the retroperitoneum previously occupied by the third portion of the duodenum was closed with a continuous 4-0 Prolene.  The jejunal loop was brought up into the upper abdomen through a rent in the transverse mesocolon and an end-to- side pancreaticojejunostomy was performed with a single layer of interrupted 3-0 silks.  A 6 cm in length of #5-French pediatric feeding tube uses a pancreatic duct stent, 4 cm were in the pancreatic duct and 2 cm were in the jejunum.  The pancreas itself was a very fibrotic and atrophied and was probably only a centimeter to a centimeter and half in diameter.  The pancreatic duct measured 3 mm in diameter.  Three inches distally an end-to- side hepaticojejunostomy was performed with a single layer of interrupted 4-0 Vicryl.  The jejunal loop was then tacked to the rent in the transverse mesocolon with interrupted 3-0 silks.  The next loop of jejunum was brought up in an antecolic fashion and a Billroth II gastrojejunostomy was performed with an inner continuous layer of 3-0 Vicryl in an outer interrupted layer of 3- 0 silk.  The abdomen was copiously irrigated with bibiotic solution.  Two closed suction Silastic drains were left in the area of the pancreaticojejunostomy and were brought out through stab wounds in the right midabdomen.  Both passed posterior to the hepaticojejunostomy.  The falciform ligament had been preserved and it was brought down to cover the hepatic artery as well as the gastroduodenal stump.  The abdomen was closed using multiple interrupted #2 nylon sutures sewn through all muscle and fascial layers. The subcutaneous tissues were irrigated with bibiotic solution and closed with a continuous 3-0 Vicryl.  The subcuticular layer was closed with a continuous 4-0 Vicryl. Steri-Strips were applied.  The patient tolerated the procedure with no difficulty and at the termination was taken to the intensive care unit in satisfactory condition.  I was present for all the critical portions of the operation.