Pancreatic head and duodenectomy

Pancreaticoduodenectomy involves three major steps: exploration, resection, and digestive tract reconstruction. Exploration is a necessary step to determine whether or not to remove. The resection is to remove the head of the pancreas, the pyloric sinus of the stomach, the duodenum and the lower common bile duct and the regional lymph nodes. The reconstruction is to match the common bile duct, pancreatic duct and stomach to the jejunum. Treatment of diseases: duodenal carcinoid pancreatic cancer Indication 1. Pancreatic head cancer, ampullary ampullary carcinoma, lower common bile duct cancer, duodenal cancer around the ampulla. Among them, the effect of pancreatic head cancer is poor, and the curative effect on periampullary cancer is better. 2. Other diseases such as duodenal leiomyosarcoma, carcinoid, pancreatic cystadenocarcinoma, etc., if necessary, this technique can be used. 3. For patients with long-term severe jaundice and poor condition, the proximal end of the gallbladder jejunum may be anastomosed or the ptcd and ercp drainage may be performed first, and then the second or elective radical resection is performed after the condition is improved. The second-stage operation is generally carried out around 10 days after the first operation, and no more than 2 weeks at the latest. The second-stage surgery often causes difficulties due to adhesions. Therefore, in principle, one-stage radical surgery should be strived for. Contraindications 1. The situation of discomfort is: the liver has metastasized; the common bile duct and hepatic duct metastasis; the liver, the common bile duct and the lymph nodes above the pancreas are widely metastatic; the tumor has invaded the portal vein and the superior mesenteric vein; the pancreatic head or ampulla The area has been tightly adhered to the inferior vena cava or aorta. Preoperative preparation 1. Correct the general condition, enter a high-calorie, high-protein diet, supplemented with bile salts and trypsin to help digestion and absorption. Repeated small blood transfusions before surgery can improve hemoglobin and blood pressure. 2. Treatment of jaundice, mainly to protect and improve liver and kidney function. Intravenous infusion of 10% glucose 1000ml daily for several days before surgery. It is very beneficial to use Chinese herbal medicines such as Yinchen, Atractylodes, Scorpion, Muxiang, Yujin and Artemisia annua. When there are conditions, the first ptcd or ercp drainage is the best yellowing measure. 3. Improve coagulation function, in addition to repeated fresh blood, should give enough calcium and vitamins K1, k3, c. Intramuscular injection of hemostatic agent 3 days before surgery. 4. Intrahepatic infection often occurs after biliary obstruction. Surgical procedure 1. Incision: the median incision in the upper abdomen or the incision in the right upper abdomen is convenient for upper, lower, and extension, and is fully exposed. 2. Exploration: The purpose of the investigation is mainly to understand the nature of the lesion to determine whether it needs to be removed; to understand the surrounding tissue to determine whether it can be removed. (1) Determining the nature of the lesion: After entering the abdominal cavity, the following conditions should be checked to determine the nature of the lesion. Gallbladder size: Intrahepatic obstruction or cholelithiasis, the gallbladder is not large or medium size, cholelithiasis can also touch the stone, while the pancreatic head cancer is obviously enlarged and can not be empty. Pancreatic head mass: The mass of carcinoma of the head of the pancreas and the cancer surrounding the ampulla are inside the descending part of the duodenum. The former is generally larger and harder, in the head of the pancreas, while the latter is smaller and softer. In the intestinal lumen. In chronic pancreatitis, the pancreas is diffusely swollen and the texture is relatively softer than the cancer. X-ray angiography: For difficult to distinguish cholelithiasis, intraoperative biliary tract angiography is feasible, or intraoperative b-ultrasound identification. Biopsy: When the diagnosis cannot identify the nature of the lesion, a biopsy of the head of the pancreas may be considered. First open the omental sac, reveal the lesion in the head of the pancreas, and cut the posterior peritoneum of the duodenum, and fix the head of the pancreas with the thumb of the left hand. The finger is lifted from the dorsal side of the pancreas to the ventral side. Open the pancreas and cut a small piece of living tissue on the lumps with a sharp-edged knife for biopsy. During the biopsy, be careful not to damage the blood vessels and pancreatic ducts. In order to reduce the risk of bleeding caused by biopsy and increase the spread of cancer cells, liver biopsy needles can also be used for biopsy of the head of the pancreas for biopsy but the accuracy is poor. Incision duodenum examination: can identify pancreatic cancer or periampullary cancer and benign tumor of duodenum, but this operation is dangerous, and it is easy to spread the tumor or intestinal bacteria into the abdominal cavity, in non-special It should be avoided if necessary. (2) Decide whether it can be removed: Whether it is possible to perform radical resection, it is necessary to check the following conditions before deciding. Local condition of cancer: Check whether the cancer itself goes beyond the gland and invades the portal vein, mesenteric arteriovenous, abdominal aorta, inferior vena cava and other important blood vessels. If it is invaded, no radical surgery can be performed. The inspection method can be carried out in 3 steps: Step 1 Explore the lateral side: Incision of the posterior peritoneum of the duodenum, inverting the duodenum and pancreatic head, using the left hand to probe the back of the pancreatic head and the ventral side of the aorta and inferior vena cava If it is easy to put your finger into this gap, it means that the cancer is still confined to the pancreas. If it cannot be inserted separately, it means that the cancer has invaded the aorta or inferior vena cava. Step 2: Explore the lower side: lift the stomach, transverse colon and omentum upwards, reveal the transverse mesenteric membrane, and cut open as far as possible from the duodenal suspensory ligament, revealing the superior mesenteric artery, colonic artery and pancreatic 12 Refers to the intestine artery. Use the right hand to extend into the dorsal side of the pancreas, and separate the pancreas from the mesenteric artery and vein from the medial side to the outside. If it has been fixed, it indicates that the tumor has invaded the blood vessels, and should not be forced to separate to prevent major bleeding. This step can also be performed by incision of the gastric collateral ligament, incision of the peritoneum at the lower edge of the pancreatic neck, before the superior mesenteric vein and portal vein, and between the pancreatic neck and the finger to detect the relationship between the pancreas and the portal vein. Step 3: Explore the upper side: cut the gastroduodenal ligament between the common bile duct and the midpoint of the small curvature of the stomach, expose the hepatic artery, ligature and cut the right gastric artery, and extend the left hand to the dorsal side of the upper edge of the pancreas. , separated downward along the ventral side of the portal vein. If the tumor does not invade an important blood vessel, the finger may meet the right hand finger on the lower side; otherwise, the tumor has invaded the important blood vessel. After careful investigation, if it is judged that the tumor cannot be removed, the operation should be terminated. 3. Resection: If carefully examined, the tumor can be removed, and the pancreatic head, the gastric antrum, the duodenum, the jejunum and the common bile duct can be removed. (1) Separately separating the organs to be resected: the posterior peritoneal incisions made at the top, bottom, and outer sides of the pancreas at the time of exploration are connected to fully reveal the organs to be removed. Separation of the lateral side: Separation of the transverse colonic hepatic curvature, and inward and downward, until the junction of the neck of the pancreas, and then the duodenal descending and pancreatic head are separated inward to the inferior vena cava and the vicinity of the aorta. Continue to cut the omentum along the lower edge of the stomach, further reveal the mesenteric upper and lower veins, and branch and cut off the small branch of the pancreas of the pancreaticoduodenal and vein, and remove the lymph nodes of the mesenteric root. Then, the duodenum is turned up to reveal the aorta and inferior vena cava behind it, and the lymph nodes around the head of the pancreas and around the aorta are removed. Separation of the upper side: ligation of the small gastro-intestinal artery and the upper pyloric region of the small blood vessel branch, and clear the liver and duodenal ligament and the upper pyloric lymph node, revealing the lower common bile duct and cystic duct. The common bile duct is pulled up and outward, and the loose tissue between the posterior part of the pancreatic head and the portal vein is further separated by fingers. While separating, the pancreatic head is pulled downward, and the splenic vein and the superior mesenteric vein branch of the lower part of the portal vein are exposed, and the dirt to be removed is sufficiently separated. (2) cut off the common bile duct: the common bile duct is cut off at the upper edge of the duodenum, the distal end is temporarily clamped or ligated, and the proximal end is clamped with a hemostat clamp for later anastomosis. At this time, the common hepatic artery trunk, the left gastric artery, and the lymph nodes around the celiac artery were further removed. (3) Severing the stomach: In order to facilitate the complete removal of the head of the pancreas and to prevent postoperative anastomotic ulcer, the antrum of the stomach should be removed. Both ends of the cut were clamped with straight clamps, and the distal end was removed with the cancer of the head of the pancreas, and the proximal end was left to be used for repair. Selective vagus nerve ablation can also be used to prevent anastomotic ulcers. (4) Cutting the pancreas: the left hand is shown, the middle finger is extended into the posterior wall of the pancreas as a support fixation, and then the thumb is used to carefully check the size range of the head cancer, and the pancreas is transected at least 3 cm from the tumor. Before the cutting, a needle is sewn on the upper and lower edges of both sides of the tangent to prevent bleeding after cutting. After cutting, the head end is fastened with a thick thread, and the body end is sutured with a medium-sized silk suture to stop bleeding. It is best to find the pancreatic duct. If it is thicker, it should be kept 0.3cm. It should be sutured and fixed on the pancreatic tissue after being cut up and down in the middle. If it is thin, it can be left untreated. After the pancreas is cut, the splenic artery trunk and the splenic lymph nodes are continuously removed along the upper edge of the pancreas.

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