Prof. A. FOUAD. By AMGAD FOUAD Professor Of Surgery Gastroenterology Center Gastroenterology Center Mansoura University. PRINCIPLES OF PANCREATIC RESECTION

Prof. A. FOUADProf. A. FOUAD

ByBy

AMGAD FOUADAMGAD FOUAD Professor Of SurgeryProfessor Of Surgery

Gastroenterology CenterGastroenterology CenterMansoura University.Mansoura University.

PRINCIPLES OF PANCREATIC PRINCIPLES OF PANCREATIC

RESECTION RESECTION


The pancreas is an endocrine & exocrine The pancreas is an endocrine & exocrine

organ and both of these functions should be organ and both of these functions should be

kept in mind during pancreatic surgerykept in mind during pancreatic surgery

Pancreatectomies continue to be one of the Pancreatectomies continue to be one of the

major operations performed by surgeonsmajor operations performed by surgeons

Fortunately the difficulties with the operation Fortunately the difficulties with the operation

and the dismal cure rate have been and the dismal cure rate have been

improved. improved.


Topographic Relationships of Topographic Relationships of surgical importancesurgical importance

1.1. The length of the Retroduod CBD allow for The length of the Retroduod CBD allow for

adequate subsequent sectioningadequate subsequent sectioning

2.2. The hepatic flexure of the colon overlies The hepatic flexure of the colon overlies

some of the 2some of the 2ndnd and 3 and 3rdrd portion of the portion of the

duodenum.duodenum.

3.3. The root of the transverse mesocolon is The root of the transverse mesocolon is

related directly to the head of pancreas.related directly to the head of pancreas.

4.4. The 3The 3rdrd part of the duodenum passes under part of the duodenum passes under

the SMVs and over the Aortathe SMVs and over the Aorta


Adequate ExposureAdequate Exposure

Midline incision : easyMidline incision : easy

BloodlessBloodless

Transverse incision: good accessTransverse incision: good access

Extended Rt subcostal incisionExtended Rt subcostal incision

Proper accessProper access

Good visulaizatrionGood visulaizatrion

Good assessmentGood assessment


Assessment of operability and / Assessment of operability and / or resectabilityor resectability

The root of Tr mesocolon is divided as it cross The root of Tr mesocolon is divided as it cross

over the Rt kidney & the 2over the Rt kidney & the 2ndnd portion of the portion of the

duodenumduodenum

Dissection along the lower border of the Dissection along the lower border of the

pancreas is conductedpancreas is conducted

If the tumour has affected the SMVs the tumor If the tumour has affected the SMVs the tumor

is considered non-resectable & the procedure is considered non-resectable & the procedure

is abandoned.is abandoned.


Vascular ControlVascular ControlThe most difficult aspect of the operation is to The most difficult aspect of the operation is to control bleeding especially from the tributaries of control bleeding especially from the tributaries of the SMVs & Vthe SMVs & V

Hepatic artery Hepatic artery → → Gastro duodenal artGastro duodenal art

SUP . PD artSUP . PD art

++SUP M.A SUP M.A →→ Inf PD artInf PD art

It is important to remember the numerous It is important to remember the numerous anatomic variations that may be presentanatomic variations that may be present


Further assessmentFurther assessment

The lat parietal peritoneum is incised The lat parietal peritoneum is incised

and the duod is mobilizedand the duod is mobilized

The SMVs & IVC now can be further The SMVs & IVC now can be further

examined for tumour involvementexamined for tumour involvement

Bx of questionable mass Bx of questionable mass

(Controversial)(Controversial)


CBD DivisionCBD DivisionThe CBD is circumferentially dissected The CBD is circumferentially dissected then encircled with a small rubber sling then encircled with a small rubber sling to retract it away from the portal vein to retract it away from the portal vein prior to with divisionprior to with division

The next step involves division of the The next step involves division of the GDA thus exposing the PVGDA thus exposing the PV

It is then decided whether the tumour is It is then decided whether the tumour is non-resectable non-resectable (PV invasion)(PV invasion) or that the or that the operation must be terminated for other operation must be terminated for other reasonsreasons


The next step involves passing a small The next step involves passing a small

soft rubber drain under the body of the soft rubber drain under the body of the

pancrease just to the left of SMApancrease just to the left of SMA

This is the safest way to avoid injury of This is the safest way to avoid injury of

the small Vs and also coincides with the the small Vs and also coincides with the

optimum site of division of the pancreasoptimum site of division of the pancreas
















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Prof. A. FOUAD. By AMGAD FOUAD Professor Of Surgery Gastroenterology Center Gastroenterology Center Mansoura University. PRINCIPLES OF PANCREATIC RESECTION