1Roux-Y Hepaticojejunostomy
Pitfalls : repair too early when peritonitis and adhesions from time of injury not improved. Failure to account for all bile ducts preop, rsiking exclusin of a duct from anastomosis or including injured duct. Creation of biliary enteric anastomosis at site of injury , to devitalized biliary tissue. Circumferential dissection of hepatic duct, interrupting important collateral blood supply. Tension on biliary-enteric anastomosis , caused by either failure to adequately mobilize jejunum or placing Roux limb in antecolic position
1. Right subcostal incision, meticulous lysis of adhesions
2. Careful portal dissection - mobilizing duodenum, omentum, hepatic flexure away from porta. Identify right and left lateral aspects of porta for proper orientation
3. Anterior only dissection on hepatic duct
4. Lowering of the hilar plate to allow exposure of the anterior aspect of the hepatic duct confluence
5. Identify the long extrahepatic portion of the left hepatic dcut to faclitate exposure of the hepatic duct conflurence
6. Creation of a tension free R-Y limb , brought up to right upper quadrant via defect in transverse mesocolon to the right of the middle colic vessels
7. Inspect biliary mucosa and seek an area for anastomsois where it is normal and not fibrotic appearing
8. Reconcile the preoperative understanding of ductal anatomy with intraoperative findings and confirm all ductal orifices are included and adequately drained via the planned anastomosis
9. Broad (2cm) side to side biliary enteric anastomosis using absorbable monofilament suture
10. Closed suction drainage
2Open pancreatic necrosectomy
Pitfalls : generalized venous bleeding requiring intra-abdominal packing, recurrent necrosis after initial operative debridement requiring return to the OR , enzymatic damage to bowel or vasculature resulting in hemorrhage, bowel wall edema caused by generous resuscitation resulting in an open abdomen
1. Midline vertical or Chevron incision and full exploration
2. Access to lesser sac obtained through the gastrocolic ligament or mesocolon
3. Drainage of purulent material
4. Debridement of necrotic tissue
5. Placement of feeding jejunostomy
6. JP drains placed into lesser sac for postoperative irrigation and drainage
3Laparoscopic liver resection
Pitfalls : central lesions and large bulky tumors can compromise working space and be difficult to resect laparoscopically, control of potential hemorrhage, risk of air embolism related to pneumoperitoneum, skills in open and laparoscopic liver surgery are required
1. Placement of trocar or hand-assisted device and induction of pneumoperitoneum
2. Laparoscopic evaluation of abdomen and liver
3. Placement of additional trocars
4. Mobilization of liver as necessary
5. Intraoperative liver ultrasound
6. Resection of liver mass / segments / lobe
7. Ensure adequate hemostasis
8. Evaluate adequate perfusion of the liver remnant and look for potential bile leaks
9. Placement of drain as indicated
10. Close abdomen
4Open liver resection
1. Upper midline incision or subcostal incision with upper midline extension
2. Evaluation of abdomen and liver
3. Mobilization of liver as necessary
4. Intraoperative liver ultrasound - Define segment by portal and hepatic venous anatomy, scan liver for all visible lesions , plan resection, with marking of capsule along line of transection . Portal dissection, encircle porta with tape to allow Pringle maneuver
5. Resection of liver mass / segment (s) / lobe
6. Ensure adequate hemostasis
7. Evaluate adequate perfusion of liver remannt and look for potential bile leaks
8. Placement of drain as indicated
9. Close abdomen
5Pancreaticoduodenectomy
Pitfalls : inadequate preoperative imaging resulting in poor characterization of tumor, misidentification of hepatic arterial anatomy resulting in transection of common or proper hepatic artery, inadvertent injury to SMV/PV due to forceful, blunt dissection of the pancreatic neck off SMV / PV, inadequate exposure of SMA during pancreatic ressection resulting in injury to SMA
1. Isolation of infrapancreatic SMV
2. Extensive Kocher's maneuver
3. Portal dissection, common hepatic artery exposure, cholecystectomy, and transection of the common bile duct
4. Transection of stomach or pylorus
5. Mobilization of jejunum and takedown of ligament of Treitz
6. Pancreatic transection, resection of pancreatic head/ uncinate process from SMV-PV and SMA margin dissection (critical Oncologic step)
7. Pancreatic anastomosis (2 layer)
8. Biliary anastomosis (1 layer)
9. GI reconstruction (2 layer)
6Laparoscopic distal pancreatectomy
1. A 15mm port placed at umbilicus, 5mm in the RUQ to help retract stomach, 5mm port in MCL in LUQ , 5mm port in left anterior axillary line
2. Enter lesser sac , lift posterior gastric wall away from pancreas
3. Examine pancreas from duodenum to splenic hilum to verify location of lesion and relationship to main pancreatic duct and vessels
4. IOUS through 15mm umbilical port
5. Leave short gastric vessels intact to attempt splenic preservation via Warshaw's technique
6. Dissect out splenic artery and divide with stapler
7. Utilize a second stapler to transect the splenic artery and vein in splenic hilum
8. If spleen does not appear viable , mobilzie spleen by ligating the short gastrics and splenorenal ligament
9. Medialize spleen and free pancreatic tail
10. The splenic vein can be taken separately or with pancreatic parenchymal division utilizig stapler
11. If possible , preserve the IMV at inferior border of pancreas
12. If stapler is too thick to be stapled , divide the pancreas proximal to the cystic lesion using cautery and oversew the pancreatic duct end and cut surface of the pancreas in the fish-mouth technique
13. Place drain at resection bed
14. Close abdomen
7Lateral pancreaticojejunostomy (Puestow)
Pitfalls : hemorrhage from pancreaticoduodenal arterial arcades , failure to remove large intraductal stones or to fully unroof pancreatic duct strictures
1. Enter lesser sac and expose pancreatic head with generous Kocher maneuver
2. Identify and unroof main pancreatic duct
3. Perform retrocolic R-Y conduit for main drainage
8Beger procedure (duodenum sparing pancreatic head resection)
Pitfalls : duodenal ischemia , hemorrhage from portal vein tributaries or pancreaticoduodenal arterial arcade , stricture of common bile duct
1. Exposure of lesser sac, pancreatic head, creation of tunnel behind pancreas neck
2. Spare GDA
3. Transection of pancreas
4. Resect pancreas head wtih 5mm margin to duodenum
5. Creation of R-Y with pancreas body and remnant head to jejunum
9Frey procedure
1. Exposure of lesser sac and pancreatic head
2. Core out pancreas head
3. Unroofing of pancreas duct from head to tail
4. Creation of longitudinal R-Y PJ
10Laparoscopic or open cystgastrostomy
Pitfalls : bleeding from pseudocyst / WON cavity walls, bleeding from splenic /portal / SMV vessels during necrosectomy, dehiscence of gastric and pseudocyst walls, loss of necrosis containment and spillage into the peritoneum
1. Cholecystectomy wiht IOC for biliary pancreatitis
2. IOUS to define necrotic collection
3. Anterior gastrotomy at least 5cm to expose posterior gastric wall
4. Aspiration of pseudocyst / WON fluid for microbiology cultures
5. Electrocautery for entry into the pseudocyst / WON cavity
6. Biopsy pseduocyst wall to exclude epithelial-lined cyst
7. Explore pseudocyst / WON cavity and debride necrosis
8. Anastomosis (at least 5cm) completed wtih locking PDS suture
11Enterolithotomy
Pitfalls : additional stones may be oresent , GB and entire bowel wall should be inspected and stones removed. Attempting to milk the stone past ileocecal valve may lead to unrecognized mucosal and serosal injuries. do not attempt cholecystectomy and takedown of cholecystoetneric fistula at initial laparotomy
1. Midline laparotomy
2. Evaluate bowel to identify point of obstruction
2. Place stay sutures prior to enterotomy
4. Perform longitudinal enterotomy along the antimesenteric border of the bowel proximal to the site of obstruction
5. Extract gallstone by retrograde approach through the enterotomy
6. Milk forward any additional stones, and extract them through the same enterotomy
7. Close enterotomy transversely to prevent stricture