• Clinical science

Pancreatic and hepatic surgery

Abstract

Pancreatic and hepatic surgeries are indicated in the management of malignant/symptomatic benign tumors and traumatic lacerations of these organs. The choice of surgery depends on the location, size, and extent of the malignancy/injury. Depending on the extent of resection, pancreatic surgeries for malignancy include enucleation (for islet cell tumors), partial pancreatic resections (distal pancreatectomy, central pancreatectomy, pancreaticoduodenectomy/Whipple procedure), and total pancreatectomy. Chronic pancreatitis patients with a dilated main pancreatic duct (> 5 mm), not responding to conservative therapy, are candidates for lateral pancreaticojejunostomy with/without resection of the pancreatic head. Complications of pancreatic surgeries include anastomotic leaks, pancreatic ascites/fistula, and exocrine/endocrine insufficiency. Depending on which segments of the liver are removed, hepatic resections include right/left hepatectomy, right/left lobectomy, and segmentectomy. Wedge resections of the liver are performed for small, peripherally located lesions. Other complications of hepatic resections include liver failure, hemorrhage, hemobilia, and bile leaks.

Pancreatic surgery

Brief anatomy of the pancreas

Types of pancreatic surgeries

Type Indications Surgical procedure

Pancreatic resections

Pancreaticoduodenectomy

(Whipple procedure)

  • Resection
  • Anastomoses
    • Pancreaticojejunostomy
    • Hepaticojejunostomy
    • Gastrojejunostomy
Pylorus-preserving pancreaticoduodenectomy (modified Whipple procedure)
Distal pancreatectomy (with/without splenectomy)
  • Lesions in the body/tail of the pancreas
    • Spleen-preserving surgery: benign lesions
    • With splenectomy: malignant/premalignant lesions
  • The body and tail of the pancreas are resected, with/without the spleen.
  • Anastomosis: pancreaticojejunostomy
Central pancreatectomy
  • Neck and body of the pancreas is resected.
  • The cut surface of the tail is anastomosed to the jejunum.
Total pancreatectomy
  • The entire pancreas, together with the duodenum, is resected.
  • Anastomoses: hepaticojejunostomy and gastrojejunostomy
  • Islet cell autotransplantation
Enucleation
  • PNET (Islet cell tumors)
  • The tumor is dissected/shelled out of the surrounding normal pancreatic parenchyma.
For acute pancreatitis

Debridement of pancreatic parenchyma

(Pancreatic necrosectomy)

  • All dead and necrotic tissue are removed (debridement).

For chronic pancreatitis

Duodenum-preserving pancreatic head resection

(Berger's procedure)

  • Head of the pancreas is resected at the level of the superior mesenteric vein.
  • Pancreaticojejunostomy

Lateral pancreaticojejunostomy + resection of the pancreatic head

(Frey's procedure)

  • The pancreatic head is resected and the dilated duct is opened length wise.
  • Anastomosis: lateral pancreaticojejunostomy

Lateral pancreaticojejunostomy

(Puestow's procedure)

  • Same as Frey's procedure, but without the pancreatic head resection
For pancreatic pseudocysts
  • Pseudocyst-gastrostomy (cystogastrostomy)
  • Pseudocyst-duodenostomy (cystoduodenostomy)
  • Pseudocyst-jejunostomy (cystojejunostomy)
  • The cyst is drained into the stomach, duodenum or jejunum
For pancreatic fistulae
  • Failure of conservative and endoscopic management

Complications

Suspect a pancreaticojejunostomy anastomotic leak in a patient with hyperchloremic acidosis (loss of bicarbonate) and high levels of amylase in abdominal secretions!
References:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]

Hepatic surgery

Brief anatomy of the liver

  • The liver is divided into right and left lobes by the falciform ligament (morphological anatomy). The right and left lobes are different from the right and left halves of the liver which are individually supplied by the right and left branches of the hepatic artery, the portal vein, and the hepatic duct.
  • Couinaud's classification of liver segments (functional anatomy):
    • The liver is divided into eight functional segments, each with its own branch of the hepatic artery, portal vein, and bile duct.
    • Cantlie's line extends from the gall bladder fossa below to the IVC above and contains the middle hepatic vein.
    • Segment I (caudate lobe) lies on the posterior aspect of the liver and is uniquely supplied by the right and left branches of the hepatic artery, portal vein, and hepatic duct.
    • Left lobe of the liver is composed of segments II, III, IV.
    • Right lobe of the liver is composed of segments V, VI, VII, VIII.

General principles of hepatic surgery

  • Access: laparotomy (transverse, midline or subcostal incisions) or laparoscopy
  • Pringle maneuver: temporary occlusion of the hepatic artery and portal vein by clamping of the free edge of the lesser omentum (hepatoduodenal ligament) in order to control vascular inflow to the liver or to reduce hemorrhage
  • Cholecystectomy is routinely performed as part of all major hepatic resections to allow for easier dissection during the surgery.
  • Cavitron ultrasonic surgical aspirator (CUSA): uses ultrasonic waves to vaporize only the liver cells while sparing the biliary radicles and blood vessels

Types of liver resections

Type Indications Contraindications Surgical procedure
Anatomical resections

Right hepatectomy (right hemihepatectomy)

  • Segments V, VI, VII, and, VIII are removed.
Right lobectomy (extended right hepatectomy or right trisegmentectomy)
  • Right hepatectomy and the additional removal of segments I and IV
Left hepatectomy
  • Segments II, III, and IV are removed.
Left lobectomy
  • Segments II and III are removed (liver to the left of the falciform ligament).
Segmental resection
  • One or more anatomical segments are removed.
Non-anatomical resection Wedge resection
  • Peripherally located lesions
  • A triangular wedge of hepatic parenchyma containing the lesion is removed.

Complications

  • Hemorrhage
  • Hemobilia
  • Bile leak
  • Liver failure

Before performing extensive hepatic resections the future liver remnant (FLR) needs to be calculated (using CT images), as patients with insufficient FLR postresection, can develop liver failure!
References:[22][23][24][25][26][27][28]