- Clinical science
Pancreatic and hepatic surgeries are indicated in the management of malignant/symptomatic benign tumors and traumatic lacerations of the liver and pancreas. 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.
Anatomy of the pancreas
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Types of pancreatic surgeries
|Pylorus-preserving pancreaticoduodenectomy (modified Whipple procedure)|| |
|Distal pancreatectomy (with/without splenectomy)|
|Total pancreatectomy|| |
|For acute pancreatitis|| |
Debridement of pancreatic parenchyma
Lateral pancreaticojejunostomy + resection of the pancreatic head
|For|| || |
|For pancreatic fistulae|| |
- Delayed gastric emptying/gastroparesis (most common)
Pancreaticojejunostomy anastomotic leak/pancreatic ductal disruption → leakage of pancreatic secretions into the abdominal cavity
- → Hyperchloremic acidosis
- → Pancreatic fistula
- Hepaticojejunostomy anastomotic leak → biliary peritonitis
- Exocrine pancreatic insufficiency
- Endocrine pancreatic insufficiency (diabetes mellitus) and lifelong dependence on insulin
- Small bowel obstruction: herniation, volvulus, anastomotic stricture
- Intraabdominal abscess or sepsis
- Gastrointestinal hemorrhage
- If the duodenum is resected: iron deficiency anemia
Suspect a pancreaticojejunostomy anastomotic leak in a patient with hyperchloremic acidosis (loss of bicarbonate) and high levels of amylase in abdominal secretions!
Anatomy of the liver
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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
|Anatomical resections|| |
Right hepatectomy (right hemihepatectomy)
| || |
|Right lobectomy (extended right hepatectomy or right trisegmentectomy)|| |
|Left hepatectomy|| |
|Left lobectomy|| |
|Segmental resection|| |
|Non-anatomical resection||Wedge resection|| || |
- 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!