Hepatobiliary Flashcards
Roux-en-Y Hepaticojejunostomy Procedure
Right subcostal incision
Careful portal dissection—mobilizing duodenum, omentum, hepatic flexure away from porta. Identify right and left lateral aspects of porta for proper orientation.
“Anterior-only” dissection of the hepatic duct.
Lowering of the hilar plate to allow exposure of the anterior aspect of the hepatic duct confluence.
Identify the long extrahepatic portion of the left hepatic duct to facilitate exposure of hepatic duct confluence.
Creation of tension-free Roux-en-Y limb, brought up to right upper quadrant via defect in transverse mesocolon to the right of the middle colic vessels.
Inspect biliary mucosa and seek an area for anastomosis where it is normal and not fibrotic appearing.
Reconcile the preoperative understanding of ductal anatomy with intraoperative findings and confirm all ductal orifices are included and adequately drained via the planned anastomosis.
Broad (2 cm) side-to-side biliary–enteric anastomosis using absorbable monofilament suture.
Closed suction drainage.
Potential Pitfalls:
Electing to perform repair too early, when peritonitis and adhesions from time of injury have not improved.
Failure to account for all bile ducts preoperatively, risking exclusion of a duct from the anastomosis or including an injured duct but with inadequate mucosal exposure.
Creation of the biliary–enteric anastomosis at the site of injury, to devitalized biliary tissue.
Circumferential dissection of the hepatic duct, interrupting important collateral blood supply.
Tension on the biliary–enteric anastomosis, caused by either failure to adequately mobilize the jejunum or placing the Roux limb in an antecolic position
Open Pancreatic Necrosectomy
Midline vertical or Chevron incision and full exploration
Access to the lesser sac obtained through the gastrocolic ligament or mesocolon
Drainage of purulent material
Debridement of necrotic tissue
Placement of feeding jejunostomy
JP drains placed into the lesser sac for postoperative irrigation and drainage
Potential Pitfalls:
Generalized venous bleeding requiring intra-abdominal packing
Recurrent necrosis after initial operative debridement requiring return to the operating room
Enzymatic damage to the bowel or vasculature resulting in hemorrhage
Bowel wall edema caused by generous resuscitation resulting in an open abdomen
Liver resection for hepatic masses
Placement of trocar or hand-assisted device and induction of pneumoperitoneum
Laparoscopic evaluation of abdomen and liver
Placement of additional trocars
Mobilization of liver as necessary (round and falciforme ligaments)
Intraoperative liver ultrasound
Resection of liver mass/segment(s)/lobe
Staple or clip vascular and biliary structures
Insure adequate hemostasis- argon beam or hemostatic agents ( can use intermittent Pringle maneuver or clamping of Infra and Supra hepatic vena cava)- ensure low CVP to prevent hemorrhage
Evaluate adequate perfusion of the liver remnant and look for potential bile leaks
Placement of drain as indicated
Close abdomen
Potential Pitfalls:
Central lesions and large bulky tumors can compromise laparoscopic 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
Pancreaticoduodenectomy
1-Isolation of the infrapancreatic SMV-the infrapancreatic border of the pancreas and the infrapancreatic SMV are defined by entering the lesser sac & removing the greater omentum from the transverse mesocolon
2-Extensive Kocher’s maneuver- expose IVC
3-Portal dissection, CHA exposure (most medial of portal structures), GDA id and ligation at site of CHA LN, retrograde cholecystectomy, and transection of the bile duct at level of common hepatic duct
4-Transection of the stomach 3 to 4 cm prox to pylorus after dividing greater and lesser sac (watch for replaced LHA in lesser sac)
5-Mobilization of the jejunum, transect 10 cm from lig of treitz, then takedown of the ligament of Treitz, transect SB mesentery with ligasure device- pass jejunum to RUQ through posterior window in transverse mesocolon
6-Pancreatic transection (after placing superior and inferior border of pancreatic neck hemostatic sutures), resection of the pancreatic head/uncinate process from SMV-PV (send border for frozen margin confirmation) and SMA margin dissection (critical oncologic Step)
Pancreatic, biliary, and gastrointestinal reconstruction:
1-Pancreatic anastomosis: two layer, end-to-side, duct-to-mucosa anastomosis with 4-0 or 5-0 monofilament suture
2-Biliary anastomosis -single layer biliary anastomosis approximately 10 to 15 cm from the pancreaticojejunostomy, using 4-0 or 5-0 absorbable monofilament suture
3-Gastrointestinal reconstruction: antecolic, end-to-side gastrojejunostomy is performed at least 50 cm from the hepaticojejunostomy
Lateral Pancreaticojejunostomy (Puestow-type) +/- Frey procedure
Midline laparotomy (or left subcostal)
Enter lesser sac and expose pancreatic head with generous Kocher maneuver.
Identify and unroof main pancreatic duct with electrocautery
Hemostatic control of anterior superior and inferior pancreaticoduodenal arteries
Perform retrocolic side to side Roux-en-Y conduit for main duct drainage with 4-0 slowly absorbable suture
Frey- add a pancreatic head coring out with electrocautery and pancreaticojejunostomy at the level of the pancreatic head is sewn to the border of the parenchymal excavation in the head
(used for inflammatory pancreatic head masses)
Beger Procedure
Exposure of lesser sac, pancreas head, and creation of tunnel behind pancreas neck.
Spare GDA.
Transection of pancreatic neck
Resect pancreas head with 5 mm margin to duodenum.
Creation of Roux-en-Y with pancreas body and remnant head to jejunum.
Cystogastrostomy
Cholecystectomy with intraoperative cholangiography for biliary pancreatitis.
Intraoperative ultrasound to define the necrotic collection.
Anterior longitudinal gastrotomy at widest part of fundus (at least 5 cm) to expose posterior gastric wall.
Aspiration of pseudocyst/WON fluid for microbiology cultures.
Electrocautery for entry into the pseudocyst/WON cavity.
Biopsy pseudocyst wall to exclude epithelial-lined cyst.
Explore pseudocyst/WON cavity and debride necrosis.
Anastomosis (at least 5 cm) completed with locking PDS suture.
Close anterior gastrostomy transversely
Enterolithotomy
Midline laparotomy.
Run bowel, evaluate to identify point of obstruction.
Place stay sutures prior to enterotomy.
Perform longitudinal enterotomy along the antimesenteric border of the bowel proximal to the site of obstruction.
Extract gallstone by retrograde approach through the enterotomy.
Milk forward any additional stones and extract them through the same enterotomy.
Close the enterotomy transversely to prevent stricture.
Potential Pitfalls
Additional stones may be present in 15% of patients, and the gallbladder and entire bowel should be carefully inspected and stones removed to prevent recurrent episodes of obstruction.
Attempting to milk the stone past the ileocecal valve may lead to unrecognized mucosal and serosal injuries and should be avoided.
Typically, cholecystectomy and takedown of cholecystoenteric fistula should NOT be attempted at initial laparotomy.
