Gastrointestinal Surgery Series: Pancreas and Hepatobiliary Surgery Prabin Bikram Thapa, Dhiresh Kumar Maharjan
INDEX
ABCDEFGHIJKLMNOPRSTUVX
Page numbers followed by f refer to figure, fc refer to flow chart, and t refer to table.
A
Abdominal distension 62
Abdominal surgery, upper 65
Abscess 115, 118
Adenocarcinoma 28, 104
Adenomyomatosis 105
Adenosquamous carcinomas 104
Adjuvant radiotherapy 69
Adrenal gland 49
Alpha fetoprotein 96
Anastomosis
anterior layer of 81
layer of 80
Anastomotic healing process 34
Aorta 49, 50
abdominal 2f
Arterial
injury 118
pathways, collateral 48f
pseudoaneurysm 59
resection 18
Artery-first 1
Ascites 62
Atrophy hypertrophy complex 114, 119
Atrophy, right 117f
B
Barcelona clinic liver cancer 85
Bile duct
common 9, 10
confluence 77f
crowding of 115f
injury 112
of anterior segment 77
of left caudate lobe 77
of posterior segment 77
of right caudate lobe 77
of segment 77
Biliary cirrhosis, secondary 117, 117f, 120
Biliovascular injury 112, 113, 114, 115, 121, 122
classification 113
diagnosis 114
incidence 112
nonsurgical management 121
pathogenesis 113
pathophysiology 115
Blood supply 113
Blumgart pancreaticojejunostomy 31f
Borderline-resectable disease 1
C
Cachexia 62
Cadaveric donor liver transplantation 96f
Calot's triangle 113
Cattell-Braasch maneuver 2, 21
Celiac
axis 48–50
ganglion 49
plexus 49
Chemoradiotherapy 51, 66
Chemotherapy 109
Child-Pugh stage 89
Cholangiocarcinoma 67, 68
distal 76, 81, 83f
Cholangiojejunostomy 80, 82
Cholangiolytic abscess 117
multiple 116f
Cholangitis 63
abscess 117
Cholecystectomy 57
Choledocojejunostomy 16
Cholestasis, management of 117
Cirrhosis 117
Congestive cardiac failure 105
Crus of diaphragm 49, 50
D
Diabetes mellitus 28
Duct-to-mucosa 30f
pancreaticogastrostomy 29, 35
technique of 36
Duodenum 49
adenocarcinoma 15
Dysplasia carcinoma 104
E
Empyema 62, 63
En bloc celiac axis resection 50f
Endoscope 55
Endoscopic
cholangiopancreatography 64
debridement 58
ultrasound 58
Estimating extent of disease 54
Extrahepatic portion 76
F
Feeding jejunostomy placement 57
Fine needle aspiration cytology 53f, 106
Fluoropyrimidine based regimens 109
G
Gallbladder 62, 105
cancer 62, 66, 104, 106fc, 107
diagnosis of 104
incidental 108
treatment of 110
carcinoma 65, 107
management of carcinoma of 104
tumor 66
wall, symmetric 105
Gamma glutamyl transpeptidase 63
Ganglions, bilateral 50
Gastric
artery, left 48
mucosa 35
Gastrocolic omentum 4f
Gastroduodenal artery 9, 10, 48, 50
right 48
Gastroepiploic vessels 10
Gastroscope 55
Gastrostomy 58
anterior 36
technique of anterior 36, 38f
tube 55
Gemcitabine based regimens 109
Glissonean pedicle 79
Growth factor 21
H
Hanging maneuver 4
Hartmann's pouch 70
Head-luncinate process 20
Heart disease, severe ischemic 78
Hemihepatectomy 68
Hemobilia 118
Hemorrhage 118
Hepatectomy 76, 120
right 120f
Hepatic
artery 18, 114
common 4, 47–50
left 79f
proper 48
right 79f, 112, 116f
hilar blocks
evaluation of 62
management of 62
parenchymal blood supply 115
vein 9, 97
pressure gradient 89
Hepaticojejunostomy, stricture of 119f
Hepatitis
acute 105
B 85
C 85
Hepatocellular carcinoma 85–87, 89, 91, 96f, 97, 98f
curative treatments for 85
selection of 87, 91
solitary 92f
Hepatoduodenal ligament 9, 9f
Hepatopancreatobiliary 76
Hilar bile duct 81, 117, 118
resection 76
conventional 76, 77f
Hilar blocks
benign lesions causing 70
causes of 70
Hilar cholangiocarcinoma 69, 68, 81, 83f
treatment of 76
Hilar malignancy, management of 78fc
Hilar plate resection 76, 77f, 79f
indication of 77
Hilar spreading 76
Hilum 118
of liver, collaterals in 117f
Hypertrophy, left 117f
Hypoproteinemia 63
I
Iliac vein graft, interposed 50
Inflammatory bowel diseases 104
Infracolic approach, inferior 2, 3f
Intrahepatic
biliary radicles 63
cholangiojejunostomy 81
Intraoperative blood transfusion 16
Intraoperative cholangiography 57
Invasive necrosectomy, minimally 55
J
Jaundice 62
Jejunal limb 12
Jejunum 4f, 81
everted 33
K
Kausch-Whipple procedure 27
Kocher's maneuver 2, 2f, 4f, 8, 10f, 21
performs 78
L
Laparoscope 55
Laparoscopic
cholecystectomy 112
debridement 57
pancreaticoduodenectomy 8
pylorus-preserving pancreaticoduodenectomy 8
Laparoscopically-assisted transperitoneal debridement 57
Liver 116f
arterial supply to 48
cancer 85
disease 86fc
chronic 85
ischemia 115
resection 88f
transplant
deceased donor 94t
programs 68
transplantation 70, 85, 88f, 91, 96f, 121
living donor 86, 87, 95t, 96f
Lobe
necrosis of right 116f
of liver
left 115f
perfusion of right 115f
right 115f
with atrophy, right 116f
Lymph node 106
clearance 8, 9f
status 108
M
Mesenteric
approach 3f
arterial supply, superior 32
artery
advantages of superior 5
superior 2f, 1, 4f, 6, 8, 11, 12, 18, 22, 48f, 50
vein, superior 1, 3f, 8, 12, 18, 32, 50
vessels 17
Metabolic complications 28
Microvascular invasion 97
Mirrizzi's syndrome 70, 71
Mucocele 62
Mucosal layer 81
Multidetector computed tomography 97
N
Necrosectomy
classification of 55
open surgical 56
techniques of 55
timing of 54
Necrotic tissue 59
Neoadjuvant
chemoradiotherapy 70
chemotherapy 66
therapy, role of 70
Nephroscope 55
Nerve
plexus 11f
sheath 11f
Neuroendocrine carcinoma 15
Nonalcoholic fatty liver disease 85
Noncirrhotic livers 87
Nontherapeutic laparotomy 66
O
Organ dysfunction syndrome, multiple 55
P
Palliative intention 78
Pancreas 12f
stump of 9
vascular supply of 32
Pancreatectomy 50f
distal 47, 48f, 49f
total 28
Pancreatic
body 19
cancer, advanced 47
debridement, complications after 59
duct 26
dilated main 14f
drainage tube 80
main 14f
occlusion 28
fistula 16, 26
head 12f, 19
neck and body 5f
necrosectomy 53
necrosis 53
neuroendocrine carcinoma 15
parenchyma, normal 32
remnant
management of 26, 27, 39
vascular supply of 32f
stents 37f
external 37f
internal 37f
stump management, anatomy-specific 33, 34f
Pancreaticobiliary duct, anomalous junction of 104
Pancreaticoduodenal arcade 48f
anterior 48
posterior 48
Pancreaticoduodenal artery
inferior 11
posterior superior 114
Pancreaticoduodenectomy 1, 6, 18, 26, 27, 65
practice of 1
reconstruction in 18
Pancreaticoenteric anastomosis 31, 37f, 38
methods of 39
Pancreaticoenteric leakage 30
Pancreaticogastric anastomosis 35
Pancreaticogastrostomy 16, 28, 29f, 30f, 35, 36, 38f
binding 32, 33f, 36, 37f
Pancreaticojejunostomy
conventional 28
mesh reinforcement of 34
technique of 32
Pancreatitis, acute 53
Parenchyma-preserving hepatectomy 76
Percutaneous
approach 58
ethanol injection 86
transhepatic biliary drainage 64, 121
Peripancreatic necrosis 53
Pigtail stents 58
Portal hypertension 85, 105, 117, 117f
Portal mesenteric vein 1
Portal vein 8, 9, 11, 13, 18, 22, 32, 49, 97
embolization 89
exposure of 10f
Porta-systemic shunt 120
Ports placement 9f
Post-cholecystectomy pseudoaneurysm 116f
Postneoadjuvant chemotherapy 6
Prerenal azotemia 63
Pseudoaneurysm 115, 118
Pseudopapillary tumor, solid 15
R
Radiofrequency ablation 93
Reconstruction techniques, types of 21
Red vessel loop 4f
Remnant liver, future 89
Renal vein 50
Resectable disease 47
Retrocolic fashion 12
Retroperitoneal debridement, video-assisted 57
Rubber-tipped forceps, small 80
S
Salvage liver transplantation, strategy of 98
Seromuscular layer of jejunum 13f
Splenic
artery 48, 49
vein 22, 22f, 49
Squamous cell 104
Stomach, arterial supply to 48
Supracolic approach, inferior 3, 4f
Systemic comorbidities, severe 78
T
Transarterial chemoembolization 86, 93
Transjugular intrahepatic shunt 121
Transluminal puncture 58
Transplant protocol 70
Trisegmentectomy, right 64
Tumor
adherence 20
recurrence after resection, managing 90
U
Umbilical portion 77
Uncinate process dissection, medial 2, 3f
Unresectable disease 47
V
Vascular endothelial growth factor 109
Vascular injury 114, 115f, 116f
Vascular resection 18
Vein 4f
Vena cava, inferior 10, 12, 49, 50, 97
X
Xanthogranulomatous cholecystitis 71, 105
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Superior Mesenteric Artery First in Pancreaticoduodenectomy: When and How?CHAPTER 1

Savio G Barreto,
Jagpreet Singh Deed,
Mahesh Goel,
Shailesh V Shrikhande
 
INTRODUCTION
Not only has the practice of pancreaticoduodenectomy (PD) changed since the first description of the two-staged procedure by Kausch and Whipple,1–3 but so has the principles of the surgery. While vascular invasion was generally regarded as a contraindication to the performance of PD for pancreatic cancer, today these reservations are restricted mainly to arterial involvement.4,5 Venous (portal and superior mesenteric vein) resections and anastomosis with or without an interposed graft are being performed the world over in centers with experience in these procedures.4,6
Although advances in imaging permitted adequate preoperative staging for pancreatic cancer, evolving clinical practices in its management (use of neoadjuvant chemoradiotherapy) along with increased surgical aggression have spawned the birth of a new subclass of potentially resectable cancers now known as “borderline-resectable” disease.7 These tumors were once considered “locally advanced” and not amenable to a curative resection. Current imaging modalities are unable to precisely determine if a complete resection can be achieved in these tumors following neoadjuvant therapy8 necessitating a trial resection.
The “artery-first” approach9 is a useful technique to determine early on in the course of PD, whether the superior mesenteric artery (SMA) is involved or not—hence determining resectability. However, this is not the only advantage of the approach. Other authors have indicated that the technique may improve lymph node retrieval, reduce operative time, and even blood loss.10 This chapter will provide the various approaches described in literature of the SMA-first technique along with its advantages while highlighting the authors’ own experience.
 
Superior Mesenteric Artery: First Technique
The technique of “posterior approach” was described in the context of PD by Pessaux et al.11 in 2003, and for the first time in English literature, in 2006.12 The description of the posterior approach was followed by various other 2approaches, each providing a specific indication for the modification. A total of six approaches have been described9 and are provided here:
  1. Posterior approach:12 This technique involves an exposure of the origin of the SMA after a liberal Kocher maneuver followed by division of its surrounding connective tissue to enable a caudal dissection of the artery behind the pancreatic head and to where it crosses the duodenum. By dividing the attachments between the SMA and uncinate process, the origins of the superior and inferior pancreaticoduodenal arteries can be identified and divided (Fig. 1.1).
  2. Medial uncinate process dissection: This approach, described as one here, essentially involves two techniques described by two groups.13,14 It involves a liberal Cattell–Braasch maneuver, followed by a liberal Kocher maneuver until the aorta as well as the superior mesenteric vessels are seen crossing the duodenum. Following the division of the ligament of Treitz, the duodenojejunal flexure is mobilized and the proximal jejunum is divided and delivered into the supracolic compartment facilitating not only the visualization of the SMA but also a dissection of the uncinate owing to the SMA being in view (Fig. 1.2).
  3. Inferior infracolic or mesenteric approach: By this technique,15,16 the SMA is approached in the infracolic compartment at the root of the transverse mesocolon and the dissection proceeds cranially. The duodenojejunal flexure is dissected, the inferior mesenteric vein is dissected, and on following the middle colic artery, the inferior pancreaticoduodenal arteries are dissected and divided (Fig. 1.3).
  4. Left posterior approach:17 After performing a Kocher maneuver of the duodenum to expose the origin of the SMA, the proximal jejunum is pulled to the left to permit division of the first and second jejunal arteries followed by the inferior pancreaticoduodenal artery. This is followed by clearance of the rest of the SMA and then the division of the first jejunal branch of the SMV. This facilitates dissection of the SMV up until its confluence with the splenic vein (Fig. 1.4).
    zoom view
    Fig. 1.1: Intraoperative photograph depicting the exposure for the “posterior approach”. A complete Kocher maneuver has been performed to expose the origin of the superior mesenteric artery from the abdominal aorta (indicated by the forcep).
    3
    zoom view
    Fig. 1.2: Intraoperative photograph depicting the “medial uncinate process dissection”. Dissection along the medial margin of the uncinate process (indicated by the red curve) permits its distraction laterally facilitating the visualization and dissection of the superior mesenteric artery (indicated by the white arrow). The neck of pancreas is indicated by the black arrow.
    zoom view
    Fig. 1.3: Intraoperative photograph depicting the “inferior infracolic or mesenteric approach”. The large triangular-shaped defect in the transverse mesocolon is noted. The neck of pancreas is slung with a yellow loop and the superior mesenteric artery with a red loop. Retraction of the large pancreatic head tumor to the right demonstrates an involvement of the superior mesenteric vein (white arrow) by the tumor.
  5. Inferior supracolic (anterior) approach:18 Following division of the gastrocolic omentum, the stomach is retracted cranially enabling division of the pancreatic neck to expose the superior mesenteric-portal venous junction. A “hanging maneuver” is then performed by looping a tape from the right side of aorta and the origins of the celiac axis and SMA, to the common hepatic artery. This enables division of the neural tissue and lymphatic laden retroperitoneal tissue. A reverse Kocher maneuver is then performed from left to right deep to the Gerota's fascia but anterior to the right renal vein and inferior vena cava (Fig. 1.5).
    4
    zoom view
    Fig. 1.4: Intraoperative photograph depicting the “left posterior approach” in which the after Kocher maneuver has been performed, the jejunum is pulled to the left to demonstrate the superior mesenteric artery is slung with a red vessel loop.
    zoom view
    Fig. 1.5: Intraoperative photograph depicting the initial steps of the “inferior supracolic approach” where the superior mesenteric artery and vein have been slung with red and blue vessel tapes, respectively, after dividing the gastrocolic omentum and retracting the stomach cranially (with the metal retractor). The neck of pancreas is indicated with a white arrow.
  6. Superior approach: After division of the hepatoduodenal ligament and exposing the gastroduodenal and common hepatic arteries, the SMA is approached by dissecting in the perineural and lymphatic tissue after removing the anterior lymph nodes. This technique is useful especially in tumors of the neck and body of the pancreas (Fig. 1.6).
5
zoom view
Fig. 1.6: Axial section of contrast-enhanced computed tomography scan depicting a large tumor in the pancreatic neck and body (white arrow) that would be ideally suited for the “superior approach”.
 
THE TATA MEMORIAL CENTRE EXPERIENCE
At the Tata Memorial Centre, we have been using the medial or uncinate process for many years.14
Since 2009, we adopted the posterior approach and published our experience of 44 patients—30 by the left “posterior” approach and 14 by the medial or uncinate process approach.19 The outcomes in the two groups were comparable in terms of median hospital stay (14 vs 12.5 days), and median lymph nodes dissected (8 vs 9). The morbidity rate was higher in the left “posterior” approach (40%) as compared to the medial or uncinate process approach (14%), although the difference was not statistically different.
 
ADVANTAGES OF THE SUPERIOR MESENTERIC ARTERY: FIRST APPROACH
The SMA-first technique may have application as a routine procedure in all cases of PD, as it helps the surgeon to decide the most important aspect of the procedure, which is resectability,10,12,20–24 by initially dissecting the SMA. However, the most common indications/recommendations for using SMA-first technique by various authors are as follows:
  • Suspected involvement of SMA21,24—where the approach permits an early decision of unresectability.
  • Anatomical variations especially right hepatic artery arising from SMA21,23–26—where the approach permits easier identification and safeguarding of anatomical variations.
  • Involvement of SMV or need of venous resection/reconstruction.23,24
  • Suspected neck of pancreas involvement, where body rather than neck may need to be transected due to involvement of neck.22–24,27–29
  • Postneoadjuvant chemotherapy patients for locally advanced disease.21
6Other proposed advantages of utilizing SMA-first technique for PD are its ability to enable an adequate lymphadenectomy11,12,22 and its utility when resection of pancreatic body rather than neck is required (due to neoplasm extending from the head to the body, or encasement of the portomesenteric junction by a head or neck tumor).23,24 A significantly reduced operative time and intraoperative blood loss has been reported by Dumitrascu et al.10 while Pessaux et al.21 reported better hemostasis by using their “hanging technique”. Another important application of this technique is the ease of doing vascular resections with a shorter period of venous clamping, reconstruction without the need of venous graft, with the least amount of bowel congestion, and allowing a “no-touch” resection with no intraportal tumor dissemination.10,21,22,25,27,28
However, to date, majority of the data on outcomes of the SMA-first technique comes from cohort or case-matched series. In the absence of high level evidence, the role of the SMA-first technique in PD continues to evolve.
 
CONCLUSION
Various approaches of superior mesenteric artery (SMA) first during pancreaticoduodenectomy would be good armamentarium for surgeons though its oncologic advantage needs yet to be determined.
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