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Prof. A. FOUAD. By AMGAD FOUAD Professor Of Surgery Gastroenterology Center Gastroenterology Center...
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Transcript of Prof. A. FOUAD. By AMGAD FOUAD Professor Of Surgery Gastroenterology Center Gastroenterology Center...
ByBy
AMGAD FOUADAMGAD FOUAD Professor Of SurgeryProfessor Of Surgery
Gastroenterology CenterGastroenterology CenterMansoura University.Mansoura University.
PRINCIPLES OF PANCREATIC PRINCIPLES OF PANCREATIC
RESECTION RESECTION
Prof. A. FOUADProf. A. FOUAD
The pancreas is an endocrine & exocrine The pancreas is an endocrine & exocrine
organ and both of these functions should be organ and both of these functions should be
kept in mind during pancreatic surgerykept in mind during pancreatic surgery
Pancreatectomies continue to be one of the Pancreatectomies continue to be one of the
major operations performed by surgeonsmajor operations performed by surgeons
Fortunately the difficulties with the operation Fortunately the difficulties with the operation
and the dismal cure rate have been and the dismal cure rate have been
improved. improved.
Prof. A. FOUADProf. A. FOUAD
Topographic Relationships of Topographic Relationships of surgical importancesurgical importance
1.1. The length of the Retroduod CBD allow for The length of the Retroduod CBD allow for
adequate subsequent sectioningadequate subsequent sectioning
2.2. The hepatic flexure of the colon overlies The hepatic flexure of the colon overlies
some of the 2some of the 2ndnd and 3 and 3rdrd portion of the portion of the
duodenum.duodenum.
3.3. The root of the transverse mesocolon is The root of the transverse mesocolon is
related directly to the head of pancreas.related directly to the head of pancreas.
4.4. The 3The 3rdrd part of the duodenum passes under part of the duodenum passes under
the SMVs and over the Aortathe SMVs and over the Aorta
Prof. A. FOUADProf. A. FOUAD
Adequate ExposureAdequate Exposure
Midline incision : easyMidline incision : easy
BloodlessBloodless
Transverse incision: good accessTransverse incision: good access
Extended Rt subcostal incisionExtended Rt subcostal incision
Proper accessProper access
Good visulaizatrionGood visulaizatrion
Good assessmentGood assessment
Prof. A. FOUADProf. A. FOUAD
Assessment of operability and / Assessment of operability and / or resectabilityor resectability
The root of Tr mesocolon is divided as it cross The root of Tr mesocolon is divided as it cross
over the Rt kidney & the 2over the Rt kidney & the 2ndnd portion of the portion of the
duodenumduodenum
Dissection along the lower border of the Dissection along the lower border of the
pancreas is conductedpancreas is conducted
If the tumour has affected the SMVs the tumor If the tumour has affected the SMVs the tumor
is considered non-resectable & the procedure is considered non-resectable & the procedure
is abandoned.is abandoned.
Prof. A. FOUADProf. A. FOUAD
Vascular ControlVascular ControlThe most difficult aspect of the operation is to The most difficult aspect of the operation is to control bleeding especially from the tributaries of control bleeding especially from the tributaries of the SMVs & Vthe SMVs & V
Hepatic artery Hepatic artery → → Gastro duodenal artGastro duodenal art
SUP . PD artSUP . PD art
++SUP M.A SUP M.A →→ Inf PD artInf PD art
It is important to remember the numerous It is important to remember the numerous anatomic variations that may be presentanatomic variations that may be present
Prof. A. FOUADProf. A. FOUAD
Further assessmentFurther assessment
The lat parietal peritoneum is incised The lat parietal peritoneum is incised
and the duod is mobilizedand the duod is mobilized
The SMVs & IVC now can be further The SMVs & IVC now can be further
examined for tumour involvementexamined for tumour involvement
Bx of questionable mass Bx of questionable mass
(Controversial)(Controversial)
Prof. A. FOUADProf. A. FOUAD
CBD DivisionCBD DivisionThe CBD is circumferentially dissected The CBD is circumferentially dissected then encircled with a small rubber sling then encircled with a small rubber sling to retract it away from the portal vein to retract it away from the portal vein prior to with divisionprior to with division
The next step involves division of the The next step involves division of the GDA thus exposing the PVGDA thus exposing the PV
It is then decided whether the tumour is It is then decided whether the tumour is non-resectable non-resectable (PV invasion)(PV invasion) or that the or that the operation must be terminated for other operation must be terminated for other reasonsreasons
Prof. A. FOUADProf. A. FOUAD
The next step involves passing a small The next step involves passing a small
soft rubber drain under the body of the soft rubber drain under the body of the
pancrease just to the left of SMApancrease just to the left of SMA
This is the safest way to avoid injury of This is the safest way to avoid injury of
the small Vs and also coincides with the the small Vs and also coincides with the
optimum site of division of the pancreasoptimum site of division of the pancreas