Pancreatic and hepatic surgery

Summary

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.

Pancreatic surgery

Anatomy of the pancreas

See “Pancreas.”

Types of pancreatic surgeries

Overview of pancreatic surgery types [1][2]
	Type	Indications	Surgical procedure
Pancreatic resections	Pancreaticoduodenectomy (Whipple procedure)	Periampullary tumors [3] Chronic pancreatitis	Resection Distal stomach (antrum and pylorus) Entire duodenum 15 cm of the proximal jejunum Head of the pancreas Gall bladder and the CBD Anastomoses Pancreaticojejunostomy Hepaticojejunostomy Gastrojejunostomy Enteroenterostomy
	Pylorus-preserving pancreaticoduodenectomy (modified Whipple procedure)	Same as Whipple procedure [4]	Same as Whipple procedure, except that the distal stomach is not resected
	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 [5]	Benign lesions in the neck/body of the pancreas Pancreatic trauma	Neck and body of the pancreas is resected. The tail is anastomosed to the jejunum.
	Total pancreatectomy [6]	Malignant pancreatic lesions Chronic pancreatitis Multiple metastasis from a RCC	The entire pancreas, together with the duodenum, is resected. Anastomoses: hepaticojejunostomy and gastrojejunostomy Islet cell autotransplantation
	Enucleation [7]	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) [8]	Complicated acute pancreatitis with infected necrosis Sterile necrosis not responding to conservative therapy	All dead and necrotic tissue are removed (debridement).
For chronic pancreatitis	Duodenum-preserving pancreatic head resection (Beger procedure) [9]	Chronic pancreatitis with a benign inflammatory mass in the head of the pancreas (not responding to conservative therapy). [10][11]	Head of the pancreas is resected at the level of the superior mesenteric vein. Pancreaticojejunostomy
	Lateral pancreaticojejunostomy + resection of the pancreatic head (Frey procedure)	Chronic pancreatitis with dilated main pancreatic duct > 5 mm and an inflammatory mass in the head	The pancreatic head is resected and the dilated duct is opened length wise. Anastomosis: lateral pancreaticojejunostomy
	Lateral pancreaticojejunostomy (Puestow procedure)	Chronic pancreatitis with a dilated main pancreatic duct > 5 mm without an inflammatory mass in the head [9] Pancreas divisum with dilated main pancreatic duct	Same as Frey's procedure, but without the pancreatic head resection
For pancreatic pseudocysts	Pseudocyst-gastrostomy (cystogastrostomy) Pseudocyst-duodenostomy (cystoduodenostomy) Pseudocyst-jejunostomy (cystojejunostomy)	Complicated or symptomatic pseudocysts (see pancreatic pseudocysts)	The cyst is drained into the stomach, duodenum or jejunum
For pancreatic fistulae	Fistulojejunostomy Pancreatic resection (e.g., distal pancreatectomy for distal duct disruption) [3]	Failure of conservative and endoscopic management [12]	Fistulojejunostomy: The fistulous tract is excised up until the pancreatic origin; a loop of jejunum is then sutured to the affected part of the pancreas. Distal pancreatectomy: see above

Important abdominal and inguinal incision sites and potential indications Pancreaticoduodenectomy (Whipple procedure)

Complications

Delayed gastric emptying/gastroparesis (most common) [13][14]
Pancreaticojejunostomy
anastomotic leak/pancreatic ductal disruption → leakage of pancreatic secretions into the abdominal cavity which leads to:

Hyperchloremic acidosis

Pancreatic fistula

Pancreatic pseudocyst

Pancreatic ascites
Hepaticojejunostomy anastomotic leak → biliary peritonitis
Exocrine pancreatic insufficiency [14]
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.

**Pancreaticoduodenectomy (Whipple procedure)**
(1) Preoperative situation: The grey mass represents a tumor in the pancreatic head. The structures depicted as transparent are resected.
- Distal stomach (antrum and pylorus)
- Entire duodenum
- ∼ 15 cm of the proximal jejunum
- The pancreatic head with the distal pancreatic duct
- The gall bladder and the CBD
(2) Post-operative situation: Four anastomoses are created.
- Pancreaticojejunostomy (I)
- Hepaticojejunostomy (II; common hepatic duct is sutured to the jejunum)
- Gastrojejunostomy (III)
- Enteroenterostomy (IV; between the afferent and efferent jejunal loop)
The blind proximal end of the jejunum is closed (red line).

© AMBOSS

**Principles of the pylorus-preserving pancreaticoduodenectomy (Traverso-Longmire procedure)**
The Transverso-Longmire procedure is a modification of the Whipple procedure that preserves the gastric antrum, the pylorus, and a small part of the duodenum to provide a more physiologic stomach emptying.

Image 1 outlines the preoperative situation and allows for a direct comparison with the postoperative situation in image 2. Organs to be resected are shown in lighter colors (1).

Green to red line:
- Partial duodenectomy preserving the proximal duodenum including the pylorus (1)
→ End-to-side duodenojejunostomy and blind ending of proximal jejunum (2)

Blue line:
- Resection of pancreatic head (1)
→ End-to-side pancreaticojejunostomy (2)

Yellow line:
- Resection of gall bladder and bile duct
→ Hepaticojejunostomy

© AMBOSS

**Important abdominal and inguinal incision sites and potential indications**
The choice of incision site depends on the indication for and urgency of surgery.

© AMBOSS

Hepatic surgery

Anatomy of the liver

See “Liver.”

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

Pringle Maneuver

Types of liver resections [15]

Overview of liver resection types
	Type	Indications	Contraindications	Surgical procedure
Anatomical resections	Right hepatectomy (right hemihepatectomy)	Hepatocellular carcinoma Secondary metastasis in the liver (e.g., metastasis from colorectal carcinoma, neuroendocrine tumors) Symptomatic benign liver tumors (focal nodular hyperplasia, hepatic hemangioma, hepatocellular adenoma) Symptomatic hepatic cysts Deep liver lacerations or parenchymal avulsions [16]	Child class C liver cirrhosis Low future liver remnant (FLR) [17] Child class B liver cirrhosis with FLR < 40% Non-alcoholic steatohepatitis with FLR < 30%	Segments V, VI, VII, and, VIII are removed.
	Right hepatectomy (right hemihepatectomy)			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 [18][19]
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.

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