Whipple surgery

Whipple surgery is used for pancreaticoduodenectomy. Treatment of diseases: duodenal carcinoid pancreatic cancer Indication Whipple surgery is available for: 1, the middle and lower stages of the common bile duct cancer. 2, lack of cancer around the ampulla. 3. Duodenal malignant tumors. 4, pancreatic head cancer early. 5, severe pancreaticoduodenal injury. Contraindications 1. There has been extensive metastasis in the abdominal cavity. 2. Pancreatic cancer invades the mesenteric vessels. 3, severe malnutrition, severe obstructive jaundice, poor general condition, 70 years of age or older, vital organ function decline, can not withstand major surgery. Preoperative preparation 1. Examination of important organs such as heart, lung, liver and kidney. 2, chest X-ray film to exclude metastatic lesions. 3. Inject vitamin K to increase prothrombin activity. 4. Correct the electrolyte imbalances such as low potassium and low sodium. 5. For those who have obvious malnutrition due to too little food intake, intravenous nutrition is added 1 week before surgery to transfer whole blood and plasma to correct anemia and hypoproteinemia. 6. For patients with obstructive jaundice, oral bile salt preparations are given 1 week before surgery to reduce bacterial growth in the intestine. 7. Serve ranitidine 150mg before surgery to reduce stomach acid. 8. Apply prophylactic antibiotics. 9, serum bilirubin > 171mol / L patients, the physical condition is still suitable for surgery, do not emphasize the routine use of preoperative transhepatic biliary drainage (PTBD) to reduce jaundice, if PTBD has been done, should pay special attention to due to a large number of Electrolyte disorders caused by loss of bile, usually performed 2 to 3 weeks after drainage, to prevent biliary infection caused by PTBD. Percutaneous transhepatic gallbladder drainage can also achieve the same goal. In the case of the condition, it is feasible to introduce the drainage through the endoscope before the operation, and insert a thicker special built-in drainage tube through the common bile duct opening to the upper of the obstruction, so that the patient's condition can be improved quickly. 10. Place the gastrointestinal decompression tube before surgery. Surgical procedure 1. The surgical incision can be determined according to the surgeon's habits. There are two commonly used incisions. One is the oblique incision under the right costal margin, which is about 2 cm lower than the general cholecystectomy incision. It extends across the midline and extends to the left upper abdomen. The falciform ligament and the round ligament are pulled upward. 2, due to bile duct, pancreas, duodenal lesions surgery, although there are more imaging diagnostic data before surgery, but in the laparotomy, still need to be diagnosed to determine the surgical plan and steps. 3, incision of the duodenal lateral peritoneum, the second segment of the duodenum together with the pancreatic head from the retroperitoneal forward, that is, Kocher technique to further explore the posterior aspect of the pancreas. 4, free duodenum and pancreas head, can explore the relationship between the mass and the inferior vena cava and abdominal aorta, and explore whether there is lymph node metastasis behind the head of the pancreas; there is very little retroperitoneal tissue in the early stage of cancer around the ampulla Invasion, but in the head cancer of the pancreas, retroperitoneal tissue infiltration and inferior vena cava wall infiltration may occur, indicating that the tumor has exceeded the scope of possible radical resection. 5. Free transverse colonic hepatic flexure and the right end of the transverse colon to dissociate the second and third segments of the duodenum forward, further examining the relationship between the pancreatic head, the uncinate process and the mesenteric vessels. Peripheral cancer of the ampulla usually has vascular invasion in the late stage, while pancreatic cancer can invade the portal vein early. The cancer originating from the uncinate part can surround the mesenteric blood vessel. B-ultrasound exploration during surgery is more helpful in determining the relationship between the head mass of the pancreas and the mesenteric vessels and the portal vein. 6. Cut the omentum on the upper edge of the transverse colon, attach or cut the gastric colon ligament in the transverse colon, open the small omental sac, hook the stomach upward, expose the front of the entire pancreas, and examine the changes of the pancreas and the mass. Relationship. Pancreatic head cancer often has uneven and hard head enlargement, while the tail of the pancreas is fibrotic and atrophic, sometimes from the surface of the pancreas to the dilated pancreatic duct depression; and the head swelling caused by chronic pancreatitis Large, the tail of the pancreas often shows an increase in consistency, and the pancreas and its surrounding tissues have changes in inflammation and edema. However, these conditions are not used as a basis for qualitative diagnosis, as they can often be combined. The lower common bile duct cancer and duodenal cancer do not affect the drainage of the pancreatic duct, so the pancreas can be close to normal and the pancreatic duct does not expand. 7. When it is decided to perform pancreaticoduodenectomy, the corpus corpus is generally first traversed. It is estimated that the amount of gastric resection is about 50%, together with the lymph nodes of the omentum and pyloric area. The treatment of the proximal stomach is generally after carefully ligating the blood vessels under the mucosa, and the small curved side of the broken end is sutured closed, and the stomach jejunum anastomosis is performed according to the Hoffmeister procedure; the distal end of the stomach is turned to the right side, and then the stomach is cut. Left blood vessel, right gastric artery, small omentum. 8. According to the pulsation of the artery, the common hepatic artery and the hepatic artery are separated, and the lymphatic-a fat tissue surrounding the artery is separated and excised together with the pancreas and the duodenum. 9, under normal circumstances should be removed together with the gallbladder, the bile duct is cut off in the common hepatic duct, and the jejunum is anastomosed. Sometimes for the earlier ampullary carcinoma, there is also a bile duct at the common bile duct, and no cholecystectomy is performed; however, when the cystic duct is open at a low position, the gallbladder must be removed. Long-term obstruction of the lower common bile duct, gallbladder enlargement, wall thickness, congestion, edema, and removal of the gallbladder are often the steps of greater trauma and more blood loss. 10. After the bile duct is cut off, the lymphatic tissue next to the bile duct is separated downward, the distal end of the bile duct is sutured, and the loose fibrous tissue outside the portal vein is cut, so that the portal vein is clearly revealed. By separating down the front of the portal vein, it can be joined with a finger or long curved vascular clamp that is separated upward from the superior mesenteric vein. 11. In the superior and inferior margin of the superior mesenteric vein, the upper and lower edges of the pancreas are sewed with a medium thick thread, and are ligated for hemostasis and traction. Another thick silk thread is introduced on the back of the pancreatic neck to ligation to the head of the pancreas to control the pancreas. Bleeding from the head of the pancreas. 12. Gradually cut the pancreas on the left side of the superior mesenteric vein, and notice the location of the pancreatic duct. The distal end of the pancreatic duct is generally about 0, 3 cm long, and a traction line is sewn with a 3-0 silk thread for subsequent searching and processing. After the pancreas is completely cut, a suitable rubber catheter or silicone rubber tube with a side hole is placed at the distal end of the pancreatic duct. The hemorrhage on the pancreatic section is carefully sutured by silk thread, and the pancreatic stump is first interrupted. Stitching to reduce leakage of pancreatic juice, and then suture the closed margin. Non-absorbent sutures are required for hemostasis and suturing used on the pancreas. Premature degradation of the gut under the action of trypsin can cause secondary bleeding and pancreatic leakage. 13. Turn the distal end of the stomach and the head of the pancreas to the right side, revealing the splenic vein, superior mesenteric vein and portal vein. The veins that drain the blood of the pancreatic head and the uncinate process merge to the right and posterior sides of the portal vein and superior mesenteric vein. There are large pancreatic superior and inferior pancreatic veins, and there are also a number of small venous branches. Lightness and patience are required to ligature and cut these venous branches. These veins can be cut between two filaments. If the isolated veins are short, the 4-0 non-invasive vascular suture can be used to ligature through the outer sheath at the portal vein and mesenteric vein. The pancreatic end can be clamped and then sewed through the seam. Here the blood vessel wall is thin, avoid using a vascular clamp clamp, otherwise it is easy to tear or damage the portal vein or superior mesenteric vein to cause bleeding. Generally, it is separated from the surrounding tissue by a mosquito hemostat, and the two filaments are ligated and cut. After the vein branch is treated here, the portal vein and superior mesenteric vein can be separated from the pancreatic head and its uncinate portion. 14. Lift the transverse colon, find the upper end of the jejunum, cut the Treitz ligament, free the proximal jejunum, cut the jejunum 10 to 15 cm away from the Treitz ligament, the distal suture is closed, and the proximal end is temporarily ligated with thick lines, pulling from the back of the small mesentery. To the right. After gradually separating, ligating, and cutting off some of the drainage venous branches, the portal vein and the necroposis of the pancreatic head are separated. 15. The distal end of the stomach, the head of the pancreas, the duodenum, and the upper end of the jejunum are pulled to the right side, and the portal vein is pulled to the upper left by the portal vein to expose the superior mesenteric artery. In order to completely remove the anterior segment of the pancreatic head, the fibrous sheath is usually cut along the anterior longitudinal line of the superior mesenteric artery; if it is slightly separated, the mesenteric membrane of the uncinate process can be clearly separated, and then the operator's left hand four fingers After feeling the pulsation and the direction of the superior mesenteric artery, the thumb retracts the uncinate part of the pancreas and senses the lower pancreaticoduodenal artery. Outside the pancreatic parenchyma, the mesenteric is clamped, cut, and ligated from top to bottom. The relationship between the superior artery and the pancreas, the pancreaticoduodenal artery is ligated and cut, and sometimes the anterior and posterior branches are ligated separately. Finally, the lower pancreaticoduodenal vein is cut and the upper jejunum is treated. Except for the whole piece of tissue that was cut. complication Gastrointestinal bleeding after surgery is more common and can be derived from: 1 gastrointestinal anastomotic bleeding; 2 stress ulcers, hemorrhagic gastritis; 3 anastomotic ulcer bleeding is rare; 4 Bleeding from the blood vessels of the pancreas or other places penetrates into the intestine. In the case of postoperative upper gastrointestinal bleeding, a fiberoptic gastroscopy should be performed to find the source of the bleeding. If the amount of bleeding is too large to stop in time, hemostasis should be performed again. The author once encountered a case of a large amount of hemorrhage due to the collapse of the gastroduodenal artery and the formation of a pseudoaneurysm that broke into the jejunum. The patient was able to recover from the hepatic artery and the proper hepatic artery.