Whipple surgery

Whipple surgery is used for pancreaticoduodenectomy. Treatment of diseases: primary duodenal malignant lymphoma pancreatic cancer Indication Whipple surgery is suitable for: 1. Middle and lower stages of common bile duct cancer. 2. There is no cancer around the ampulla. 3. Duodenal malignant tumor. 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, advanced age over 70 years old, decline in vital organ function, and inability to withstand major surgery. Preoperative preparation 1. Examination of vital organs such as heart, lung, liver and kidney. 2. Chest X-ray 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 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. Patients with serum bilirubin >171mol/L, the physical condition is still suitable for the operator, do not emphasize the routine use of preoperative transhepatic biliary drainage (PTBD) to reduce jaundice, if PTBD has been done, special attention should be paid to 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. The incision is parallel to the axis of the pancreas, and the augmented bead automatically retractor can be used when necessary to maximize the exposure of the surgical field. We use this incision more often; another commonly used incision is a right incision in the right upper abdomen. The incision must be long enough to be fully exposed, so it often needs to be extended to about 4 cm below the umbilicus, and a transverse incision may need to be added to the left side for convenient operation. Straight incisions are often difficult for patients with obesity. In addition, there is also a transverse incision in the upper abdomen, and the surgical field is also better. 2. Due to the operation of bile duct, pancreas and duodenal lesions, although there are more imaging diagnostic data before surgery, in the laparotomy, re-diagnosis is needed to determine the surgical plan and procedure. Intraperitoneal exploration should pay attention to the presence or absence of peritoneal, pelvic, omentum, liver, hepatoduodenal ligament, peri-pancreas, peri-peri-valvular artery, mesenteric root, and para-aortic lymph node metastasis. Although tumors of different origins have slightly different routes and ranges of metastasis, when there is distant metastasis, it indicates that it is advanced, and it is impossible to perform radical surgery. For tumors with high malignancy, it should be used instead. Simpler palliative surgery. If a metastatic nodule is found in the abdominal cavity, the tissue should be taken for pathological examination of the frozen section. At present, there are still claims to perform laparoscopy before laparotomy. If metastasis is found, unnecessary laparotomy can be avoided. The transverse colon is lifted to check for the direct invasion of the transverse mesenteric root, the mesenteric root, and the lower edge of the pancreas with or without metastatic lymph nodes or tumors. Because of the above-mentioned metastasis or tumor invasion, pancreatic uncinate and body-tail cancers often occur. When the pancreas and the ampulla are surrounded by cancer, the gallbladder and extrahepatic bile ducts are obviously dilated. It is often necessary to puncture the suction at the bottom of the gallbladder to reduce the tension, which is beneficial to the exploration. 3. Incision of the duodenal lateral peritoneum, the second segment of the duodenum along with the pancreatic head from the retroperitoneal forward, that is, Kocher technique to further explore the posterior aspect of the pancreas. There is a normal anatomical space between the duodenum and the posterior and posterior retroperitoneal structures. When the pancreatic cancer has no pancreatic invasion to the peripancreatic tissue, as long as it does not deviate from this gap, the fingers can be bluntly separated and separated from some loose. Connective tissue, the duodenum and the pancreas can be released from the retroperitoneum, the free range to the left should reach the front of the abdominal aorta, the third segment of the duodenum should be free, so the front of the transverse mesentery needs to be cut leaf. Once the duodenum and pancreatic head are free, they can be lifted into the shallow part of the abdominal surgery field for further exploration and subsequent surgical procedures. Then the operator uses the left hand to indicate the finger and the middle finger behind the duodenum, with the thumb in front of it, touching the mass at the lower end of the common bile duct, the ampulla and the head of the pancreas, and paying attention to its nature and its relationship with the adjacent structure. 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. For the mass located at the lower end of the common bile duct and the ampulla, it is necessary to further determine its nature. The most important thing is to judge whether it is a benign lesion or a malignant lesion. In benign lesions, the incarcerated calculus of the ampulla and the pancreatic head induration of chronic pancreatitis should be considered. Most of the tumors of the nipple and duodenum can be determined by preoperative endoscopy and biopsy. Incarcerated stones are characterized by hard texture when touched, clear boundary with surrounding tissues, and no change in invasiveness. In the case of difficult discrimination, the mass can be fixed with the left thumb and thumb, and then directly puncture with a 20-gauge needle. If the needle encounters the feeling of hard objects and the core is blocked by stone slag, the diagnosis of the stone can be determined. However, it should be noted that both the lower bile duct cancer and the pancreatic head cancer can be combined with gallstones and/or common bile duct stones. Therefore, after the bile duct exploration is performed to remove the stones, it is still necessary to check whether there is a coexistence between the two, and When necessary, the tissue was taken at the obstruction site for cryosection examination. In the literature, there are reports of misdiagnosis of the incarcerated calculi at the lower end of the common bile duct for cancer and pancreaticoduodenectomy. It should be cited as training. Chronic duodenal ulcer may penetrate into the head of the pancreas to form an inflammatory mass. Endoscopy before surgery can generally make a diagnosis, but it is also mistaken for pancreatic head cancer and pancreaticoduodenectomy. Report. For lesions of the nipple and duodenum, if the diagnosis is not confirmed before surgery, it can also be diagnosed by incision of the duodenum and pathological diagnosis. When cutting the duodenum, care must be taken to prevent the tumor cells from spreading in the peritoneal cavity. The identification of chronic pancreatitis and early pancreatic head cancer is sometimes the most difficult, because pancreatic cancer often has chronic pancreatitis. When the location of the cancer is deep, the pathological report of pancreatic biopsy results is mostly "chronic inflammation". The material is too shallow, but if it is deeper and proved to be chronic pancreatitis, pancreatic fistula is often formed in the biopsy after surgery, which increases the risk of pancreatic biopsy. The method of puncture needle biopsy can obtain deeper tissue, and can take multiple materials to increase the accuracy of diagnosis. If there are still doubts, it is currently preferred to have an experienced surgeon rely on the general findings to determine whether to perform pancreaticoduodenectomy. This is because in the eyes of experienced physicians, pancreaticoduodenectomy is a more common procedure, and the operative complication rate and mortality are lower, so it is difficult to distinguish early pancreatic cancer or chronic pancreatitis. Patients, rather than a more thorough pancreaticoduodenectomy. When a pathological diagnosis is necessary, the mass can also be fixed with the left thumb and thumb so that the biopsy needle can be inserted into the mass through the duodenum and the tissue is removed for pathology for cytological examination. This method of biopsy has fewer complications and can avoid pancreatic fistula, but it should be accompanied by a skilled pathologist. 5. Free the right side of the transverse colonic hepatic flexure and transverse colon to displace the second and third segments of the duodenum, 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. Whether the portal vein infiltration is used as a contraindication for pancreaticoduodenectomy, the opinions are still inconsistent. The author's opinion is that when only partial infringement does not hinder the operation, the portal vein wall can be partially removed and re-repaired or do the opposite end; as the side wall and the posterior wall of the portal vein are violated, the pancreas Digestive resection, although including the removal of the portal vein, does not effectively prolong the life of the patient or improve the quality of life, but increases the postoperative complication rate and mortality. In this case, it is advisable to switch to a more conservative surgical procedure. 6. Cut the omentum on the upper edge of the transverse colon, attach or cut the gastric collateral 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. Then, at the lower edge of the pancreas, according to the position of the superior mesenteric artery, the peritoneal layer and fibrous adipose tissue are cut, and some small venous branches that drain the blood of the pancreas are ligated, and the superior mesenteric vein can be reached by a little separation. Cut the loose tissue in front of the vein and continue to separate upwards. There is no vascular branch communication between the back of the neck of the pancreas and the portal vein, so it is easy to separate until the finger can extend along the front of the portal vein to the upper edge of the pancreas, indicating that the portal vein has not been invaded by the tumor. If there is chronic pancreatitis, the adhesion between the pancreas and the portal vein is tight, but it can still be separated. If there is invasion of pancreatic cancer, the adhesion is tight and firm, and the portal vein wall is thickened and cannot be separated from the pancreas. When it is difficult to find the superior mesenteric vein, it can be separated along the middle colon vein to reach the junction with the superior mesenteric vein, so that the superior mesenteric vein can be exposed more quickly. When the procedure is performed up to this step, it is generally possible to make a decision whether or not pancreaticoduodenectomy can be performed. 7. When it is decided to perform pancreaticoduodenectomy, the corpus corpus is generally first traversed, and the amount of gastric resection is expected to be 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 proper hepatic artery are separated, and the lymphatic-a fat tissue surrounding the artery is separated and excised together with the pancreas and the duodenum. The gastroduodenal artery can be isolated by pulling the common hepatic artery upward. The trunk of the gastroduodenal artery is sometimes short, and can be first pulled through a wire and then separated distally until the free artery has sufficient length; the double wire is ligated, the distal clamp is cut, and the distal end is generally It is necessary to suture through the suture to prevent the knot from slipping off during the operation. Sometimes the gastroduodenal artery is thick and short. Older patients may have atherosclerotic changes. When ligation, it may cause rupture of the inner wall of the vessel wall. After surgery, a pseudoaneurysm is formed and rupture occurs. In this case, it is better to use a 4-0 vascular suture to suspend the end of the gastroduodenal artery with a non-invasive vascular clamp to control the hepatic artery blood flow. It should be safe after the operation is completed. The omentum separates the broken end of the artery from the end of the pancreas and the anastomosis of the biliary tract to reduce the chance of subsequent blood. 9. Under normal circumstances, it should be removed together with the gallbladder, the bile duct is cut off in the common hepatic duct, and it is anastomosed with the jejunum. 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. The bile duct is cut transversely under the traction of the two sutures to absorb the thick bile. If the gallbladder remains intact, the contents are evacuated slightly; the upper end of the bile duct is temporarily closed with a non-invasive forceps. Anti-biliary outflow, the lower end can be detected through the lumen to determine the location of the obstruction, if the pathological diagnosis has not been obtained, a small spoon can be used to scrape a small tissue, and the pathological examination is performed together with the bile duct end tissue. 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, which is used 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. Through the pancreas and the superior mesenteric vein, to the distal end of the pancreas, on the left side of the two traction sutures, place a heart ear pliers or other non-invasive vascular clamp, which is supported by the assistant and gently clamped to control the bleeding on the pancreatic section. For degree. 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 pull line is sewn with a 3-0 silk thread for subsequent searching and handling. 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, reveal the splenic vein, superior mesenteric vein and portal vein. The veins that drain the blood of the pancreatic head and the uncinate process will merge to the right and the posterior side 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 from the Treitz ligament, the distal suture is closed, the proximal end is temporarily ligated with thick lines, pulled 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. Another method is to pull the duodenum to the right side after fully dissipating the third segment of the duodenum, and to cut the peritoneal attachment of the Treitz ligament on the right side, so that the upper end of the jejunum can be pulled to the right abdomen, away from the Treitz ligament. The jejunum was cut about 10 cm, the distal suture was closed, and the left upper abdomen was also taken. The proximal end was left for traction to facilitate the removal of the pancreatic head and the duodenum. The distal end of the jejunum that was severed was closed. Returning to the left upper abdomen, the proximal jejunum and the duodenum are used for traction to further separate and sever the uncinate and duodenal mesentery. 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. When the small branch of the portal vein has been cut, the portal vein can be partially free and pulled to the left. The superior mesenteric artery is located at the left rear of the portal vein. At this time, the surgeon can determine the position of the superior mesenteric artery by the finger. The superior mesenteric artery can be revealed by hooking the portal vein to the upper left side with a vein hook or a curved vascular clamp with a small ball. The superior mesenteric artery is wrapped with fibrous sheath and can be touched by fingers. The arterial sheath is cut longitudinally along the anterior wall of the superior mesenteric artery, and is separated to the right edge. The superior intestinal artery and the branch of the pancreaticoduodenal artery can be clearly displayed, and the artery can be separately separated and ligated. Cut off. Exposing and isolating the superior mesenteric artery ensures that the uncinate portion of the pancreas can be completely removed. Sometimes the superior mesenteric artery is not well exposed and separated due to local adhesion or oozing. At this time, under the traction of the pancreatic head and the duodenum, a lower inferior vena cava can be placed in parallel along the mesenteric artery in the direction of the superior mesenteric artery, and then the uncinate portion is gradually cut and ligated. The nerves, fibers, and blood vessels of the mesentery reduce residual pancreatic tissue to a minimum. The uncinate part of the mesenteric section is most likely to occur during surgery and postoperative bleeding. Because of its deep position, it is often covered by the portal vein and small mesentery, which is difficult to detect. Therefore, when the specimen is removed, the blood and blood clots at the wound should be exhausted, the portal vein and the small mesentery should be pulled up, and the broken end of the uncinate mesentery should be carefully examined for oozing or small bleeding points. They were sutured one by one to stop bleeding until they were completely satisfied. Sometimes, from a safety point of view, a continuous suture can be added to the broken end of the mesangium. It is also suggested that when the uncinate process membrane is removed, it can be slightly away from the superior mesenteric artery, and a small amount of pancreatic tissue can be retained when the clamp is cut to shorten the operation time. However, the pancreatic tissue left by this method may cause necrosis and hemorrhage after surgery, and also affect the thoroughness of resection of pancreatic head cancer. Therefore, we advocate complete resection of the uncinate part of the pancreas. The second operation of the biliary drainage (common in the periampullary cancer), at this time there is often congestion, edema and more adhesion around the duodenal ligament and bile duct, and often have drainage channels and Bacterial growth in bile, for technical reasons and to reduce contamination of the surgical field, often cut the bile duct in the final step. After cutting the stomach and cutting the pancreas, the common hepatic artery and the gastroduodenal artery are separated at the upper edge of the pancreatic head. The treatment method is the same as described above. After cutting the upper end of the jejunum and cutting off the connection between the pancreatic uncinate process and the superior mesenteric artery, the specimen is pulled downward, and the adhesion between the portal vein and the common bile duct is separated, and then the heart bile duct is clamped with a heart ear clamp, and the appropriate site is selected to cut the bile. General manager. Cut off the lower end of the common bile duct and remove the specimen. In patients undergoing reoperation, due to the thickening of the bile duct wall, it is sometimes difficult to distinguish it from tumor invasion. Therefore, the bile duct margin should be sent to the cryosection to ensure the thoroughness of the resection. 16. There are many methods for digestive tract reconstruction after pancreaticoduodenectomy. Pancreatic duct jejunostomy is usually used. The suture closes the gap between the small mesentery and the posterior wall of the abdomen. The avascular region of the transverse mesenteric membrane on the left side of the middle cerebral artery is incision, and the upper end of the jejunum is lifted, and the pancreatic duct jejunum is firstly anastomosed with the residual pancreas. The distal end of the jejunum, which has been sutured and closed, is pulled up to the right upper abdomen through the avascular zone on the transverse mesenteric membrane, ready to be anastomosed first. The jejunum of the upper jejunum should be tension-free, and the end of the pancreas should be separated from the anterior wall of the portal vein by about 3 cm to facilitate anastomosis. The suture on the end of the pancreas was used as a traction to lift the pancreas, and the posterior margin of the pancreas and the corresponding part of the jejunum to the mesenteric margin were sutured together by a thin thread or a synthetic suture. Cut the muscle layer of the corresponding jejunum sputum, and then cut a small hole in the symmetrical jejunal mucosa for the pancreatic mucosa to match the jejunal mucosa; 3-0 silk thread of the 3-needle pancreatic duct and jejunum mucosa in the corresponding part The suture was sutured as the posterior wall of the pancreatic duct jejunum anastomosis. Then, the drainage catheter originally placed in the pancreatic duct is taken out through the jejunum, and the position is generally located upstream of the anastomosis, and the catheter is fixed by suture at the anastomosis to prevent slippage during the operation. The catheter is worn out of the jejunum and fixed with a purse string to prevent leakage of pancreatic juice in the early postoperative period. Then, the anterior wall of the jejunal anastomosis of the pancreatic duct was sutured with 3 sutures, and finally the sarcolemma of the anterior wall was sutured and fixed on the pancreatic capsule. When the pancreatic duct has obvious dilatation, the pancreatic duct jejunum anastomosis is easier and firmer, and there is less chance of postoperative pancreatic fistula. At this time, a short tube can be inserted into the pancreatic duct and the jejunum as a temporary support drainage without draining. The tube is taken out of the body. 17. Bile duct jejunal anastomosis is the second anastomosis in the reconstruction of the digestive tract. The anastomosis of the pancreatic duct is about 10 cm. The segment of the jejunum should not be too long. Bile duct jejunal anastomosis with double suture, the inner mucosa for mucosal anastomosis is best to use 4-0 absorbable synthetic suture or 3-0 non-absorbable suture to reduce postoperative inflammation due to suture reaction and anastomotic stricture Forming stones. T-shaped tube drainage is generally placed in the bile duct, and the long arm is taken out from the bile duct. The end of the short arm is cut with a side hole and placed in the jejunum through the anastomosis. As a drainage and decompression, after the anastomosis is completed, the jejunum is completed. The suture is fixed to the lower edge of the liver to make it natural and not to be angled or excessively pulled. When the total jejunum is anastomosed, a T-shaped tube is placed through the common bile duct, and a short arm is placed in the jejunum through the anastomosis. As a postoperative drainage decompression, when the common bile duct is highly dilated, the wall is thin, and the anastomosis is satisfactory, sometimes Without the T-tube, the position of the intestines should be natural. Close the gap between the transverse mesenteric membrane and the jejunum. 18. The final anastomosis is end-to-side anastomosis of the jejunum. Gastric jejunal anastomosis is generally performed by the jejunum of the anterior input of the transverse colon to the small curved side of the stomach. The distance between the gastrointestinal anastomosis and the anastomosis of the biliary tract is about 35-40 cm. The input jejunum should not be on the side of the stomach, otherwise it will cause food reflux. In patients with obstructive jaundice with gastrointestinal anastomosis, special attention should be paid to the submucosal suture of the blood vessels in the stomach wall to completely stop bleeding. The incidence of gastric bleeding after surgery in these patients is high, some from stress ulcer bleeding on the gastric mucosa, and some from bleeding from the gastrointestinal anastomosis. Generally, before the pancreatic duct jejunum anastomosis, the omental tissue is covered and fixed at the end of the gastroduodenal artery to prevent corrosion and bleeding of the ligated blood vessel stump when pancreatic juice leaks may occur. 19. The placement of the drainage in the abdominal cavity should be appropriate, and the drainage should be sufficient to effectively drain the bile leakage or pancreatic leakage that may occur. The drainage is generally a combination of tubular drainage and Pan's drainage. The drainage of the gallbladder fossa and the biliary anastomosis are drawn from the right upper abdomen; the drainage of the pancreatic duct and the posterior gastric region are taken from the left upper abdomen. In addition, the T-shaped tube and the pancreatic duct drainage are also separately taken out. 20. The typical surgical resection of Whipple pancreaticoduodenectomy includes the distal end of the stomach, the gallbladder and the common bile duct (sometimes also preserves the gallbladder), the entire duodenum, and the upper end of the jejunum 10-15 cm. Although the arrangement of the digestive tract reconstruction after typical Whipple pancreaticoduodenectomy is different between different authors, we often use the reconstruction method. complication Complications after pancreaticoduodenectomy are still common and can occur early in the postoperative period or after discharge. 1. Intra-abdominal hemorrhage occurred within 24 to 48 hours after surgery, mainly due to insufficient hemostasis. For example, in the rupture of the mesenteric mesenteric membrane, the treatment of the pancreatic stump, intraoperative injury of the blood vessels, the gastro-intestinal artery, and the pancreaticoduodenal artery are not properly handled. In severe cases with complicated operation and long time, there is intravascular disseminated coagulation (DIC) and blood clotting material to consume bleeding on the wound surface. Coagulopathy and bleeding due to vitamin K deficiency are rare in pre-operative preparation. If the amount of early bleeding after surgery is too high to stop quickly, emergency measures should be taken to detect the hemostasis. It should be avoided because the treatment is not timely or the use of blood pressure-up drugs can cause the patient to be in shock or hypotension for a long time, otherwise, although Bleeding can stop, but patients may die from multiple organ failure. 2. Postoperative gastrointestinal bleeding is more common, can be derived from: 1 gastrointestinal anastomotic bleeding; 2 stress ulcer, hemorrhagic gastritis; 3 anastomotic ulcer bleeding is rare; 4 bleeding from the pancreas or other blood vessels Into the intestines. 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. When choledochal or pancreatic fistula is combined after surgery, bleeding may occur due to corrosion of adjacent blood vessels. For those who have difficulty in locating the source of the bleeding, an emergency angiography can be performed to understand the source of the bleeding and to immediately stop embolization. 3. Pancreatic fistula. 4. Timid. 5. Gastrointestinal anastomosis. 6. Intra-abdominal infection, underarm abscess is often associated with anastomotic leakage. 7. Acute renal failure. 8. Liver failure. 9. Gastric retention, gastric emptying dysfunction. 10. Other complications such as cardiovascular complications, portal vein thrombosis and so on. 11. Late complications after pancreaticoduodenectomy may have (1) biliary anastomotic stricture and obstructive jaundice. (2) anastomotic ulcer. (3) Diabetes. (4) pancreatic exocrine dysfunction.