PANCREATIC CYST DRAINAGE

Drainage of Pancreatic Cyst (Pseudocyst)

Objective

To drain a pseudocyst by anastomosing the cyst wall to an adjacent hollow organ, marsupialization.

Position

Supine.

Anesthesia

General.

Procedure

1.  A vertical or transverse incision.

2.  The cyst is identified and anastomosed to an adjacent viscus. An incision is made into the anterior wall of hollow viscus (e.g. stomach) to gain access to the posterior wall to which the anastomosis is made.

3.  Prior to suturing the cyst, the contents are aspirated.

4.  The abdomen is closed in layers. A drain may be used.

Instruments

•   General set

•   Biliary tract set

•           Hemoclip appliers (variety of sizes and lengths) (Fig. 17.25)

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Pancreatico-jejunostomy

Pancreato-Jejunostomy

Objective

In case of:

•   Chronic pancreatitis with a dilated pancreatic duct

•   An anastomosis of jejunumotomy to pancreatic duct.

Position

Supine.

Anesthesia

General.

Incision

Midline.

Procedure

1.  Expose anterior surface of pancreas through the lesser sac.

2.  Mobilize pancreas.

3.  Identify pancreatic duct and cut it along the length of the pancreas.

4.  Carry out a lateral pancreaticojejunal anastomosis (Roux-en-Y) in two layers using nonabsorbable suture.

5.  Close wound in layer with drainage.

Instruments

•   General set, 1

•   Gastrointestinal set, 1

•   Deep set, 1.

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Distal Pancreatectomy

Distal Pancreatectomy

Objective

In case of:

•   Tumors of body and tail of pancreas

•   Traumatic injury of body and tail

•   Chronic pancreatitis localized to body and tail.

Position

Supine.

Anesthesia

General.

Incision

Midline.

Procedure

•   Mobilize spleen and pancreas

•   Ligate splenic vein at its junction with SMV with vascular sutures

•   Ligate splenic artery at the same level

•   Divide pancreas in a fish-mouth manner

•   Close pancreatic duct with a nonabsorbable suture, e.g. prolene

•   Approximate anterior and posterior surfaces of the pancreas using interrupted nonabsorbable sutures

•   Drain pancreatic bed

•   Close wound in layer.

Instruments

•   General set, 1

•   Gastrointestinal set, 1

•   Deep set, 1

•   Hemoclip applier (Fig. 17.25).

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Abdomino-pereneal Resection

Abdominoperineal Resection

Objective

In case of rectal cancer to remove the rectum anal canal.

Position

Lithotomy Trendelenburg. Urethral catheter in site.

Anesthesia

General.

Procedure

1.  The operation is done synchromously by two teams.

2.  The rectum is mobilized as for an anterior resection down to the levator one.

3.  The anus is closed with subcutaneous purse string.

4.  A circumferential incision is made and deepened through the ischis-rectal fossa.

5.  Posteriorly the Waldeyer’s fascia is divided to enter the presacral space and the levator ani is divided.

6.  Anteriorly the incision is deepened.

7.  Using the catheter as a guide to expose the retroprostatic space where the encircling fibers of the puborectalis are divided.

8.  The abdomen and perineum are closed after reconstituting the peritoneum and colon brought out through the rectus sheath. It is now sutured as a colostomy with interrupted mucocutaneous catgut sutures.

Instruments

•   General sets, 2 (one for perineal approach)

•   Deep sets, 1

•   Gastrointestinal set, 1

•   Cope crushing clamps (Fig. 8.72).

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Anterior Resection

17. Anterior Resection

Objective

In case of:

•   Rectal cancer more than 6 cm from anal verge

•   Trauma to the rectum

•   Polyps of the rectum

•   To remove the rectum with anastomosis of sigmoid to anal canal.

Position

Supine with Trendelenburg.

Anesthesia

General.

Incision

Lower midline or transverse.

Procedure

1.  The rectum is mobilized after incising the peritoneal reflections on both sides of the rectal tube.

2.  The branches of the inferior mesenteric artery are divided between ligatures and the rectum is mobilized off the presacral space till the desired level is reached.

3.  The lateral ligaments are divided after protecting the ureters.

4.  At the deserved levels of resection the mesorectum is divided between ligatures and the rectum is divided.

5.  The colon is then anastomosed to the rectal stump using a single layer interrupted anastomosis.

6.  A stapled anastomosis is a good alternative. The presacral space is drained and the wound closed in layers.

Instruments

•   Harrington’s retractor (Fig. 9.26)

•   General set, 1

•   Gastrointestinal set, 1

•   Deep set, 1.

Any questions be sent to drmmkapur@gmail.com

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