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.

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Total Colectomy

Total Colectomy

Indications

•   Injury or lower GI bleeding where site cannot be located

•   Ulcerative colitis

•   Multiple cancers or polyps of the large bowel.

Position

Supine.

Anesthesia

General.

Procedure

1.  Mobilize right, transverse and left colon by incising lateral peritoneum. In benign conditions, retain greater omentum. In malignancies separate it from the stomach to take it with the colon.

2.  Ligate right colic, ileocolic, middle colic and inferior mesente­ric vessels at their base.

3.  Remove divided bowel taking precautions to avoid spillage

4.  Anastomose terminal ileum to rectum using interrupted non-absorbable sutures in one layer.

5.  Close abdomen without drainage.

Instruments

•   General set, 1

•   Gastrointestinal set, 1

•   Leylands Jones clamp (Fig. 9.25).

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Left Hemicolectomy

Left Hemicolectomy

Indications

•   Tumors of the splenic flexure and descending colon

•   Diverticular disease with perforation or bleeding.

Position

Supine.

Anesthesia

General.

Procedure

1.  Midline incision.

2.  Mobilize descending colon and splenic flexure.

3.  Divide the inferior mesenteric vessels between ligatures at its take off.

4.  Separate greater omentum from the stomach to take it with the left half of the transverse colon.

5.  Divide colon between clamps removing left lateral third of transverse colon.

6.  Descending and simoid colon.

7.  Anastomose transverse colon to the rectum using single layer of interrupted non-absorbable suture.

8.  To avoid tension, it may be necessary to mobilize the right transverse colon.

9.  Close abdomen without drainage.

Instruments

•   General set, 1

•   Gastrointestinal set, 1.

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