Sample Report: Hemicolectomy & Pancreaticoduodenectomy
PROCEDURES PERFORMED
1. Partial colectomy with anastomosis (right hemicolectomy).
2. Pancreaticoduodenectomy (Whipple procedure).
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite and was administered a general intubation anesthetic. Foley catheter was placed to gravity drainage. The abdomen was prepped with Betadine and sterilely draped.
A midline incision was made with a scalpel and electrocautery through the subcutaneous fat and then through the rectus fascia. The peritoneal cavity was entered above the level of the umbilicus. The lower abdomen and pelvis were obliterated, with adhesions involving the omentum. These omental adhesions involved the entire lower abdomen and pelvis. Dissection was carried out with electrocautery and Metzenbaum scissors to free up the omentum and to free up multiple loops of small bowel which were adherent to each other. There were noted to be sutures from a previous surgery in what appeared to be the sigmoid colon. The patient also had sutures in the distal small bowel, about 6 to 8 cm from the ileocecal valve, also consistent with what appeared to be some type of small bowel resection.
The ascending colon was mobilized with sharp dissection, and palpation revealed a soft mass within the proximal ascending colon. Dissection was carried around the hepatic flexure, incising the peritoneum, separating it into pedicles, which were clipped and then divided. Dissection was carried around and through the gastrocolic tissue. Again, this tissue was either divided between large Weck clips or between clamps, and the tissue was tied with 2-0 silk. It was at this point that a mass was noted in the head of the pancreas that measured about 3 cm x 4 cm. The remainder of the pancreas was smooth with only one or two other areas of slight induration, one in the body and one in the tail.
There were enlarged lymph nodes around the common bile duct. These were soft. One of these was removed and sent for frozen section. Meanwhile, dissection was carried out to complete mobilization of the terminal small bowel and the ascending colon over to the mid transverse colon. The omentum was divided up to the midpoint of the transverse colon. The vessels along the right side of the middle colic artery and vein were sacrificed after the bowel had been divided between a bowel clamp and a Kocher. The dissection extended to the origin of the right colic and ileocolic vessels, and these vessels were divided between clamps and tied with 0 silk. There were small palpable nodes evident in the proximal mesocolon. These nodes were included as much as possible. The duodenum was dissected away from the mesocolon to allow for proximal ligation of the respective vessels. The distal small bowel was divided between a Kocher clamp and a bowel clamp. This was just proximal to the area of the previous anastomosis. The remaining mesentery of the terminal ileum and cecum was divided between clamps and tied with 2-0 silk.
The bowel was then prepared for an end-to-end anastomosis. This was carried out in two layers with the outer layer of interrupted seromuscular 3-0 silk and an inner layer of continuous interlocking 3-0 chromic. The mesenteric defect was closed with interrupted 3-0 silk. By this time I received word that the lymph node removed from the common bile duct area did not show any evidence of malignancy. Both right and left lobes of the liver were unremarkable to palpation. The gallbladder was moderately distended. The stomach was unremarkable. There was no evidence of any tumor studding the peritoneum. There was no free fluid within the peritoneal cavity. At this point, I went out and spoke with the patient's family and apprised them of the situation involving the pancreas. After discussion, it was decided to proceed at this time with the pancreaticoduodenectomy for the suspected neoplasm at the head of the pancreas.
The midline incision was extended up to the xiphoid. The self-retaining Bookwalter retractor was used, and the mobilization of the duodenum was completed to the inferior vena cava. The ligament of Treitz was mobilized by incising the peritoneum there. Gastroepiploic vessels were divided near their origin at the region of the head of the pancreas, and the head of the pancreas and duodenum were mobilized. The dissection was carried along the middle colic vein to the identified superior mesenteric vein, which then led into the identification of the portal vein. Blunt dissection was carried out easily over the portal vein behind the neck of the pancreas. The neck of the pancreas was totally normal. Dissection was then carried out in the lesser curvature area of the stomach over the duodenum to identify the gastroduodenal vessel. This was identified as being separate from the hepatic artery. The gastroduodenal vessel was encircled with a vessel loop. The opening was made in the lesser sac, and dissection was carried out over the superior aspect of the pancreas to allow for passage of a large Kelly clamp behind the neck of the pancreas. Again, a vessel loop was wrapped around the neck of the pancreas. Dissection was then carried out over the common bile duct, separated from the hepatic artery and the portal vein. The common bile duct appeared to be about 8 mm to 9 mm in diameter. It was encircled again with a vessel loop. At this point another enlarged node was located just above the neck of the pancreas near the celiac access. This lymph node was not hard, but it was enlarged and appeared to be slightly discolored. At this point there was no evidence of any extension of the tumor beyond the region of the head of the pancreas. It was elected then to proceed with the pancreaticoduodenectomy.
The pancreas was divided over its neck, with the TA-55 stapler applied across the proximal portion. The severed neck of the pancreas had bleeding, which was controlled easily with several 3-0 silk sutures. The pancreatic duct was found to lie in the posterior portion of the gland, and it measured perhaps 3 mm to 4 mm. Dissection was carried along the lateral aspect, right along the portal vein. The pancreaticoduodenal arteries were divided between clamps. The tissue along here was separated into small pedicles, and these were divided between clamps and tied with 2-0 silk. In this fashion, the head of the pancreas and the uncinate process were removed and dissection carried up towards the gastroduodenal vessel, which was then divided between clamps and tied with 2-0 silk. The distal common bile duct was also subsequently divided, and this allowed resection of the head of the pancreas along with the uncinate process.
The duodenum was divided between clamps just distal to the pylorus, and the small bowel at the duodenojejunal junction was divided as well, with a TA-55 stapler being applied distally, and then the bowel transected. The resected specimen, then, was the head of the pancreas, duodenum and distal common bile duct. Later inspection revealed that the preserved pylorus and 3 cm of duodenum appeared a bit dusky, and so I elected to resect the distal half of the stomach as well. The antrectomy was carried out by dividing the gastric vessels and ligating them with 0 silk.
The pancreaticojejunostomy anastomosis was carried out. This was an end-to-side fashion. The outer layer of the pancreaticojejunostomy was interrupted 3-0 silk. The inner layer was mucosa to mucosa with interrupted 4-0 silk, and the anterior outer layer was interrupted 3-0 silk in two layers. Approximately 8 cm distal to this anastomosis, the site was selected for the choledochojejunostomy. Before this was accomplished, the gallbladder was resected. The gallbladder was taken down from the fundus to the cystic duct in the usual fashion with electrocautery and also in some areas tissue divided between clamps, tied, and divided with 2-0 silk. Weck clips were also used in these areas. The dissection was carried down to identify the cystic artery, which was ligated with 2-0 silk and divided. The cystic duct was dissected down and then divided and ligated with 2-0 silk. The choledochojejunostomy was an end-to-side anastomosis. This was carried out in essentially one layer with interrupted 3-0 Vicryl, although 3-0 silk was used on either side of the anastomosis. The loop of jejunum was then brought around so that a gastrojejunostomy could be performed. This again was an end-to-side anastomosis. The midpoint of the stomach was divided between a ball clamp, which was applied along the greater curvature for about 4 cm, and then the medial half of the stomach was closed with a TA-90 stapler, 4.8 staple height. Again the anastomosis was carried out in two layers. An outer layer was interrupted 3-0 seromuscular silk, and the inner layer was continuous interlocking 3-0 chromic. All three anastomoses were accomplished with excellent blood supply to the respective organs and without any tension.
Irrigation of the abdominal cavity was carried out. Inspection revealed good hemostasis. Some of the omentum over the transverse colon appeared to be dusky, so this was resected. Next, two Jackson-Pratt drains were brought through the abdominal wall, one on the right side and one on the left side. One was placed near the area of the choledochojejunostomy, and the other one was located near the pancreaticojejunostomy. These were secured to the skin using 2-0 nylon. After an accurate sponge, instrument, and needle count was conducted, the abdomen was closed with continuous 1-0 Panacryl. The skin was approximated with skin staples. The patient was subsequently transferred to a cart and taken to recovery in good condition.