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Pancreaticoduodenectomy(Pylorus-Preserving Whipple Procedure)

Operative Indications:

Pancreaticoduodenectomy, or the Whipple procedure, may be indicated for a variety of benign and malignant diseases. It

is most commonly performed for one of the four periampullary adenocarcinomas arising in the head of the pancreas, the

ampulla, the distal bile duct, or the duodenum. The procedure is also utilized for less common neoplasms that may arise in

the head of the pancreas. These include the cystic neoplasms, both serous and mucinous cystadenomas and mucinous cys-

tadenocarcinomas, intraductal papillary mucinous neoplasms, islet cell tumors (both benign and malignant), and solid and

pseudopapillary neoplasms (Hamoudi tumor). Benign ampullary and duodenal adenomas may also occasionally require a

pancreaticoduodenectomy for management. There are also a handful of rare tumors, including gastrointestinal stromal tumors

and acinar cell tumors, that are treatable by pancreaticoduodenectomy. Some pancreatic surgeons feel that pancreaticoduo-

denectomy is the procedure of choice for chronic pancreatitis when a dilated duct is not present and a Puestow proce-

dure, therefore, cannot be performed. It is a particularly attractive operation for chronic pancreatitis when the disease is

most severe in the head and uncinate process, with less extensive involvement of the body and tail of the gland. Rarely,

pancreaticoduodenectomy may be indicated for extensive pancreatic and duodenal trauma, when it is felt that duodenal

repair and pancreatic drainage would be inadequate surgical management. In most instances, however, a pancreaticoduo-

denectomy is performed for a malignant neoplasm arising in the periampullary region. The

pylorus-preserving modification of the classic Whipple procedure has become our standard,

and it is utilized in over 80% of the pancreaticoduodenectomies done for neoplasms.

Operative Technique:

The operative procedure can be performed through either a bilateral subcostal or an upper

abdominal midline incision. Once the abdomen is entered, a thorough exploration must be


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carried out to detect any evidence of tumor

spread outside the limits of resection. The liver is carefully

examined, as are all serosal surfaces for metastatic spread or peri-

toneal dissemination. Ultrasound can be further used to clear the liver. In

addition, lymph node spread outside the boundaries of resection should be

determined (1). Involvement of the periportal and celiac axis lymph nodes used to be considered a contraindication for

resection. Today, however, these areas can easily be included in the lymphadenectomy accompanying a pancreaticoduo-

denectomy. The root of the transverse mesocolon also should be examined to determine whether there is direct tumor exten-sion into this area. The root of the transverse mesocolon, if involved, can often be excised along with a segment of the

middle colic artery. Generally, the marginal artery of the transverse colon will continue to supply adequate blood to the

transverse colon, even in the instance when a segment of middle colic artery has to be excised.

Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 285

1

Stomach

Spleen

Gallbladder

Liver

Gastrohepaticligament

Celiac axis

Duodenum


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Once tumor dissemina-

tion has been ruled out, the

duodenum is extensively mobi-

lized. The duodenum, head of the

pancreas, and tumor are generally

easily elevated off the inferior vena cava

and aorta. Direct extension posteriorly into

these structures is very unusual. This maneuver

is important, however, to be certain the tumorhas not extended beyond the uncinate process

to involve the superior mesenteric artery. For

this reason, an extensive kocherization should

be performed so that one can palpate the

superior mesenteric artery and be reasonably

comfortable that there is normal uncinate

process adjacent to it (2, 3). If, upon per-

forming this maneuver, one feels tumor extend-

ing over to and involving the superior mesen-

teric artery, the lesion is not resectable.

286 Atlas of Gastrointestinal Surgery: Pancreas

2

3

Stomach

Kocherizedduodenum

Tumor

Pancreas

Duodenum

Head ofpancreas

Inferiorvenacava

Aorta

Uncinateprocess

Superiormesenteric

v. and a.


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One next needs to identify the

portal vein and to be certain the

portal and superior mesenteric veins

are not involved with tumor. The

quickest way to accomplish this is

to mobilize the gallbladder and

divide the common hepatic duct

(4). The gallbladder is no longer

considered an acceptable means

of decompressing the biliary tree

into a jejunal loop if the tumor

proves to be unresectable. The

hepaticojejunostomy is the biliary

bypass of choice even if a pallia-

tive double bypass is to be car-

ried out. Therefore, the common

hepatic duct can be divided early.

This allows one to immediately come

down upon and identify the portal vein.

The next step usually involves dividing the

gastroduodenal artery, passing inferiorly from the

common hepatic artery (5). This vessel passes

anterior to the portal vein, just at the point

where the portal vein passes posterior to the

duodenum and neck of the pancreas. Prior to lig-

ating and dividing the gastroduodenal artery, it

should be occluded with either a vessel loop or

a bulldog clamp, to be certain that a good pulse

remains in the hepatic artery. In some instances,

when the celiac axis is partially or completely

occluded either by atherosclerosis or the arcuate


4

5

Commonhepaticductdivided

Gastroduodnala. divided

Gallbladder

Commonbile duct


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ligament, the hepatic artery is fed by the gastroduodenal artery through the arcade originating from the superior mesenteric

artery. In this instance, if one divides the gastroduodenal artery, there is risk of liver ischemia and necrosis, and serious life-

threatening morbidity. One therefore has to be certain that a good pulse remains in the hepatic artery before division of

the gastroduodenal artery.

At this point, one should also check for a replaced right hepatic artery (6)a right hepatic artery originating from the

superior mesenteric artery rather than from the common hepatic artery. In the past, angiography was performed to deter-

mine this anomaly prior to surgery. That is no longer felt necessary because, with great accuracy, one can easily identify a

replaced right hepatic artery at the time of surgery.

This vessel will be found originating from the superior mesenteric artery (SMA), just after the take-off of the SMA

from the aorta. The replaced right hepatic artery then passes up to the liver just lateral to, and posterior to, the biliary

tree. With the use of three dimensional CT scans, this anomaly can usually be identified preoperatively.

Another anomaly that is less frequent but even more difficult to recognize, is a replaced common hepatic artery off the

superior mesenteric artery. In this instance, a sizable vessel passes anterior to the portal vein just at the point where the

portal vein passes behind the first portion of the duodenum and the neck of the pancreas (7). This is in the usual loca-

tion of the gastroduodenal artery. This also has to be identified and carefully preserved, because division of this vessel

would be particularly disastrous, disrupting the blood supply to the liver.


6 7

Replaced right hepatic a.

Replaced

right

hepatic a.

Replaced common

hepatic a.

(off superior

mesenteric a.)

Gastroduodenal a.

Gastroduodenal a.

Hepatic aa.L. hepatic a.

Splenic a.R. gastric a.

L. gastric a.

Replaced common heaptic a.


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Once the common hepatic duct and

the gastroduodenal artery have been

divided, one can easily dissect the

anterior surface of the portal vein off

the posterior surface of the neck of the

pancreas (8). The insertion of a vein

retractor on the neck of the pancreas will

allow excellent exposure for this dissection

(inset). It is unusual for veins to origi-

nate from the anterior surface of the

portal vein and enter the posterior

neck of the pancreas, so this dissec-

tion can often proceed fairly rapidly

and bluntly, without risk. Occasionally,

however, a coronary vein or a superior

pancreaticoduodenal vein (vein of Belcher), will

come off the anterior surface of the portal vein, and one

has to be aware of these possibilities.

Next, the third portion of the duodenum iskocherized extensively. The first structure that is iden-

tified crossing anterior to the third portion of the

duodenum is the superior mesenteric vein. This is a

much easier route by which to identify the superior

mesenteric vein, rather than going through the lesser

sac. We do not enter the lesser sac during a pylorus-

preserving pancreaticoduodenectomy. Once the

superior mesenteric vein is identified as it passes ante-

rior to the third portion of the duodenum, its anteri-

or surface is cleaned up under the neck of the pancreas (9).

Again, the use of a vein retractor on the neck of the pancreas is

helpful in exposing the superior mesenteric vein for this dissection.

The anterior surface of the vein is usually free of significant venous

branches, except for the origin of the right gastroepiploic vein.


9

8

Portal v.

Superiormesenteric v.

Superiormesenteric

v.

Superior

mesentericv.

Superior

mesenterica.

Portal v.

Neck ofpancreas

Neck ofpancreas

R. gastroepiploic v.


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This venous structure is almost always

present, coming off the anterior, or

anterior left lateral, aspect of thesuperior mesenteric vein just below

the neck of the pancreas, and has to

be carefully dissected, ligated and

divided.

Once this large venous structure has

been divided, the dissections between

the portal vein from above and the

superior mesenteric vein from below can

easily be connected (10). After this is

accomplished without any evidence of

direct involvement by tumor of these major

structures, proceeding with the operative pro-

cedure is appropriate.

The first portion of the duodenum is then

mobilized and dissected free, off the neck of

the pancreas. It is divided with a gastroin-

testinal anastomosis GIA stapler (11). At

times, the dissection of the neck of the pan-

creas off the portal and superior mesenteric

veins can be enhanced by dividing the duode-

num at an earlier stage.


10

11

Portal v.

Dissection ofpancreas offsuperiormesenteric v.

Dissection ofpancreatic neckoff portal v.

Gastroduodenal a.

Splenic v.

Superiormesenteric v

First portion of

duodenumdivided


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At this point, the neck of the

pancreas can be divided. We gener-

ally pass a small Penrose drainunderneath the neck of the pancreas,

and then, using the electrocautery,

divide the gland down to the

Penrose drain (12). If the pancreatic

duct has been occluded by tumor, and

the gland is fibrotic, this division is relative-

ly bloodless. But if the patient has an

ampullary tumor, or another neoplasm that

has not obstructed the pancreatic duct, and

the pancreatic parenchymal is relatively nor-

mal, care has to be taken to achieve hemosta-

sis from a variety of bleeding vessels.

Once the neck of the pancreas has been

divided, a neck margin should be sent for

frozen section to be certain that the margin

is free of tumor (13).


12

13

Portal v.


Tumor

Pancreatichead

Duodenum

Pancreas

divided


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The superior mesenteric and portal veins are then dissected off the uncinate

process. Again, this is generally done with very little need to ligate and divide sub-

stantial vessels. The superior pancreaticoduodenal vein draining into the portal vein,

also known as the vein of Belcher, is a fairly constant landmark and needs to be

identified, doubly ligated and divided. In addition, more distally on the superior

mesenteric vein, near the inferior border of the uncinate process, the first jejunal

branch is a constant landmark, arising from the right lateral border of the supe-

rior mesenteric vein, and coursing around and posterior to the superior

mesenteric artery to the proximal jejunum, to the left of the mesenteric ves-

sels. This generally has to be ligated and divided (14).

A good deal of the dissection of the superior mesenteric and por-

tal veins off the uncinate process, however, can be done gently,

but bluntly. The uncinate process of the pancreas ends flush

against the right lateral border of the superior mesenteric

artery. In most instances, the dissection and division of

the uncinate process should be flush with the superi-

or mesenteric artery, cleaning approximately 180

degrees of the arterys circumference (15).

There are several sizable arterial branches that

have to be identified, ligated and divided.

Finally, the first jejunal venous branch, as itcourses underneath the superior mesenteric

artery to pass to the proximal jejunum, often

has to be doubly ligated and divided for a

second time (16).


14

15

16

Vein of Belcher

Vein of Belcher

First jejunalbranch divided(first time)

First jejunalbranch divided(second time)

Superior

mesentericv.

Superiormesenterica.


Superiormesenteric a.


Superior

mesenteric v.

Superiormesenteric a.

Uncinateprocessdivided

Hepatic a.

Neck of

pancreas


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One then retracts cephalad the transverse

colon and identifies the ligament of Treitz

and the proximal jejunum. The proximal

jejunum at a convenient point distal to the

ligament of Treitz, in the middle of a large

arcade, is divided with a GIA stapler

(17). The mesentery to the proximal

jejunum and fourth and third portions of the

duodenum are then doubly clamped,

divided and ligated with 2-0 silk.

Since the third portion of the duode-

num has been extensively kocherized

and mobilized during the earlier

part of the dissection, and since

the uncinate process has been

completely divided during the ear-

lier dissection, this dissection

below the transverse mesocolon to

completely mobilize the specimen

proceeds easily and quickly. Once

the jejunum is divided and themesentery is clamped, divided

and ligated down to the ligament

of Treitz, the proximal jejunum is

passed underneath the superior

mesenteric vessels over to the right

side of the abdomen, and the

specimen is removed from the

operative field (18).


17

18

Jejunumdivided

Mesenterydivided

Transverse

colon

First portion of

duodenum

Common hepatic a.

Commonhepatic duct

Duodenum

Pancreatichead

Uncinate

process

Transverse colon

Jejunum


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The specimen consists of the distal

portion of the first part of the duode-

num, all of the second, third and

fourth portions of the duodenum, and

approximately 10 cm of proximal

jejunum. In addition, the neck, head

and all of the uncinate process of the

pancreas are included, as are the gall-

bladder and distal biliary tree (19).

There are a variety of ways to

perform the pancreaticojejunostomy.

Many have been used very effec-

tively, with a reasonably low inci-

dence of pancreatic leakage and with low morbidity and mortality. We prefer to invaginate the end of the pancreas into

the side of the jejunum. Other pancreatic surgeons prefer to perform a duct to mucosa pancreaticojejunostomy, also in an

end-to-side fashion. Whether or not to stent the anastomosis with a small polyethylene tube is still under debate. We will

demonstrate the invagination technique with an end-to-side pancreaticojejunostomy (20), which also includes a duct-to-

jejunal mucosal anastomosis; we will also demonstrate a duct-to-mucosa anastomosis; finally, we will demonstrate teh invagi-

nation technique.

The end-to-side invagination anastomosis is carried out in two layers: an outer interrupted layer of 3-0 silk and an inner

continuous layer of 3-0 synthetic absorbable material. The jejunum is brought up into the lesser sac through a rent in thetransverse mesocolon, generally through the bare area of transverse mesocolon that resided over the junction of the second

and third portions of the duodenum. The outer row of the posterior layer is placed first. The 3-0 silks are placed through

the posterior surface of the pancreas, and then through the jejunum (21).


19

20

21

Pancreas

Pancreaticojejunostomy

Resection specimen

Outer layer ofposterior row

Jejunum

Duodenum

Proximaljejunum

Gallbladder

Distalbiliarytree

Uncincateprocess

Head and neck of pancreas


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When all sutures have been placed, they are secured. A

jejunotomy is then performed. The inner posterior layer of

the anastomosis consists of a continuous 3-0 synthetic

absorbable suture placed in a locking fashion (22). The

pancreatic duct is included in this inner layer. If it is a nor-

mal-sized duct, only two or three throws are placed

through the duct. If the duct is dilated, however, several

throws are placed through and through the dilated pan-

creatic duct. Thus, this technique combines both the

invagination technique as well as a duct-to-mucosa anasto-

mosis. The inner layer of the anterior row of the anastomosis is

performed next. This consists of an over-and-over suture passing

from above to below, through the capsule of the pancreas and out

through the divided parenchyma, and then from inside out on the

jejunum. Again, the pancreatic duct is incorporated in several throws

of this inner layer of the anterior row (23). When this has been com-

pleted, the outer interrupted layer of 3-0 silk sutures is placed such

that some of the jejunum is drawn over to cover the anastomosis (24).


22 23

24

Inner layer oifanterior row

Inner layer of

posterior row

Pancreatic ductincluded in inner layer

Outer layer ofanterior row


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This is performed by passing the

silk sutures through the capsule of

the pancreas about 1 cm from the

anastomosis, then out at the anas-

tomosis, and then through and

through the jejunum about a cen-

timeter away from the anastomosis.

This anastomosis results in invagina-

tion of the end of the pancreas into

the side of the jejunum, utilizing two lay-

ers, and also incorporates the pancreatic duct

(25). This anastomosis can also be performed

in an end-to-end fashion, when the pancreat-

ic remnant has a relatively small diameter, and

the jejunal diameter is of sufficient size. The

anastomosis is performed in an identical fash-

ion as the end-to-side anastomosis.

For the duct-to-mucosa anastomosis, the

outer layer is placed exactly as it is for the

invagination technique. The next step createsa jejunotomy the same size and exactly adja-

cent to the pancreatic duct (26). The duct-

to-mucosa anastomosis is performed with

interrupted 5-0 synthetic absorbable suture

material. The posterior row is placed first, the

sutures passing from inside out on the duct

side and outside in on the mucosal side.

Once all posterior row sutures have been

placed, they are secured (27).


25

26

27

Jejunum

Jejunotomy(small)

Invaginatedpancreas

Posteriorduct-to-mucosarow


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Next, one can choose to place a stent or

not. We demonstrate a stent created from a

No. 8 French pediatric feeding tube, 8 cm in

length, being secured with one of the 5-0

sutures previously placed in the posterior row

(28 29). The anterior row of the duct-to-

mucosa anastomosis is completed by placing a

row of interrupted 5-0 synthetic absorbable

sutures from outside in on the duct, and insideout on the jejunal mucosa (30). The outer

anterior layer is completed with an interrupted

row of 3-0 silk sutures placed in a Lembert

fashion (31).


28

29

30

31

Completed anastmosis

Stent

Stent placed inpancreatic ductand secured

Anteriorduct-to-mucosarow


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Finally, in the unusual

situation of a very thin, soft gland

in which the pancreatic duct can not be

identified, we resort to placing the end of

the pancreas into the end of the jejunum for a 5-

cm distance and then tacking the jejunum circumfer-

entially to the body of the gland. This is accom-

plished by mobilizing the end of the pancreas for a

5-cm distance and then placing stay sutures 2.5 cm

from the cut end on the superior and inferior bor-

ders. These stay sutures are tied, then passed into

the end of the jejunum and out the side, 2.5 cm

from its end (32).

When these are secured, the pancreas

is inserted into the jejunum for a 5-

cm distance. The end of the

jejunum is then sutured to the

body of the pancreas circumfer-entially with a series of interrupt-

ed 3-0 silk sutures (33).


32

33


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Two to five centimeters distal to the pancreaticojejunostomy, the

hepaticojejunostomy is performed (34). This is carried out with a single

layer of interrupted 4-0 synthetic absorbable suture material. An appro-

priately sized enterotomy is performed, and the posterior row is placed

with through-and-through sutures passing from inside out on the jejunum

and outside in on the hepatic duct (35). When all sutures are placed,

they are secured. The anterior layer is then carried out, again first placing

all sutures before securing them. They pass from outside in on the jejunum,

and inside out on the hepatic duct (36).


34

35 36

Hepaticduct Anterior row

Posterior row

Hepaticojejunostomy


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The final anastomosis is an end-to-side duodenojejunostomy(37). If one leaves only a 2-cm cuff of duodenum on the pylorus, it

is not necessary to preserve the right gastric artery, although this is

always preferable. The right gastric artery is often small, arises from the

hepatic artery, and actually joins the first portion of the duodenum. In

most instances, the right gastric artery can be identified and preserved.

The duodenojejunostomy is performed with an outer interrupted layer

of 3-0 silk and an inner continuous layer of 3-0 synthetic absorbable

suture (38). Once the outer layer of the back row of the

anastomosis has been placed, these sutures are

secured and an enterotomy is made on the

side of the jejunum (39).


37

38

39

Duodenojejunostomy

HepaticojejunostomyJejunum

Stent placed inpancreatic duct

and secured

Outer layer ofposterior row

First portion ofduodenum

Stomach

Enterotomy


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The staple line on the first portion of the duodenum is thenexcised. The inner layer on the posterior row is a continuous

locking suture of 3-0 synthetic absorbable material (40).

This is continued onto the anterior row and placed in a

Connell fashion (41). The duodenojejunostomy is complet-

ed with an outer layer of interrupted 3-0 silk sutures (42).


41

42

40

Inner layer of

posterior row

Inner layer of

anterior row

Outer layer ofanterior row


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When performing the pylorus-preserving Whipple procedure, a

portion of the first part of the duodenum; all of the second,

third, and fourth parts of the duodenum; and the proximal

jejunum are resected, along with neck, head, and uncinate

process of the pancreas. Also removed are the gallbladder

and distal biliary tree (43). Although there are many ways

to perform the reconstruction following the resection, as

just demonstrated, we prefer the end-to-side pancreaticoje-

junostomy, the end-to-side hepaticojejunostomy, and then

an end-to-side duodenojejunostomy (44). Many surgeons

continue to prefer the classic Whipple, in which a hemigastrec-

tomy is performed instead of pylorus preservation (45).


43 44

45

ResectionReconstruction

Alternate: Hemigastrectomy

with gastrojejunostomy

End-to-sidepancreaticojejunostomy

End-to-sidehepaticojejunostomy

End-to-sideduodenojejunostomy

Proximaljejunum

Pancreas

Tumor

Duodenum

Distalbiliary

tree

Gallbladder


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Many pancreatic surgeons also feel that, in selected patients with

tumor involvement of the portal and/or superior mesenteric vein (but with

otherwise favorable tumors), resection of a segment of these venous structures

should be performed, along with venous reconstruction. If the tumor involves just

a very small area of the portal vein or superior mesenteric vein, a Satinsky clamp or

DeBakey clamp can partially occlude the venous structure, and a small ellipse of the

vein that is involved with the tumor can be excised (46). If this ellipse is small, the

venotomy can be closed with a continuous 5-0 synthetic non-absorbable suture (47). If

the ellipse is larger and its direct closure would result in narrowing of the superior mesenteric

vein, a vein patch can be utilized to maintain diameter (48).


46

47

48

Portal v.

Portal v.

Veinotomyclosed

Patch

Superiormesentericv.

Tumor involvement ofsuperior mesenteric v.


Inferiormesentericv.

Splenic v.


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In some patients, enough of the

vein is involved so that tangential

resection is not feasible. In these

instances, a segment of portal

and/or superior mesenteric vein gen-

erally has to be excised (49). In these

instances, if the segment includes the

splenic vein, the splenic vein can be ligated

and divided with impunity. After the segment

of superior mesenteric vein and portal vein is

excised, if it is 3 cm or less in length, a direct

end-to-end anastomosis can be performed

(50) If the segment is longer than 3 to 4 cm,

an interposition vein graft of either saphenous

vein or jugular vein is preferable (51). It is not

necessary to reimplant the splenic vein.

It has been controversial as to whether or not a retroperitoneal lymphadenectomy accompanying a pancreaticoduo-

denectomy is of benefit in prolonging survival after a resection for cancer of the pancreas. Some pancreatic surgeons have

felt an extensive retroperitoneal dissection, as well as dissection of the nodes sur rounding the celiac axis and porta hepatis,

has resulted in prolonged survival.When we perform a retroperitoneal lymphadenectomy, we first perform a classic Whipple including a hemigastrectomy

so that the prepyloric and pyloric lymph nodes are included. The retroperitoneal dissection then starts at the medial aspect

of the right kidney hilum and proceeds laterally to the left side of the aorta. It


49

50 51

Portal v.

Portal v. Portal v.

Tumor

Superior

mesentericv.



Interpositionvein graft

End-to-endanastomosis


22/22

extends superiorly from the

portal vein to inferiorly at the takeoff of

the inferior mesenteric artery (52). In our experience,

when retroperitoneal nodes are positive, they general-

ly are in the caval-aortic groove. This dissection also

includes the tissues surrounding 180 degrees of the

circumference of the superior mesenteric artery. In

addition, the celiac axis lymph nodes are dissected

(53), and the dissection can pass laterally along the

hepatic artery into the porta hepatis. It remains contro-

versial as to whether or not such a retroperitoneal lym-

phadenectomy prolongs survival. In the largest single-insti-

tution, prospective randomized study carried out, radical

retroperitoneal lymphadenectomy was of no survival benefit.


52

53

Inferiorvenacava

Stomach

Alternative: Retroperitoneal lymphdenctomy


Superiormesenteric a.Aorta

Hepatic duct

(clamped)

Right kidney

Inferior

mesenteric a.

Retroperitonealnodes

Celiac axis nodes

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