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Pancreatic and hepatic surgery

Last updated: November 22, 2019

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Pancreatic and hepatic surgeries are indicated in the management of malignant/symptomatic benign tumors and traumatic lacerations of the liver and pancreas. The choice of surgery depends on the location, size, and extent of the malignancy/injury. Depending on the extent of resection, pancreatic surgeries for malignancy include enucleation (for islet cell tumors), partial pancreatic resections (distal pancreatectomy, central pancreatectomy, pancreaticoduodenectomy/Whipple procedure), and total pancreatectomy. Chronic pancreatitis patients with a dilated main pancreatic duct (> 5 mm), not responding to conservative therapy, are candidates for lateral pancreaticojejunostomy with/without resection of the pancreatic head. Complications of pancreatic surgeries include anastomotic leaks, pancreatic ascites/fistula, and exocrine/endocrine insufficiency. Depending on which segments of the liver are removed, hepatic resections include right/left hepatectomy, right/left lobectomy, and segmentectomy. Wedge resections of the liver are performed for small, peripherally located lesions. Other complications of hepatic resections include liver failure, hemorrhage, hemobilia, and bile leaks.

Anatomy of the pancreas

See the article on pancreas.

Types of pancreatic surgeries

Type Indications Surgical procedure

Pancreatic resections

Pancreaticoduodenectomy

(Whipple procedure)
Pylorus-preserving pancreaticoduodenectomy (modified Whipple procedure)
Distal pancreatectomy (with/without splenectomy)
  • Lesions in the body/tail of the pancreas
    • Spleen-preserving surgery: benign lesions
    • With splenectomy: malignant/premalignant lesions
Central pancreatectomy
Total pancreatectomy
Enucleation
For acute pancreatitis

Debridement of pancreatic parenchyma

(Pancreatic necrosectomy)

For chronic pancreatitis

Duodenum-preserving pancreatic head resection

(Berger's procedure)
  • Head of the pancreas is resected
  • Pancreaticojejunostomy

Lateral pancreaticojejunostomy + resection of the pancreatic head

(Frey's procedure)

Lateral pancreaticojejunostomy

(Puestow's procedure)
  • Same as Frey's procedure, but without the pancreatic head resection
For pancreatic pseudocysts
For pancreatic fistulae
  • Failure of conservative and endoscopic management

Complications

Suspect a pancreaticojejunostomy anastomotic leak in a patient with hyperchloremic acidosis (loss of bicarbonate) and high levels of amylase in abdominal secretions!
References:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]

Anatomy of the liver

See the article on liver.

General principles of hepatic surgery

  • Access: laparotomy (transverse, midline or subcostal incisions) or laparoscopy
  • Pringle maneuver: temporary occlusion of the hepatic artery and portal vein by clamping of the free edge of the lesser omentum (hepatoduodenal ligament) in order to control vascular inflow to the liver or to reduce hemorrhage
  • Cholecystectomy is routinely performed as part of all major hepatic resections to allow for easier dissection during the surgery.
  • Cavitron ultrasonic surgical aspirator (CUSA): uses ultrasonic waves to vaporize only the liver cells while sparing the biliary radicles and blood vessels

Types of liver resections

Type Indications Contraindications Surgical procedure
Anatomical resections

Right hepatectomy (right hemihepatectomy)
  • Segments V, VI, VII, and, VIII are removed.
Right lobectomy (extended right hepatectomy or right trisegmentectomy)
  • Right hepatectomy and the additional removal of segments I and IV
Left hepatectomy
  • Segments II, III, and IV are removed.
Left lobectomy
Segmental resection
  • One or more anatomical segments are removed.
Non-anatomical resection Wedge resection
  • Peripherally located lesions
  • A triangular wedge of hepatic parenchyma containing the lesion is removed.

Complications

Before performing extensive hepatic resections the future liver remnant (FLR) needs to be calculated (using CT images), as patients with insufficient FLR postresection, can develop liver failure!
References:[22][23][24][25][26][27][28]

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