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Pancreatic and hepatic surgery

Last updated: March 25, 2021

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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

Types of pancreatic surgeries

Overview of pancreatic surgery types [1][2]
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 [5]
Total pancreatectomy [6]
Enucleation [7]
For acute pancreatitis

Debridement of pancreatic parenchyma

(Pancreatic necrosectomy) [8]

For chronic pancreatitis

Duodenum-preserving pancreatic head resection

(Beger procedure) [9]

Lateral pancreaticojejunostomy + resection of the pancreatic head

(Frey procedure)

Lateral pancreaticojejunostomy

(Puestow procedure)

  • Same as Frey's procedure, but without the pancreatic head resection
For pancreatic pseudocysts

Pseudocyst-gastrostomy (cystogastrostomy)

Pseudocyst-duodenostomy (cystoduodenostomy)

Pseudocyst-jejunostomy (cystojejunostomy)

For pancreatic fistulae

Fistulojejunostomy

Pancreatic resection (e.g., distal pancreatectomy for distal duct disruption) [3]

  • Failure of conservative and endoscopic management [12]

Complications

Suspect a pancreaticojejunostomy anastomotic leak in a patient with hyperchloremic acidosis (loss of bicarbonate) and high levels of amylase in abdominal secretions.

Anatomy of the 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 [15]

Overview of liver resection types
Type Indications Contraindications Surgical procedure
Anatomical resections Right hepatectomy (right hemihepatectomy)
  • Segments V, VI, VII, and, VIII are removed.
  • 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.

  1. de Virgilio C, Frank PN, Grigorian A. Surgery: A Case Based Clinical Review. Springer ; 2015
  2. Noorani A, Rangelova E, Del chiaro M, Lundell LR, Ansorge C. Delayed Gastric Emptying after Pancreatic Surgery: Analysis of Factors Determinant for the Short-term Outcome. Front Surg. 2016; 3 : p.25. doi: 10.3389/fsurg.2016.00025 . | Open in Read by QxMD
  3. Holzheimer RG, Mannick JA, Sayek I, Onat D, Lerut T. Surgical Treatment: Evidence-Based and Problem-Oriented. W. Zuckschwerdt Verlag GmbH. ; 2001
  4. Bachmann J, Michalski CW, Martignoni ME, Büchler MW, Friess H. Pancreatic resection for pancreatic cancer. HPB. 2006; 8 (5): p.346-351. doi: 10.1080/13651820600803981 . | Open in Read by QxMD
  5. Christein JD, Smoot RL, Farnell MB. Central pancreatectomy: a technique for the resection of pancreatic neck lesions. Arch Surg. 2006; 141 (3): p.293-299. doi: 10.1001/archsurg.141.3.293 . | Open in Read by QxMD
  6. Kulu Y, Schmied BM, Werner J, Muselli P, Büchler MW, Schmidt J. Total pancreatectomy for pancreatic cancer: indications and operative technique. HPB. 2009; 11 (6): p.469-475. doi: 10.1111/j.1477-2574.2009.00085.x . | Open in Read by QxMD
  7. Laparoscopic Pancreatic Surgery. http://www.surgery.usc.edu/divisions/tumor/pancreasdiseases/web%20pages/pancreas%20resection/LAP%20PANCREATIC%20SURGERY.html. Updated: April 9, 2017. Accessed: April 9, 2017.
  8. Surgery for Acute Pancreatitis. http://www.surgery.usc.edu/divisions/tumor/pancreasdiseases/web%20pages/PANCREATITIS/surgery-acute%20panc.html. Updated: April 9, 2017. Accessed: April 9, 2017.
  9. Surgery for Chronic Pancreatitis. http://www.surgery.usc.edu/divisions/tumor/pancreasdiseases/web%20pages/PANCREATITIS/surgery-chronic%20pancreatit.html. Updated: April 9, 2017. Accessed: April 9, 2017.
  10. Köninger J, Friess H, Müller M, Büchler MW. Duodenum preserving pancreatic head resection in the treatment of chronic pancreatitis. Rocz Akad Med Bialymst. 2004; 49 : p.53-60.
  11. Strobel O, Büchler MW, Werner J. [Duodenum-preserving pancreatic head resection: technique according to Beger, technique according to Frey and Berne modifications].. Chirurg. 2009; 80 (1): p.22-7. doi: 10.1007/s00104-008-1577-8 . | Open in Read by QxMD
  12. Nair RR, Lowy AM, Mcintyre B, Sussman JJ, Matthews JB, Ahmad SA. Fistulojejunostomy for the management of refractory pancreatic fistula. Surgery. 2007; 142 (4): p.636-642. doi: 10.1016/j.surg.2007.07.019 . | Open in Read by QxMD
  13. Malleo G, Crippa S, Butturini G, et al. Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: validation of International Study Group of Pancreatic Surgery classification and analysis of risk factors. HPB. 2010; 12 (9): p.610-618. doi: 10.1111/j.1477-2574.2010.00203.x . | Open in Read by QxMD
  14. Tejedor L, Serrablo A. Postoperative Pancreatic Biliary Surgical Complications. J Gastroenterol Hepatol Res. 2013; 2 (7): p.661-671.
  15. Aragon RJ, Solomon NL. Techniques of hepatic resection.. J Gastrointest Oncol. 2012; 3 (1): p.28-40. doi: 10.3978/j.issn.2078-6891.2012.006 . | Open in Read by QxMD
  16. Letoublon C, Morra I, Chen Y, Monnin V, Voirin D, Arvieux C. Hepatic arterial embolization in the management of blunt hepatic trauma: indications and complications. J Trauma. 2011; 70 (5): p.1032-1036. doi: 10.1097/TA.0b013e31820e7ca1 . | Open in Read by QxMD
  17. Ribero D, Chun YS, Vauthey JN. Standardized liver volumetry for portal vein embolization. Semin Intervent Radiol. 2008; 25 (2): p.104-109. doi: 10.1055/s-2008-1076681 . | Open in Read by QxMD
  18. Zaydfudim VM, Angle JF, Adams RB. Current Management of Hemobilia. Curr Surg Rep. 2014; 2 : p.54. doi: 10.1007/s40137-014-0054-1 . | Open in Read by QxMD
  19. Galun D, Basarić D, Lekić N, et al. [Hemobilia].. Acta Chir Iugosl. 2007; 54 (1): p.41-5. doi: 10.2298/aci0701041g . | Open in Read by QxMD
  20. Herold G. Internal Medicine. Herold G ; 2014