PREOPERATIVE DIAGNOSIS: Pancreatic mass.

POSTOPERATIVE DIAGNOSIS: Pancreatic carcinoma.

OPERATION PERFORMED: Proximal subtotal pancreatectomy, Whipple procedure CPT code 48150

BLOOD LOSS: 1200 cc.

POSTOPERATIVE CONDITION: Satisfactory.

COMPLICATIONS: None.

DESCRIPTION OF OPERATION:

PROCEDURE: With the patient in a supine position, the abdomen was entered through a bilateral subcostal incision. The liver was found to be distended because of the bile back-up but no definite metastases were seen anywhere. The right colon was then taken off the duodenum and the anterior surface of the head of the pancreas. Next, the duodenum was kocherized and the mass was found to be free of the aorta and the vena cava. Following this, the gastrocolic ligament was taken down to reveal the body and tail of the pancreas. The middle colic vein was identified. It was followed to the superior mesenteric vein to the under-surface of the pancreas which was found to be free of the vein. Next, attention was then directed to the superior border of the pancreas. Here it was noted that the pancreatic mass had come to the extra-pancreatic tissue. A biopsy was taken at the junction of the first portion of the jejunum and pylorus and this was positive for malignancy. 

However it was felt that the area could be dissected free from the hepatic artery and therefore it was felt at this point attention be directed to the gallbladder and the bile duct. The peritoneum of the gallbladder fundus was incised and the gallbladder delivered from the liver bed, the cystic artery tied and the cystic duct tied, ligated and the gallbladder removed. An aberrant right hepatic artery was found behind the common duct. The common hepatic duct now was encircled just above the cystic duct and stay sutures were placed and the common hepatic duct transected. The dissection was then continued to the upper border of the head of the pancreas. The portal vein was found to have reaction around it, but dissection revealed it to be free from the superior border of the pancreas. At this point the gastroduodenal artery was then ligated and suture ligated and incised. Following this, the hepatic artery was further separated away from the superior border of the pancreas. Next, a vessel loop was passed around the neck of the pancreas. Following this, the lesser and greater curvature of the stomach was cleaned at the junction of the body and the antrum and the stomach was transected with a GIA stapler. Following this, the sutures were placed on the cephalad and caudal borders of the pancreas with 2-0 Prolene figure-of-eight sutures. The pancreas was then transected between the two rows of sutures. Following this, the superior mesenteric and portal vein were dissected free from the inner surface of the pancreatic head and then finally the uncinate process was separated from the superior mesenteric artery and dissected free and its connections tied with 2-0 silk until the wall of the duodenum was reached. After the duodenal mesentery was taken down between 2-0 silk ties, the duodenal jejunal junction attachments were incised as were the ligament of Treitz attachments and the proximal jejunum delivered into the right upper quadrant. The duodenum was now transected at its junction with the jejunum and the specimen was sent in a fresh state after it was marked, to pathology. Next, the pancreas was elevated off the splenic vein for a distance of 4 cm and a pancreaticogastrostomy was done. Sutures were taken from the posterior superior gastric wall to the anterior surface of the pancreas. A gastrotomy was made and the sutures were taken from the posterior inferior gastric wall to the posterior wall of the pancreas and tied in such a way that 1 cm of the pancreas was invaginated into the stomach. Next, the end of the jejunum was closed over and an end-hepatic duct to side-jejunum anastomosis was made with interrupted 4-0 PDS suture. Following this, the lesser curvature of the stomach was oversewn with 3-0 silk and then a gastroenterostomy was made to the greater curvature of the stomach in two layers, outer interrupted 3-0 silk and inner running 3-0 Monocryl sutures. After the anastomoses were done, the lumens were all checked. A nasogastric tube was put in the proper position in the stomach. The abdomen was well irrigated. One drain was placed by the hepaticojejunostomy and another drain by the pancreaticogastrostomy and brought out below the incision on the right and left and anchored to the skin with 3-0 nylon and the wound was now closed with interrupted #1 Vicryl for the midline and running #1 PDS for the anterior and posterior fascia on both sides. 

Skin staples were used, dressings were placed and the patient discharged to the recovery room in satisfactory condition. 

______________________________ DATE OF OPERATION: 04/18/2000