SURGERY OF PANCREAS

PROF DR SA DIK PE REK

DEPARTMENT OF GENERAL
SURGERY
 Pancreatic Surgery

Anatomy
Surgical Principles
Terminology
Complications
 ANATOMY

Pancreas lies Parts :

transversely in Head
the Uncinate process
retroperitoneal
Neck
sac,between the
duodenum on the Body
right and the Tail
spleen on the left.
 Pancreatic Ducts

1. Main Pancreatic Duct (WIRSUNG)

2. Accessory Duct (SANTORINI)

 In 60 percent both ducts open into the

duodenum.
 In 30 percent the duct of Wirsung carries
the entire secretion.The duct of Santorini
ends blindly.
 In 10 percent the duct of Santorini carries
the entire secretion.
 Duodenal Papilla of Vater

 Lies at the end of the intramural poriton of the

common bile duct.
 It is on the posteromedial wall of the second
part of the duodenum.
 There is a complex of 4 sphincters surrounding
the intramural portion of the common bile and
pancreatic ducts;the sphincter complex varies
from 6 to 30 mm in length.
 The entire complex should be termed
“Sphincter of Boyden”
The ampulla is the common
pancreaticobiliary channel below the
junction of the ducts within the
papilla.
TYPE I : The pancreatic duct opens
into the common bile duct at a
variable distance from the orifice of
the major duodenal papilla,the
common channel.( % 85)
TYPE II : The pancreatic and common
bile ducts open seperately on the
major duodenal papilla.(% 5 )
TYPE III : The pancreatic and common
bile ducts open into the duodenum at
seperate points.( % 9 )
The Arterial Supply of The Pancreas

 From both the celiac trunk and the superior

mesenteric artery.
 Gastroduodenal artery divides to form the
anterosuperior and posterosuperior
pancreaticoduodenal arteries.
 Anteroinferior pancreaticoduodenal artery arises
from the superior mesenteric artery.
 Transverse (inferior ) pancreatic artery is the left
branch of the dorsal pancreatic artery.
 Branches of the splenic artery.Splenic artery is
located on the posterior surface of the body and tail
of the pancreas.2-10 branches of the splenic artery
anastomoze with transverse pancreatic artery.
 Venous Drainage of The Pancreas

The drainage is to the portal vein,the

splenic vein and the superior mesenteric
vein.
Portal vein is formed behind the neck of
the pancreas by the union of the superior
mesenteric and splenic veins.
Portal vein lies in front of the inferior
vena cava with the common bile duct to
the right and the hepatic artery to the
left.
 Lymphatic Drainage of The Pancreas

Superior Nodes
Inferior Nodes
Anterior Nodes
Posterior Nodes
Splenic Nodes
 Nerve Supply of The Pancreas

The pancreas is innervated by

symphatetic and parasympathetic
divisions.

The celiac ganglion is the central

station of both symphatetic and
parasymphatetic innervations.
Evaluation of Resectability of Pancreas

Good general exploration of the abdomen

Attention to pyloric and pancreaticoduoenal
nodes and nodes at the root of the mesentery
first.
Attention to celiac,left gastric nodes and
superior and inferior borders of the pancreas.
Exploration of the TREITZ region.
Posterior surface of the pancreas and distal
common bile duct,inferior vena cava.
Examination of the uncinate process,elevation
of the neck of the pancreas to ensure that
they are not fixed to superior mesenteric
vessels and the portal vein.
 Exploration of The Pancreas

 There are 6 routes for exploration of the

pancreas.
2. Through the gastrocolic ligament.
3. Through the gastrohepatic omentum.
4. By detaching the greater omentum from the
transverse colon.
5. Through the mesocolon.
6. KOCHER maneuver
7. By mobilizing the splenic flexure of colon
inferiorly and the spleen and tail of the
pancreas as well.
 PANCREATECTOMİES

1. 95 percent Distal Pancreatectomy for chronic

pancreatitis.
2. Distal Pancreatectomy
(with or without splenectomy)
3. Total Pancreatectomy
(with or without splenectomy)
4. Pancreaticoduodenectomies :
• WHİPPLE Procedure :
 The specimen includes;
 Distal stomach
 Duodenum
 Part of proximal jejunum.
 Head and neck and uncinate process of the pancreas.
 Distal common hepatic duct,gall bladder.
• Pancreaticoduodenectomy with pyloric preservation.
Drainage of Chronic Pancreatitis :
 Pancreaticojejunostomy
(PUESTOW Procedure)

Internal Drainage of Pancreatic

Pseudocysts
 Cystoduodenostomy
 Cystogastrostomy
 Cystojejunostomy
 Anatomical Complications of
Pancreatic Resection
Pancreaticoenteric anastomosis
o Leakage or disruption with ;
 Abscess or peritonitis
 Ileus
 Pancreatic Fistula
 Wound Infection and Dehiscence
 Bleeding from Erosion of Large Vessels
 Anatomical Complications of
Pancreatic Resection

 Complications of Biliary-enteric Anastomosis

o Leakage or disruption with ;
 Abscess or Bile Peritonitis
 Biliary Obstruction
 Biliary Fistula
 Obstruction of Anatomotic Site
 Cholangitis
 General Complications

 Operating Room  Acute Postoperative

Hemorrhage from Major Pancreatitis with ;
Vessels :
 Portal Vein  Distal Obstruction

 Hepatic Artery  Direct Injury to Pancreas

with
 Superior Mesenteric
Artery or Vein Leakage from
Pancreatic Parenchyma
 Splenic Artery or Vein
 Interference with Blood
 Inferior Vena Cava Supply or
 Renal Artery or Veins
Drainage

 Middle Colic Artery