Indications】
Chronic pancreatitis with recurrent attacks and prolonged treatment.
Preoperative preparation
1, chronic pancreatitis recurrent, long untreated, patients may have epigastric pain, diabetes, steatorrhea, malnutrition, etc., need symptomatic treatment before surgery to adapt to the needs of surgery.
2.Barium meal examination of the whole gastrointestinal tract is performed to understand the condition of the gastrointestinal tract.
3.B ultrasound examination to understand the condition of the biliary tract.
4.Blood calcium and blood phosphorus levels are checked before surgery.
5.Prepare skin in the surgical area.
6.Gastric tube insertion.
[Anesthesia].
General anesthesia with endotracheal intubation.
Body position
Supine position with appropriate padding on the low back.
Surgical steps
1, incision: take the epigastric median incision, if necessary, the left side can be extended around the umbilicus.
2.Probe: After entering the abdominal cavity, the following organs are explored from top to bottom: stomach, duodenum, jejunum, liver, bile, and finally the pancreas, which should be fully explored for tumors, cysts or stones.
Expose the pancreas: raise the stomach and transverse colon into the abdominal cavity, open the gastrocolic ligament, carefully separate the adhesions between the posterior wall of the stomach and the pancreas, and pay attention to the rich blood vessels between the pancreas and the posterior wall of the stomach due to inflammation, which should be separated, cut and ligated one by one to prevent bleeding and formation of hematoma, which will affect the surgical field and exposure.
The stomach is pulled upward with a wide “S” shaped hook, and the colon is placed back into the abdominal cavity and filled with a gauze pad to fully expose the pancreas. The head of the pancreas should be exposed as much as possible so that the right side of the pancreatic duct and the duodenal end can be explored for stones.
4, find and dissect the pancreatic duct: you can touch it with your fingers, because chronic pancreatitis and pancreatic fibrosis can cause segmental stenosis and dilatation of the pancreatic duct, so you can touch the dilated pancreatic duct. The pancreatic duct can also be located by puncture with a fine needle, and after determining the location of the pancreatic duct, the needle is not removed first, and the pancreas is incised along the long axis of the pancreas to the pancreatic duct with an electric knife along the puncture needle.
Continue to extend the pancreatic duct to both sides along the position of the pancreatic duct, and in general, 6 to 8 cm of the pancreatic duct can be cut. When extending to the right side, do not exceed the medial wall of the duodenum to avoid injury to the pancreaticoduodenal artery here, which can lead to hemorrhage. The pancreatic duct can be dissected and found to be segmentally dilated, and while dissecting the pancreatic duct, attention should be paid to the presence of stones, which can be removed with a small lithotripter. The right side of the pancreatic duct and duodenal papilla should be probed for patency. A fine biliary probe or a fine catheter can be inserted into the pancreatic duct to test its permeability; saline can also be injected from the catheter to see if the duodenum is distended to further confirm the patency of the duodenal papilla. If stones are found, all of them should be removed carefully and meticulously. In addition, the bleeding on the cut surface during pancreatic incision can be stopped by electrocautery or ligated with fine silk.
5. Pancreatic duct-jejunostomy: lift up the transverse colon, find the flexor ligament, cut off the jejunum at 15 cm from this ligament, and cut the mesentery to ensure sufficient length of free jejunum up to the pancreas. When cutting the mesentery, care should be taken to preserve sufficient vascular arch to ensure blood supply. The transverse colonic mesentery is incised longitudinally in the left avascular area of the mesocolonic arteries and veins, and the distal end of the jejunum is
The distal end of the jejunum was lifted from the incision to the top of the transverse colonic mesentery and the pancreas was brought together in preparation for the anastomosis. There are various methods of anastomosis between the pancreatic duct and the jejunum, and three of them are introduced here.
(1) Lateral fish-mouth anastomosis of the pancreatic duct and jejunum: Take the jejunal segment slightly longer than the pancreatic duct in the distal section of the jejunum, and after pressing along the opposite edge of the mesentery first, cut the jejunal wall longitudinally and pay attention to the ligature bleeding point. The entire posterior wall of the jejunum was intermittently sutured to the pancreatic peritoneum with small circular needles and No. 1 wire, so that the jejunum and pancreas were close together and the pancreatic duct was not sutured. Then use small circular needles and 1 gauge wire to intermittently suture the entire posterior wall of the open jejunum along the entire length of the pancreatic duct incision and the pancreatic peritoneum. The open jejunum needs to be trimmed to fit the course of the pancreatic duct. It should be noted that the pancreatic parenchyma and pancreatic duct should not be sutured because there can be more tiny pancreatic ducts in the fibrotic pancreatic section, and opening can promote the drainage of the pancreas.
(2) Lateral anastomosis of the full-length jejunum of the pancreatic duct: first close the broken end of the distal jejunum with a wire, take the same length as the pancreatic duct at the opposite edge of the jejunal mesentery, cut the jejunum, and intermittently suture the entire posterior wall of the jejunum and the pancreatic peritoneum with a small circular needle and a wire. The sutures should be of moderate density to avoid postoperative leakage. The anterior wall should be sutured in the same way.
(3) Pancreatic jejunostomy sleeve method: This procedure is suitable for patients with relatively heavy pancreatic inflammation. In this case, the volume of the pancreas is mostly shrunken and small. The method of exploration and exposure of the pancreas is the same as above. After exposing the pancreas, the peritoneum at the upper and lower margins of the caudal body of the pancreas is incised, and the inferior margin of the peritoneum is incised without injuring the inferior mesenteric vein. First, the lower edge of the tail of the pancreatic body is gently and bluntly separated with the index finger, and the upper edge of the pancreas is gradually reached backward, and the splenic artery and vein running along the upper edge of the pancreas and the back of the pancreas are separated together with the body and tail of the pancreas, respectively. A gauze strip was passed behind the pancreas to pull the body and tail of the pancreas and further separate the fibrous tissues between the tail and the spleen, and at the same time, the gastrosplenic ligament, diaphragmatic splenic ligament, splenic colonic ligament and splenorenal ligament were separated and severed to prepare for splenectomy. The splenic vessels were cut and double ligated and the spleen was removed. The tail and body of the pancreas were turned up to expose the dorsal splenic artery and vein, and the splenic artery was carefully separated and double ligated with 7 gauge wire at its origin to remove the excess artery. The splenic vein was also carefully separated and cut at its confluence with the superior mesenteric vein, and the redundant vein was excised by double ligation with a 7-gauge ligature. The tail of the pancreas was clamped with Aills clamp, and the tail of the pancreas was cut transversely with a knife to expose the pancreatic duct, and the bleeding point of the section was ligated with l-gauge or electrocautery to stop bleeding. After finding the pancreatic duct, a fine probe was inserted. The body of the pancreas is fixed with the left hand and thumb, and the probe is used as a guide to cut the pancreas and the main pancreatic duct up to the head end of the pancreas, but not more than the medial duodenum, for the reasons described previously. After incision, the pancreatic duct can be found to be narrowed or dilated, and if there are stones in it, they should be removed together. A fine biliary probe can be inserted from the pancreatic duct incision into the duodenal segment of the pancreatic duct to investigate the patency and the presence of stones in it. The bleeding point on the cut surface is ligated with a 1-gauge ligature, and the pancreatic duct and the incised pancreas do not need to be sutured to facilitate drainage. The distal end of the free jejunum was straightened, and the intestinal duct slightly longer than the incised pancreatic duct was measured and marked with a small circular needle and a stitch at the farthest point with a 1-gauge needle. On the upper and lower margins of the pancreatic tail section, a traction line A and B were sewn with a small circular needle and a small needle and a small needle and a small needle with a small needle and a small needle with a small needle and a small needle with a small needle and a small needle. In the same way, thread B is passed through the jejunum wall at the marker line. At the same time, gently pull the A and B lines and slowly sleeve the pancreas into the jejunum until the marker line, and then tie the A and B lines together. Be careful not to use excessive force to avoid pulling off the sutures or tearing or tearing the jejunal wall. The whole layer of jejunum and the pancreatic peritoneum can be sutured with small circular needles and interrupted sutures of line 1 for 1 week, and the pulpy muscle layer can be reinforced with sutures of 1 layer.
After the above anastomosis is completed, Roux-en-y anastomosis of the proximal jejunum and distal jejunum can be performed under the transverse colon mesentery. The free edge of the proximal jejunal mesentery should be fixed with interrupted sutures in the ascending jejunum, and the opening of the transverse colonic mesentery should be sutured to the jejunum.
6.Close the abdomen: put a rubber tube to drain the pancreatic duct and jejunum anastomosis, lead out to the outside of the abdominal wall, count the gauze and instruments, and suture the layers of the anterior abdominal wall in turn.
【Postoperative treatment
1, clean up after taking a semi-sitting position.
2, continuous gastrointestinal decompression, to intestinal peristalsis recovery can be stopped, into the liquid diet, gradually transition to ordinary diet.
3. Intravenous fluids should be given during fasting period, glucose solution, saline and potassium chloride, insulin, vitamin C and B. If necessary, plasma, albumin or whole blood can be given.
4, systemic and combined application of antibiotics to control and prevent infection.
5, pay attention to observe the quality and quantity of drainage fluid from the drainage tube, no increase in 2-3 days after surgery can remove the drainage tube.