)f I Contents Gallbladder and Biliary Tract Cbolecystectomy:1 CommonDuctExplorationJ() Sphinctcroplasty,Including T ransampullaryCommonDuctExplorationl."i Side-to-SideCholedochociuodeno'lomy28 Resection of a BenignBile Duct Stri cture Wit h iacron gran Pancreas , ~ 1 ...:.:j~ Supenor mesemen:;:v Alarge bore needle ispassed into the most anterior portion ofthe prosthesisand the clampsremovedslowly fromthe superior mesentericvein(Q). The clamp onthe inferior vena cavaisleftin place.This allows the prosthesis to fi llwith blood,with theneedle acting as a vent forthe release of air. Once the prosthesis has completely filledwith blood,the clamp isremoved fromthe inferiorvena cava and flowthroughthe prosthesis established (R). The course ofthe prosthesis assumes a "C" configuration. The anastomosis betweenthe prosthesis andinferior vena cavais actually partially underneaththe third portionofthe duodenum.The prosthesis hastopass inferiorly as wellas anteriorlytopassbelowthe thirdportionofthe duodenum. It then passes ontop ofthethirdportion ofthe duodenum,ontop ofthe uncinate process, tobeanastomosed obliquely tothe anterior surface ofthe superior mesenteric vein. This "C" configuration allowsthe prosthesistobeanastomosedtothe anterior aspect ofthe superiormesenteric veinwellabovewhere the superior mesenteric veinbranching occurs (S). Thus oneisalways assured of superior mesenteric veinwith a large diameter.Furthermore,sincethe anastomosis is obl ique,ittends tobevery large.Inaddition,since the anastomosis is tothe anterior aspect ofthe superior mesenteric vein, ittechnicall y is easy toperform. This is incontrast tothe old "R" shunt,which runs directly anteriorly from the inferiorvena cava, belowthe lowerborder ofthe third portion ofthe duodenum, and joinsthe posterior aspect ofthe superior mesenteric vein. The "R" shunt anastomosisismuchharder toperformand oftenis performed to a segment of the superior mesenteric vein that has already branched. s Q Duodenum _____-;_ Inferiorvena cava ----- -t Lateralview ' ),.. c ..graft Superior i-:r------mesenteric v. ---i!;......-- ----.. c ..graft / 1':>,: / 1.- mesenteri c v. Theprosthesis ispuncturedwith a 19-9auge needle connectedto intravenous extension tubing.This caneither bepassed off the head ofthe table sothat pressures maybe recordedonelectronic equipment by the anesthesiologist. orit canbe connectedtoa manometer by the surgeonandmeasureddirectly (T). The fi rst measurement is taken withthe prosthesis openandmesenteric systemic flow intact (U). This figureis takenasthe decompressedportal pressure. The prosthesisisthen clamped ontheinferior venacava side ofthe manometer M. andthis elevated pressure is taken astheundecompressed portal pressure. Finally. the prosthesis is clampedonthe superior mesenteric venous side (JI). andthispressure should represent the pressure intheinferior venacava. It is alsoimportant forthe anesthesiologisttorecordright atrial orsuperior yena caval pressure.tobe certainthat the portal pressuredropcanbe corrected forany gradient that exists betweenthe inferiorvena cavaatthelevel ofthe anastomosis andtheright atrium.Takingthese pressure measurementsatthe endofthe operative procedure allowsthe surgeontoproceedwiththe shunt without theinitial delay requiredformeasuring undecompressedportal pressure. T Superior mesenteric l Ineoor vena cava Duodenum Superior mesenteric " t-::. "'- . :Jerformedat :::c':-c-f:-::--'::-.,;== ::-.:- ;:-:'::-:_:":-.' ',-ei:1i:.-... itl:c JL..odenum -"=-=-= --0::-- _ Commonbil e duct Portal v. Short gastricvv. ~ ? ~ Splenic v Superior. mesentericv. Inferior vena cava--- , Portal v. + ~ c r , graft Smallbowel Mesenteric v. J :!asofSurgery Direct Mesocaval Shunt Operative Indications The direct mesocaval shunt was introducedthree decadesago for the management of esophagealvaricealbleeding secondary toportal hypertension inthepediatric age group.This procedure requires di visionofthe inferior vena cava and itsuse asa receptacle for mesenteric blood.This is welltolerated inchildren. Anattempt wasmadeto extendtheuse ofthisprocedure tothe adult.Edema and venous disease inthe lower extremities obviated its extension to adults. There currently isonly infrequent indication forportasystemic decompression forportal hypertension andbleeding esophageal varicesinthepediatric age group.Portal hypertension inchildren ismost oftensecondary toportal veinocclusion. Mesenteric angiography isperformedpreoperativelyto determine the anatomy ofthe mesenteric venous system.The portal veinisusually thrombosed,with significant cavernous transformation of the portal veinor recollateralization.For the directmesocavalshunt tobe effective,it is esentia! that the superior mesenteric veinbepatent andincommunication withthe major venous collaterals.This totalshunt has demonstrated excellent long-term patency inthe pediatric age group andhasbeenvery effective incontrolling varicealhemorrhage. Operative Technique The operative procedure isperformedthrough a midline incision. Upoo entering the abdomenthe peritoneal cavity isexploredfor evidence Ii other pathology. The liverusually is grossly normal.If it has not beenbiopsiedpreoperatively,a liverbiopsyis obtained. The omentum and transverse colonare reflectedina cephalad direction (A). A transverse incisionismadeintheroot ofthetransversemesocolon. The dissectionisdeepeneduntilthesuperior mesenteric veinisidentified. There are no clear landmarks to identifythe superiormesenteric vein. The superiormesenteric artery is usually to the left andoftenposterior to the superior mesenteric vein. The relationshipsofthese two vessels are inconstant, however,and palpating for the superior mesenteric arterypule igenerally Ii li ttle helpinidentifying the superiormesenteric vein. Athe dissection is deepenedin the mesocolon,however,the superior mesenteric veinialways easilyidentified. Transverse cokln Transverse ___...;-_ _ _ _L_-'-mesocolon ! Superior mesentericv. There are many large lymphatic channels inthe retroperi toneum, and these shouldallbe clamped andligated before division. Once the superiormesenteric veinhas beenidentified,it is loopedwith vesselloops andmobilizedfora length of several centimeters (B). The superior mesenteric vein diameter isalways greatest inits most cephalad portion.Therefore, itiscleanedina cephalad direction tothe point where it passes posterior to the neck ofthe pancreas.Atthis level major branching hasnot occurred inthe superior mesenteric vein, and the diameter is generally quite large. Large branchesbetween the posterior and right lateral aspect ofthe superior mesenteric veinand the uncinate process and head ofthe pancreas are identified, ligated,and divided.The inferior mesenteric vein occasionally enters the left lateral aspect ofthe superior mesenteric vein,and itisdoubly looped with a vessel loopforcontrol.There frequentlyisalarge branch emanating fromthe posterior aspect ofthe superior mesenteric vein, passing directly posteriorly (B).This veinis difficult toisolate,ligate,and divideandis best controlledby double looping with a vessel loop. Once a 5- or 6-cmsegment of superior mesentericveinis completely mobilized,one isready toexpose andmobilizethe inferior vena cava. Portasystemic Shunts / Theright coloniscompletely mobilizedout ofthe retroperitoneum towards the midline (C).The inferior vena cava isidentified, cleaned, and mobilizedcircumferentially along its entire length extending fromthe inferior border ofthe kidney,downto and including its bifurcation.Lumbar vessels are identified, doubly ligated, anddivided.This mobilization, which wouldbe very difficult and bloodyinthe adult, is accomplished more easily inthe child. Once the entire length, including the bifurcation,has beenmobilized,an acutely-curvedDeBakey clamp isusedto occlude the most cephalad portion of the inferior vena cava (D).The left iliac veinisdivided flushwith the inferior vena cava and the distal end oversewn with a continuous 5-0 synthetic nonabsorbable suture. The right common iliac vein ismobilizeddowntoitsbifurcation.This isto provide additionallength,in case the inferior vena cava itself isnot long enough to reach the superior mesenteric vein.It isnecessary toidentify,mobilize,and retract the right ureter off the right iliac vein toavoidinjury.The iliacveinis then clamped with vascular clamps just prior tothe take-off ofthe internal iliac veinand divided. Lumbar v. A.iliac a.and v. Inferior ~ - - ~ - - - - - - ~ ~ - - - - - - - - v e n a c a v a ~______~ ~_________ Aorta Right colon R.renalv. Rweter Duodenum --~ - - \leila cava L --___iiac v_ Riliac aand ,,_ The distal end ofthe right iliac vein isoversewn with a continuous 5-0 synthetic nonabsorbable suture. A holeismade inthe mobilized mesentery tothe right colon,just anterior tothe duodenum,to allow the inferior vena cavatobe brought into approximationwiththe superior mesenteric vein (). Prior totransposing the inferior vena cava,the medial and lateral aspects ofthe right iliac vein are marked with sutures.This facilitatespassing ofthe inferior vena cavathrough the opening made inthe mesentery tothe right colon and also helpsthe surgeon maintain orientation of the vein.The veinisthen passed through the window (inset) sothat it can beapproximatedtothe superior mesenteric vein. The inferior vena cava and right iliac vein are trimmed sothat the systemic vessel can beanastomosedto thesuperior mesenteric veinwithout tension, but also without redundancy. Often the entire rightiliac vein can be excised (F). l I II Tunnel T ,.--'-;--'-- - - in mesocolon R.colon R. colon DuodenumTunnel I ~ TransversE mesocolo-Pancreas The superior mesenteric vein isclamped proximally and distally with straight Cooley clamps. Any large branches into this segment of the superior mesenteric vein,such as the inferior mesenteric vein, are controlled with vesselloops. Anellipse isexcised fromthe rightlateral wall ofthe superior mesenteric vein (G). Anendtoside anastomosis isperformed with continuous 5-0 synthetic nonabsorbable suture. Stay sutures are placed at either end ofthe anastomosis passing fromoutside in onthe superior mesenteric vein and inside out onthe inferior vena cava.The most cephalad suture issecured, and one needle is passed onthe inferior vena cava sidetowithin the anastomosis.The posterior row isthen run inan overandover continuous fashiontothe lower stay suture, which isthen secured.The needleispassed outside through the inferior vena cava and tiedtothe lower stay suture. The running of this posterior rowis often made easier by placing stay sutures midway along the anterior wall ofthe inferior vena cava and superior mesenteric vein (H). Since this shunt isperformed inchildren, the anterior layer should be interrupted to allow for growth. This isperformed by placing a number of 5-0 synthetic nonabsorbable horizontalmattress sutures everting the anterior suture line (I). This shunt isa total shunt diverting the entire mesenteric blood flowinto the end of the inferior vena cava (J). Since this shunt isusually doneinthe presence of a thrombosed portal vein,the subsequent consequences of a total shunt that are seen inadults with parenchymal liver disease are generally not seen.However, emotional disturbanceshave been identified in some individuals whohave survived formany years after this shunt wasperformed inchildhood. r'erior vena cava -' Inferior venacava -:-''::-___ Superiormesenteric v. Duodenum ______--''';-_ _ -',:;.---___ Superiormesenteri c v. Superior mesentericv. ts oiSurgery Mesoatrial Shunt Operative Indications Inmost instances whenportalhypertension is an indication for a mesenteric-systemic venous decompressionprocedure,the inferior vena cava isused asthe receptacle.Inunusual instances,however, the inferior vena cavamay bethrombosed or havea venous pressure that approaches the portalpressure. Inthose instances the inferior vena cava isnot a suitable or appropriate receptacle fora mesenteric-systemic venous shunt. The situationin whichthis ismost commonly foundisthe Budd-Chiari syndrome. In the Budd-Chiari syndrome a significant percentage ofpatients have thrombosis ofthe inferior vena cava as wellas thrombosis oftheir hepatic veins.In others, because of the marked congestion ofthe liver and hypertrophy ofthe caudate lobe, the inferior vena cava iscompressed,resulting insuch a high pressure that its use as a receptacle fora shunt is obviated. Inthose instances when decompression ofthe mesenteric venous system is deemednecessary,a mesoatrial shunt is the shunt procedure of choice. The typicalpatient willbe an individual with the Budd-Chiari syndrome,inwhom the diagnosis has been confirmed by liver biopsy and byattempted catheterization of the hepatic veins. Angiography should beperformedto demonstrate a patent mesenteric venous system.Inferior vena cavography shouldbe performedto look for inferior vena cava occlusion or an inferior vena cava compressed wi th a high pressure. Operative Technique Themesoatrial shunt isperformed through along midline abdominal incision and aright anterior thoracotomy. After entering the peritoneal cavity,the abdomen is explored to rule out otherpathology.The li verwillbemarkedly congested (A). H a liver biopsy hasnotbeen performed preoperatively, one should be performed. Massive ascites will generally be present, andthis shouldbe suctioned fire. Congested liver . ~ ~ ~ ~ ~ ~ ~______________ T r ~ colon 299 Theinitial steps of a mesoatrial shunt are identicalto those of a mesocaval shunt. The transverse colonand omentum are reflectedin a cephalad direction.The rootofthe transverse mesocolonis dissectedtoidentify the superior mesenteric vein.There arenoclear landmarks toleadone tothe superiormesenteric vein.The superior mesenteric artery istothe left andposterior to the superior mesenteric vein.However , the relationships ofthese two structuresare variable andpalpating forthe superior mesenteric artery generally doesnot help in identifying the superior mesenteric vein. However,ifthe dissectionis widened and deepened through the root ofthe transverse mesocolon, the superiormesenteric vein is always identified (B). There are many large lymphaticchannels in the retroperitoneum,and to decrease the amount of ascites formationsubsequently,these tissues shouldbe clamped,divided, andligated. Oncethe superior mesenteric veinhas been identified,a 6- or 7-cmlengthis mobilized circumferentially (C). Small venous branches are ligated and divided. Large branches are controlledby doubly looping with vessel loops. Once a long length of superior mesentericveinhasbeen cleaneduptothe inferior border oftheneck ofthe pancreas, the root ofthe transverse mesocolon isdivided and the lesser sac entered (D). This requiresexposing a short length ofthe inferior border ofthe pancreas. It also oftenrequires dividing sizable arterialbranches, occasionally including the middle colic artery, coursing anteriorly fromthe superior mesenteric artery. If an artery issolarge that one is concerned with viability ofthe colon,the artery shouldbe occludedwith a bulldog clamp temporarily tobe certain that a goodpulse remains in the marginal artery. - aarc sa Superior mesenteric v. Large posterior branch of. Superi ormesenteric v. Pancreas Transverse mesocolon Tolesser sac SuperIOr II:lIlaew.. The prosthesisused foramesoatrial shunt isa16-mm Goretex graft with external support rings.Inaddition, an 8-cmSilas tic cuff is bondedtothe midportion of the prosthesis. The Silastic cuff willbe positioned under the sternum to prevent compression ofthe graft. In preparing the course forthemesoatrial prosthesis, one passes one's hand into the lesser sac throughthe opening previously made inthe rootofthe transverse mesocolon. A second opening isthenmade inthe omentum in the midline, just belowthe gastroepiploic vessels. The caudal portion ofthe prosthesis willpass fromthe area of the superior mesen teric veinthrough the opening made inthe rootofthe transverse mesocoloninto the lesser sac andthen outthe opening inthe omentum. The prosthesisthen passes anterior tothe stomach and anterior tothe left lobe of the liver. A right anterior thoracotomy isthen performedthroughthe fifth intercostal space. Oncethe thoracotomy incisionhasbeenmade,the abdominal and thoracic wounds are connectedbypassing one's fingersdirectly under the sternum into the anterior mediastinum and then out throughthemediastinalpleura into the right chest (E). A.anterolateral thoracotomy inCISiOn .. .t:' Xiphoid Goretex graft cuff /Silastic Stomach Transven;e color. Themesoatrial prosthesis isanastomosed first tothe superior mesenteric vein.The superiormesenteric veinis occludedproximally with an acutelycurved Cooley clamp and distally witha straight Cooley clamp. A smallellipse isremovedfromthe anterior surface of the superior mesenteric vein. The mesoatrial prosthesis is cut withthe appropriate bevel.The anastomosisis performed with continuous 5-0 synthetic nonabsorbable suture. Mattress sutures are placedat eachendofthe anastomosis by passing the suture material fromoutside inonthe superior mesenteric vein,theninside out onthe prosthesis.The suture then passes outside inonthe prosthesis and inside out onthe vessel (F). The anastomosis isperformedby firstsecuring the most cephaladstay suture andthen running downthe right lateral sidewith a continuous over-and-over suture (G).It istiedtothe securedinferior stay suture. The right lateral suture lineisthenrun fromabove downward and downwarduptomeetinthe mid portion ofthe anastomosis (H). Whenthe anastomosishasbeencompleted,the prosthesis isclamped, and oneCooley clamp is removedfromthe superior mesenteric veintobe certain that the anastomosis is secure.The Cooley clamp isthen replacedandthe prosthesis clamp removed. ) (. Superior mesentericv. Superior Transverse :.-'l''----- --- mesocolon graft Gorelex graft mesentericv._______-The atrial anastomosisisperformed next. It isvery important prior to performing either anastomosis to becertain that the prosthesis is positioned so the Silastic cuff resides under the sternum and ontop ofthe hypertrophied left lobe ofthe liver.Once the position ofthe Silastic cuff isdetermined, only then isthe inferiorprosthesis length determined and thebevel cut. After performing the anastomosis between the prosthesis and the superior mesenteric vein,the pericardium isopened, and the right atrium and atrial appendage are grasped ina Satinsky partial occlusion clamp.The clamp is placed inthe same oblique direction that the prosthesis enters the right pleural cavity and approaches the atrium. The atrial appendage isexcised and the trabeculi within the atrial appendage divided.The mesoatrial prosthesis iscut with the appropriate bevel and to the appropriate length. The atrial anastomosisisperformed with continuous 4-0 synthetic nonabsorbable suture. Stay sutures are placed at each end ofthe anastomosis, passing from outside in onthe atrium and inside out onthe prosthesis (1).The most cephalad stay suture issecured and then passed inside through the prosthesis. The posterior suture line isrun fromwithin over-and-over downtothe inferior stay (J).The suture isthen passed tothe outside ofthe prosthesis and secured to the inferior stay suture. The anterior row ofthe anastomosis isthen completed by running the cephalad suture down caudally (Kand L). ..~ ~ "-Ratrium LNer / ~ .,lL--Goretex - -graft Xi phoid col ! "-. "' lliJ l Once both anastomoses have been completed with the vascular clamps on,a large bore19-9auge needleisplaced into the prosthesis at its highest point where it passes over the leftlobe ofthe liver (M). The clampsare removed fromthe superior mesenteric vein,and the prosthesis isallowedto fillwith blood,evacuating allthe air throughthe needle.When oneiscertain that allair has been eliminated fromthe prosthesis, theright atrial clamp isremoved and flowisestablished. Utilizing the previously placed needle,pressures canbe measured.The needle is connected viaintravenous tubing to a water manometer.When the prosthesis isclamped onthe atrial side ofthe needle,the resulting pressure is interpreted as un decompressed portal pressure.Whenit isclamped ont he superior mesenteric venous side ofthe needle,the pressure isinterpreted as right atrial pressure.Withno clamp, the pressure representsthe decompressed portal venous pressure. Goretex _____-'::..-grall Transverse colon Xiphoid _ - -=-------Goretex graft

mesenteric v. Themost common route forthe mesoatrialprosthesis passes fromthe superior mesenteric veinthroughthe transverse mesocoloninto the lesser sac, out through the greater omentum anterior to the stomach, and anterior tothe left lobeofthe liver.It then passesunderneath the sternum, protected fromcompressionbythe Silastic cuff,into the anterior mediastinum, and then into the right chest tobe anastomosed tothe right atrium (N). Occasionally the liver isso hypertrophied and congestedthat the prosthesis cannot easily pass anterior tothe lower edge oftheliver.Inthose instances we have routed the prosthesis into the lesser sac, posterior tothe stomach, and through the diaphragm into the right chest just anterior and lateral tothe inferior vena cava.Thus the prosthesispasses fromthe superior mesenteric vein into the lesser sac throughthe transverse mesocolon,posterior tothe stomach,thenthrough the diaphragminto the right chest,prior tobeing anastomosedtothe right atrium. Inthese instances it isnot necessary to use a prosthesis towhich has been bonded a Silastic cuff. Inthe firstinstance the prosthesis passes directly posterior tothe sternum into the mediastinum and right chest, andinthe second it passes throughthe diaphragm, just anterior andlateraltothe inferior vena cava (P).

S:>peiiOlmesen eric v.______--',:\ Inerior R.atri um - ----J:: \\:_-';-_ _Sternum -4.---Silasticcuft +-_____G'oretex graft ____________----'\ f----- Omentum Transverse mesocolon Transverse colon _ _Smallbowel Xiphoid I , "... .. ., . Diaphragm Pancreas_ _--':-'-:''-Duodenum________venacava ________f)1.-- - --- ---:--":---- - Esophagus Vi ) Le Veen Shunt Operative Indications Most patients with asci tes secondary toportalhypertensionan3-disease are amenable tomedicalmanagement.This mightreq-severe sodium restriction andlarge doses of diuretics_With andappropriate medicalmanagement , however, most patients with ascites can bemanaged satisfactorily. However, in some instances, even with the strictest, most fastidiousmanagement,ascites willpersist and be intractable.Such patients are candidates for the LeVeen shunt. Inaddition, there isa smaller group of patientswith malignant ascites,whose overall stahl ofhealth suggests that theyhave a significant chance for continuingurvival Inthese patientsthe inconvenience ofmassiveascites with pulmonary compromise mightbesuch that a LeVeenshunt isindicated. Relativecontraindications forperforming the LeVeen shunt include significant liver failure,with an uncorrectable coagulopathy or a serum bilirubin greaterthan 10mg%.Experience indicatesthat few ofthese patients do well.In addition,adequate renal functionmust be present as a successful LeVeen shunt requiresmarked diuresis of the ascitic fluidshuntedinto the vascular system. Lastly,there shouldbenohistory ofheart failure, aa si7;lbl!! volume load wi llbe placed onthe heart following LeVeen shuntplacement. Operative Technique ALeveenshunt canbeplaced on either side, but generallythe right siiI is preferred, as the thoracic duct is avoided.The transverse abdominal incisionto insert the one-wayvalveisplaced201" 3 ioc:Ir' belowthe costal margin, inthe anterior axillary li ne. The neck incisionto exposethe internal jugular veinis placed obliquely along the auto. border ofthe sternocleidomastoid muscle (A).The procedure can be perlarDlllld under local anesthesia.Wi th an illpatient with severe liver disease. local anesthesia is an excellent choice.In otherpatients generalanesthesia is wdI tolerated. The neck incisionis made along the anterior border ofthe sternocleidomastoid muscle anddeepeneddownthroughplatysma. The sternocleidomastoid muscle is retracted laterall y andthe carotid pulse palpated The jugular vein willreside justlateral to the carotid artery (A). The internal jugularvein is cleanedandmobilized fora 3- or 4-cmIe (B). Once the internal jugular veinhas beenmobilizedadequately.the wound~ packedwitha sponge soakedin an anti biotic-containing saline solution_ Internal jugular v. \ , . , StemoCle;.:fonlasi,oii d m. ICff,:1:1' I,llr . ~ Hema! ". '-;-_ _ __ R.camtida '\:- ----_ ____ Jl bcl on1inal incision Small opening Transversus abdominis m. ______ __~ : , _ ~ Peritoneum_______~ Avariety ofinstruments can be used tomake the subcutaneous tract that passes fromthe abdominal incision to the neck (E).Wegenerally have used bronchoscopy forcepswith alligator tips. If the procedure isperformedunder local, at this point the patient should bemildly sedated, and the tract infiltrated with localanesthesia.Once the instrument has beenpassed upinto the neck wound over the clavicle (F),an umbilical tape issecured tothe instrument, and then retracted back down through the tract (G). SmalloPI9nilng ._ _____t / J ~ Subcutaneous tract Bronchoscooy forceps The LeVeenshunt valve with attached venous tubing isthen positioned by firstpassing a tonsil clamp throughthe muscular layers ofthe anterior abdominal walltothe area ofthe peritoneum through whichthe Le Veenshunt valve willbeinserted (H). With the LeVeenshunt nowpositioned so that the tubing onthe end ofthe valve can be inserted into the peritoneal cavity (I),it istime to place the two pursestrings inthe peritoneum.The pursestrings consist of2-0 or 3-0 synthetic nonabsorbable suture material.The pursestrings arenot placed untilthe valve and its tubing are positioned forinsertion, because asthe sutures are placed through the peritoneum, ascitic fluidbegins toleak. Oncethe two concentric pursestrings have beenplaced, a small opening is made inthe center (K). The Le Veenvalvetubing isthen inserted into the peritoneal cavity.The abdominal tubing shouldbeshortened prior to insertion sothat nomorethan 8 inare inserted into theperitoneal cavity. ,. < Small oOl, ri il'o in abdominal wall muscles R---Peritoneum _____ Valve ___ Venous tubing Peritoneum --------------- Umbil icaltape J _ __ AhOOrnir,,' tubing I J ~ ....j Priorto inserting the Le\-een sbmn mlWng into the peritooeal canty, some oithe ascite5 can be ~~suaioning .11. This ckrreases the amount of ascites and endotoxin that \\'il\ enter the vascular spare, thus decreasing the likelihood of disseminated intravascular coagulation. The tubi ng isthen inserted.maki ng an effort to guideitin a caudal di rectiontowardsthe pelvis (M). Once the abdominaltubing has beeninserted andthe val ve seated, the two pursestrings are secured. The outer pursestring isthen furthertied around the valve neck towhichthe venoustubing is attached (N). The LeVeenshunt is now seated such that it resides ontop ofthe peri toneum,but underneat hthe muscle layers ofthe anterior abdominalwall. The venoustubing passesthrough a smallholeinthe muscle layers into t he subcutaneous space (inset). The end oft he venoust ubing ist hentiedto the umbilicaltape that resides inthe subcutaneous tunnel (0 ). The tubing ispulled upthroughthe track into the neck by withdrawing the umbilicaltape into the neck incision.The flowof ascitic fluidisimmediately evident fromthe end of t heintravenous tubing. It is allowedto flowinto a small basin. Umbilical ----------tape ) '-.,;." )Abdominallubing Peritoneum enous____ Venous tubing Peritoneum Transversus m. \ __ Internalobliquem. '-____ External oblique m. __ ______ bng ::;:::io:=t::::----- --Peritoneum

Abdominal wallmuscl es Valve Venoustubing '-________________Abdominal tubing 322 The YenOU5t'Jbing isthen inserted into the internal jugular yein.. A pu.::etJing of -l-Osynthetic nmabscrbabIe suture is placed inthe anterior wallof the jugular yein,P '. \\"iththesegment of internal jugular veincontaining the pursestring occludedproximally anddistally \\ith \esselloops, a small \enotOmyismade.The length ofvenoustubing to beinserted should be carefullymeasured ..-illteriorly it canbebrought out onthe chestwalland CUt off atthe lewlofthe secondrib (Q). Generally thisisa length of tubing that extendsinto the jugular veinforapproximately 4 to ;)in.The tubinghould resideinthe superior venacava orright atrium.If it is cuttoo short and resides inthe internal jugular vein,malfunction andthrombosiswillalmost certainly follow.It isimportanttohave the catheter resideinthe chest andbeinthe environment ofthenegative intrapleural pressure. Oncepositioned,the pursestring is secured(R),andthenthe vesselloops removed(S). Analternative means of securing the venous catheter inthe internal jugular veinis toplacea ligature superiorly, andthen after the venoustubing hasbeenpositioned, place a 2-0 silkligature aroundthe veinandtubing inferiorl y (T).Some feelthis interruption ofvenous fl owmakesthrombosisand malfunction ofthe shunt morelikely. If one inserts the tubing through a pursestring, flowcontinues inthe jugular vein. Whenthe shunt has been successfully inserted,the abdominaltubing from thevalvewillresideinthepelvis (U).Ascitic fluidwillenter the tubing, traverse the one-way valvebeing propelledbythepositiveintraabdominalpressure against a gradient ofthe negative intrapleural pressure. If the venous tubing is appropriately placed,it willreside inthe superior vena cava or right atrium.. Atthispoint a fine needle should beinsertedobliquely into the shunt tubing, clamping the tubing distally, and fluidwithdrawn untilbloodis seen. The clamp is then removed andthe bloodshould be washed out,thus confirming function of the shunt. Contrast media can also be injected via the needle andradiographic confirmation of function obtained. Radiographic confirmation ofright atrial placement ofthe shunt can also be obtained intraoperatively. I Lateral jugular v. _ H-- - R.carotida. --'--- _ __' _Venous tubi ng / /' /' Internal

_ _,./"7Tip inr. atrium tubingi" ,:\) ;;.'\\'- ;;::- m/ ::: tI I.-.. / ,', " " " " :: :: :, .' Abdominaltubing / .., to' IIII The Pancreas Longitudinal Pancreaticojejunostomy: Puestow Procedure Operative Indications Patients with chronic pancreatitis, abdominal pain, and a dilated pancreatic duct are candidates forlongitudinal pancreaticojejunostomy, or the Puestow procedure. There isno evidence that endocrine or exocrine insufficiency isimproved bythe Puestow procedure,but 75 to 85 percent ofpatients with pain achieve significant relief.Patients with calcification intheir pancreas appear tobe more apt tobenefit fromthis operation than those without calcification. Among those patients with abdominal pain secondary to chronic pancreatitis, less than 50percent have a dilated pancreatic duct (8mm indiameter or greater) and are thus candidates forthe Puestow procedure.The remaining patients with abdominal pain and chronic pancreatitis, without a dilated pancreatic duct, are candidates foran ablative procedure if surgical therapy is required. Operative Technique The chain oflakes pattern ofpancreatic duct dilatation (A) lends itself welltothe Puestow procedure. This anatomic pattern isactually seen somewhat less frequentlythan the pattern where the entire pancreatic duct isdilated, without multiple intervening strictures.. The operative procedure can be done either through a midline or a bilateral subcostal incision. Once the abdomen is entered the pancreas is exposed throughthe lesse!" sac by dividing the greater omentum (B). COmmon________~ ~ - - - - ~ bile duct Duodenum , Head of pancreas Pancreaticoduodenal arcade Stomach Superior mesenteric aand v. The entire pancreas should be ellmed andpalpated ilirougfi ~ \ e s sac andbykocherizing the duodenum. Once the tail, body,neck. ant head ofthepancreas have been e.xposed,the dilatedpancreatic duel frequently canbe identifiedby finger palpation along the anterior surface of the gland.Its position is confirmedby aspirating with a 19-9auge needle and a 10ml syringe (C). Once clear pancreatic secretionsare obtained,using an electrocautery a pancreatotomy is made along the needle downinto the dilatedpancreatic duct The needle is then removed,anda rightangle clamp is insertedinto the dilate duct. The duct is filletedopen forits entire lengthusingthe electrocautery (DJ Several studies have demonstrated that thepancreaticojejunostomy needs to 1 at least 6 emin lengthtomaximize good long-term results. Oncethe duct isfilletedopen,an attempt shouldbemadeto paa ~ dilator carefully into the proximalpancreatic duct, through the ampulla. and into the duodenum.If this is not possible, some surgeons recommend performing a duodenotomyand sphincteroplasty. This procedure is demonstrated onpages 18-27. In addition,most pancreatic surgeons feelthat a cholecystectomy should be performed at the same time a Puestow procedure is carriedout if the gallbladder is stillinplace, eventhough definite gallbladder-pathology maynothave beendemonstrated.The technique of cholecystectomy isdepictedonpages 2-9. Asplrabonof dilatedduct Stomach Dilatedpancreatic duct Pancreas 'r---r--- Dividett Dilated pancreaticduct orne . '--___ Spleen ARoUX-en-y jejunal loop60cm inlengthis constructed. It isour feel ing that the loopshouldbe 60cminlength,rather than 45 cm, fortwo reasons:the longer loopshould providebetter protectionagainst reflux ofenteric contents tothe end ofthe jejunalloop;andifa reoperative procedure isrequiredinthe future and the Roux-en-Y anastomosis has toberevised, there isenough length such that a new Roux-en-Y loopwill nothave to be created_ During construction ofthe Rouxloop,the jejunum shouldbedi videdas closetothe ligament ofTreitz as goodarcades willallow.It is oftenhelpful , particularl y with a fattymesentery,toturn offthe operating roomlights and to \-isualize t he vascular arcade byhaving t he headlight directed onthe small bowelmesentery (inset). Once a convenient area islocated,the mesentery is divided (E)and cleaned fromthe anti mesenteric surface ofthe boweldown towards t he root ofthe mesentery (F)-Pro"""a1jejt.nJn Transillumination of Mesentery rr--'":"---- - D,vided Vascular arcadein small bowel meseme Inferior 2 . ~ _ - - ; - - ; ; ~ _ - , - - ; - _ _ _border of pancreas Palpation of body and of pancreas Because ofthe relatively thinnature of the pancreas, and because insulinomas are spherical, often a portion of the neoplasm willbe evident underneath the capsule of the pancreas (D). It willusually appear tohave a bluish coloration,although occasionally lesions are flesh colored. Such lesions willusually shellout with a combination of blunt and sharp dissection (E). A variety of techniques canbeused,but placing smali ligaclips on the pancreas slide and cauterizing toward the insulinoma side willprovide fora rapid,bloodless mobilization ofthe lesion (inset). Oncethe lesion isremoved, one should examine the bedofthe tumor carefull y tobe certain there isno evidence of amajor pancreatic duct injury that occurred during the dissection (F). If not, the remaining portion ofthe gland shouldbe carefully examinedagain tobe certain that a secondlesionis not present. Penrose or closed suctiondrains are left inthe area of the insulinoma removal and are brought out through a stab wound inthe leftupper quadrant. If afterthorough examination, anislet celltumor cannot be identified,most surgeonsprefer to performa distal85percent pancreatectomy, sincethis will encompass the pancreatic tissue where statistically most lesions reside.In addition, if islet cellhyperplasia is present, this procedure may be ofbenefit. Islet cell tumor Cauterizevessels ontumor C l i p ~ s onpanoreas Shelling out of Islet Cell Tumor Pancreaticbedof islet celltumor AtlasofSurgery Drainage of a Pancreatic Abscess Operative Indications Pancreatic abscess and/or sepsis isthemajor cause ofmorbidityand mortalityinacute pancreatitis. Early diagnosisisessential if pancreatic debridement anddrainage istobe performed early enough toprevent life-threatening morbidity.WithCT scanning to identify peri pancreatic fluidcollections and areas ofnecroticpancreas with or without air bubblesandwiththe ability to fine-needleaspirate fluidcollections tolook forbacteria,the diagnosis of a pancreatic abscess often cannow be made relatively early inits development.Whenthe diagnosis ismade, the patient should be stabilizedandtakentothe operating roomassoonas possible. Operative Technique Either a longmidline or a bilateralsubcostal incision can be used. Adequate exposure isparticularly important asit isessentialthat the entire abdomenbe explored for extensions ofthe abscess away from the pancreas, down either paracolic gutter, into the transverse mesocolon, orintothe leftor rightupper quadrants. Once the abdomenisentered the omentum isdividedwidelysothat the entire lesser sac canbe exposed (A). Rather thanlarge collections ofpus,the more frequent findingis of grumousnecroticmaterial fillingthe lesser sac and surrounding the pancreas. Omentum .'" Transversecok>n It is essential that the entire abdomen be explored forextensions ofthe abscess out ofthe lesser sac.The transverse colonisbeing reflected in a cephalad direction, identifying extension ofthe abscess inferiorly in the retroperitoneum, and into the root of the transverse mesocolon (B). Transverse mesocolon Retropentoneal extensl()(\ cAabscess Proximal jej unum :; It isimportant to take down the hepatic flexure and mobilize the right colon out ofthe retroperitoneum tobe certain the abscess doesnot extend down the right gutter (C).This isone ofthe most common sites of extension that ismissed at laparotomy fora pancreatic abscess. Generally, this isa goodtime to extensively kocherize the duodenumtobe certain there are no extensions fromthehead ofthe gland ina cephalad direction.The left colon should be mobilized ina similar fashion. Extension ofthe abscess down the left gutter can beseen (D). Debridement ofthe necrotic grumous materialhas begun at the root ofthe transverse mesocolon.Debridement can becarried out sharply using scissors, but generally blunt debridement using one's fingers or instruments such as the sponge forcepspictured here (E)ispreferred. R.paracolic gutter Rootoftransverse mesocolon ProXJmalI"Junum ! Transverse colon MotJiIized ,. colon Transverse colon L.colon ExI"..5""" L.colon What often appears initially tobenecroticpancreas isusually fat necrosis andinflammatory debristhat isactually ontop of and surrounding a still viablepancreas (F).During this phase ofthe debridement it is essential to followthe abscess out tothe tip of the tail of the pancreas, tobe certain that one doesnotmissextension ofthe abscess into the leftupper quadrant under the left hemidiaphragm. Once the debridement has progressed tothe point where further debridement results inbleeding, extensive irrigation should be carried out (G). Weprefer a dilute antibioticcontaining saline solution.Overly aggressive debridement can leadtobleeding that is very difficult to control. Transverse colon I ~ I It Stomach Irrigation of lesser sac T ~ colon Following adequate debridement , two options are available to achieve drainage.One optionisto insert a series of silastic sump andPenrose drains into allofthe various extensions of the abscess.Inthis patient, the lesser sac, leftpara colic gu tter,therootofthe transverse mesocolon,andthe retroperitoneum atthe rootofthe mesocolonhave allbeen debridedand drained (H). Oncethe drains have been inserted, the abdomenis closed (assuming that allofthenonvital tissue has beenremoved).Asthe patient improves, sinograms can be obtained through the axiomsump drains,and eventually allofthe drains willbe slowly advanced out ashealing occurs. Stomach of pancreatic abscess Transversecolon Ptaremelll: 01 drains Another option fordrainage istopackthe entire lesser sac andall extensions ofthe abscesswith Mikulicz's pads (1). The corner of each Mikulicz's pad with the ring tag isbrought out throughthemiddle of the incision (J). These packs are placedwiththe intention of changing them every two orthree days.thereby continuing tomechanically debride the abscess cavities. The upper and lowerportions ofthe wound are closed with large stay sutures ofNo.1 nylon.with rubber bumpers constructed fromFrench catheters (J. inset). The dressings canbe periodically saturated postoperatively with antibiotic-containing solutions. The initial repacking shouldbe done under general anesthesia inthe operating roomin 48hours.Eventually. however. the repackingsmay beperformed under heavy sedation intheintensive care unit. The packing changes continue every two or three daysuntilthe abscessis thoroughly debrided andthe cavity has started granulating. This usually takes several packing changes. At this point one can insert Penrose and sump drainsasdemonstrated previously (see pages 450-451) and close the abdominal wound. The other option is to continue the packingsuntil granulation and contracture haveprogressed to the point where the cavity has actually closed.This optiontakes longer. but is perhaps safer. Bed ol paoc:reatic abscess Transversecolon Stay suture f'aliol!l -----Pancreas Open packing OJ Transverse cokD Divided o m e ~ Diverticu1arization of the Duodenum and Pancreatic Drainage for Combined Duodenal and Pancreatic Trauma Operative Indications The surgicalmanagement of combinedpancreatic and duodenal trauma can be very challenging to the trauma surgeon.These combinedinjuries carry ahighmorbidity and significant mortality. Operative Technique Virtually allpatients with blunt or penetrating trauma shouldbe explored through a long midline incision. Once the abdomenhabeen completely explored and only the pancreatic andduodenalinjuries found,these lesions are attendedto. Inthisinstance there is a contusion of the duodenumwith two perforatioos and a stellate injury tothe head and neck ofthe pancreas (A). Insuch instances, ifthe patient isstable, one shouldrule out amajor injury to the biliary treeandpancreatic duct radiographically.Occasionally the ampulla canbe cannulated and cholangiography andpancreatography carried outthrough one of the duodenotomy wounds. If the ampulla isnot easily accessible, contrast canbeinjectedinto the gall bladder and then forcedinto the biliary tree.However,with an unstable patient, visualization and palpatioo at the time of surgery may be allthat one can dotorule inor out amajor duct Inj ury. If combined pancreatic and duodenal trauma isso severe that the duodenum and ampulla are destroyed andreconstruction cannotbe carried out. a pancreaticoduodenectomy (see pages 386-413) may rarely benecessary. In ID05t instances, however, duodenal repair canbe carried out andpancreatic drainage performed. wounds Slomach ______----'_ Hepalic flexure of colon Stellale injury ofpancreas Divided greater omentum Body of pancreas If the duodenal and pancreatic lesions are severe but repairable, one may decidetoperformthe diverticularizationprocedure. Thisrequires resection ofthe antrum ofthe stomach, closure of the duodenum to divert gastric flow,and decompression ofthe duodenum with a duodenostomytube. The duodenalinjuriesare repaired, and the pancreatic injury is drained. Enteric continuity isreestablished via a gastrojejunostomy.The midportion of the stomach isdividedbetweentwo sets of Kocher clamps (B).The firstportion ofthe duodenum isdividedbetween stone clamps, although aGIA stapler can also be conveniently used.The two duodenal perforations havebeen closed. First portIOnof Repaired duodenal wounds Pancreatic inj ury G'EOEX Antrumof stomach DIvided greater omenn.m Proximalstomach , \ \ The end ofthe normal duodenumisclosed around a Foley catheter, using two inverting purse strings of 3-0 silk (C).This catheter serves to decompressthe duodenum and allows forsafer healing of the contused duodenotomies.If one of the closed duodenallesions opens anda duodenocutaneous fistuladevelops,having the duodenostomytube in place should facilitate decompression ofthe duodenumandclosure of the fistula. The lesser curvature of the stomachisclosedwith aninner layer of 3-0 synthetic absorbable suture runina horizontal mattress fashionunderneath the Kocher clamp and then carriedback inan overandover locking fashion. Repaired duodenal wounds 1 Pancreatic injury Body of pancreas Transverse colon An inverting outer layer of interrupted 3-0 silk sutures isplaced onthe lesser curvature, and then a gastrojejunostomy isperformed tothe proximal jejunal loop.This iscarried out with an inner continuous layer of 3-0 synthetic absorbable sutures and an outer layer of interrupted 3-0 silk (D). Often the surgeon will decidetoperform a cholecystectomy and decompress the biliary tree byinserting aT- tube.This isparticularly important ifone has notbeen ableto evaluate the biliary tree cholangiographically or if it has been identified cholangiographically and aninjury ispresent. The pancreatic injury isdebrided carefully toremovedevitalized tissue. Great care should be taken toavoid injuring the pancreatic duct. The duodenal closures as wellas the T -tube insertion site are drainedwith Penrose drains.The stellate pancreatic injury isdrained with a silas tic sump brought out through a separate stab woundinthe right upper quadrant. -tube in common duct Hepatic Ilexure 01 colon Repaired duodenal wounds - ~ - - Pancreatic injury Proximal jejunum --... -. Pyloric Exclusion and Pancreatic Drainage for Combined Duodenal and Pancreatic Trauma Operative Indications In some instances of combined duodenal andpancreatic trauma,theinjury maynotbe extensive enough towarrant a hemigastrectomy and diverticularization of the duodenum.Inaddition,the patient may be unstable, andthe surgeonmay prefer nottoperforma hemigastrectomy but stilldesire to divert gastric contents away fromthe injured duodenum.In these instances pyloric exclusion isan attractive alternative to duodenal diverticularization. Operative Technique Allabdominaltrauma patients are exploredthrough a midline incision. The abdomenisthoroughly exploredtoidentify all intraperitoneal injuries.Inthis instance there is a contusion ofthe duodenumwithtwo perforations anda stellate injury to thehead and neck ofthe pancreas. Asintheprior procedure (see pages 454-461), anattempt shouldbemade, ifthe patient is stable,to look fora major duct injury. If the ampulla hasbeenexposed by one of the duodenalinjuries, cholangiography and pancreatography might be possible; ifnot,contrast canbeinjected intothe gallbladder andthen forcedinto the biliary tree. If one decidestoperformpyloric exclusion, a distal gastrotomy ismade with the electrocautery (A),andthe pylorus is closed fromwithinusi ng a continuous 3-0 synthetic absorbable suture (B). Liver Gallbladder Duodenal wounds Stomach Stomach I Pylorus The gastrotomy isclosedwith aninner continuous layer of 3-0 synthetic absorbable suture andan outer layer of interrupted 3-0 silk sutures. A gastrojejunostomy isperformedto empty the stomach forthe two or three-week periodthat the pyloric closure stays intact. The gastrojejunostomy iscarried out with aninner continuouslayer of 3-0 synthetic absorbable suture and an outer interrupted layer of 3-0 silksutures (e). A vagotomy shouldbe performedifthe clinicalsituation allows. If not,the patient willrequire long termtreatment withH2blockers. The duodenalinjuriesarerepaired,using two layer closuresifpossible.As withduodenaldiverticularization, ifadequate cholangiography has notbeen obtained, or if a biliary injuryhasbeenidentified,the gallbladder should be removedandthe commonduct decompressedwith aT-tube. Insertion of a duodenotomy tube inthis instance isoptional. Gallbladder T -tube in common duct ___ Divided cystic duct Repaired

wounds NI.r.I 'ANIlON t;. , , , , , , I f __________Common duct I , . , .. ...,--,--Gastrojejunostomy , , , \ , --\ \ \ , , , , \ , , , , ,, \ ....... ... Transversemesocolon Gastrotomy closureOmentum Stell ate inj uryof pancreas , , , , , , , , , The operative procedure is completed by suturing the transverse mesocolontothe gastrojejunostomy onthe gastric side with interrupted 4- 0 sil ks(D,inset). The pancreatic injury is debrided carefully and drained with a silasticsump. The duodenal closuresand the T -tubeinsertionsite are drained with Penrose drains (E). The synthetic absorbable sutures inthe pylorus will generally stay intact fortwo or three weeks,effectively diverting the gastric contents into the jejunum. If the patient does well,oralintake can beresumedwhile duodenal healing continues.After two orthree weeks, the pyloric sutureswillslough and the pylorus willreopen. ~ y ~ - - - - - - ~ - - ~ Omentum --+----:1j Transverse colon Smal l bowel mesentery Jejunal loop Transverse colon Gastrojej unostomy Index Abdomi nalpain pancreas divisumand,366 pancreaticojejunostomy for end-to-end,342 longitudinal, 326 Abscess(es) liver, 224-235 pancreatic, 442-453 Accessory ductpapi llotomy, forpancreas divisum, 366-369 Adenocarcinomas distalpancreatectomyfor,428-435 periampullary,pancreat icoduodenectomy for,386 Alcohol,inchemical splanchnicectomy,422, 423 Ampulla.See alsoPeriampullary carcinoma comrnonductexplorationthrough, sphincteroplasty and,18.Seealso Sphincteroplasty patency of,14 Amylase elevations,pancreas divisum and, 366 Anastomoses.Seespecifictype or procedure Angiography. SeealsoCholangiography distal splenorenal shunt and, 266 portacaval shunt and, 276 proximal cholangiocarcinoma and,58 Arteries.See specific arlery Arteriography,mesenteric,portacavalshunt and, 276 Arteriotomy,infusion catheter insertion through,204 Asci tes, 266 LeVeenshunt and, 312, 320,321 portacaval shunt and, 282 Atrial anastomosis,mesoalrialshunt and, 306 Atriotomy,hepatic veininjury and, 248 B Bakesdil ators, 14, 15 Silastic transhepatic biliary stent and, 46, 102 Ballooncatheter bilia,,-. 12. 13 ainety-fiy percentdistalpancreatectomy and.362-36-! hepatic duct.SecHeparicdue: '='::'J:-ca: io::. B:;:;: r:: ca:r.t:c:- . ::2.E::: ::.:-:.- =-:.-;:..a55 .Biliarystricrure(s) benign,resectionof.38-57 distal secondary tosclerosing cholangitis. 108- 115 side-to-side choledochoduodenosromy and, 28 Biliarytree,152 exploration of,instruments for, 12- 15 intrahepatic, dilatationof,100, 101 retractionof, 276,277 stonesin,10 transhepatic stenting of, 2 benign biliary stricture and, 44-47 Caroli's disease and,128- 141 proximal cholangiocarcinoma and,64-71, 82-83,84-89 sclerosing cholangitis and,102,103 Bil iarytumor(s),proximal.SeeProximal cholangiocarcinoma Bowel, smalldivisionof,332, 333 Budd-Chiari syndrome,252-254 inferior vena cava and, 298 C Calculi ,2 commonduct, 10 side-to-side choledochoduodenostomy and. 28 sphincteroplasty and.SeeSphincteroplasty Calot 's triangle, dissectionof, 4 Cannulation, accessorypapilla, 366 Carcinoma_SeealsoMetastases; specifictype distal pancreatectomy for , 428-435 gall bladder, wedgeresectionofliver and regionallymphnode di ssectionfor. 142- 149 periampull ary pancreaticoduodenectomyfor,386 unresectable, 414-427 Caroli'sdisease, transhepat icstenting for indications for, 128 technique for , 128- 141 Catheter(s). Seealso Cholangiocatheter balloon biliary, 12, 13 ninetyfivepercent distalpancreateCtomy and,362-364 eoude. SeeCoudecathetelisl French.biliarytreeand.14.15 infusion. 204 :or ?Dnalpressuremeasurement. 276 !e::g. Sa Ring catheter> s , 3:jas:r.:. liyer and. 23t 235 :-:-:..:. portacaval shunt and. 2ii2. 2;'3 Chemical spla,)chni=wm y.422.423 Chcmmher4?Eutlc agents.hepatic anery mfusionof.Infusaidpumpfor.200-205 Children. direermesoca"alshunt ior.288 Cholangiocarcinoma Caroli 's disease and.128,132 proximal.SeeProximalcholangiocarcinoma Cholangiocatheter. 8, 9 Cholangiography.SeealsoAngiography cholecystectomy and, 8 closing,16 commonduct explorationand,10 pancreaticoduodenectomyand, 392 proximal choiangiocarcinoma and,58 Ring catheterinsertion during.38 Cholangi tis, sclerosing, 94-107 di stalst ri cturing secondary to,108-11 5 Cholecystectomy benignbile duct stricturesand.38 biliary drainage and. 8 cholangiography and, 8 indications for,2 Puestow procedure and, 328 righthepatic arteryocclusionand, massive liver trauma and, 244 technique for , 2-9 trauma and, 460 Cholecystojej u nostomy hepaticojejunostomy versus.unresectable periampul lary carcinomaand, 418 technique for, 41 8-423 Choledochal cyst Caroli's di sease and.128 resectionof indicat ions for.116 technique for,116-127 Choledochoduodenostom y, sidetoside indicationsfor,28 technique for , 28-37 Choledochoscopy,16, 17,110, III inCaroli's di sease,132,133 Choledochotomy,10-12. 32 anterior,110,111 hepaticajejunostomy and.fordistal stricturing secondarytosclerosing cholangi tis,114,115 Chromic catgutmattresssutures,liver resectionand lateral segment ofleftlobe,164.165 wedge,146.147. 158 Closing cholangiography, 16 Colon, right.directmesocaval shunt and, 292, 293 Colorectal metastases,toli ver, 2 hepatic arreryinfusionand.200 Commonduct distal.di"ision of.60-62.120.121 hepaticojejunosrorny anc.-t25 Idenri :ication or.nme::.-::',-c;:.c:-,:r:,,_: .- -,;>ar.c-ea:c.::c::::.' a.:::.:r._- :r.:: ...-:_:-_:.l.::.::.:;..-;;"-:.;. (_.::-.z:(.::c:,: ..-:=.. :.:.::c. : " lIl5U WlitillS lor. 12- 15 technique f.... 10-1; rransampul/ary. spluncteroplasty and.1 Sa alsophmcrerop!asty Twbe insertion ai[er.Ifl"i CommondUClstones,side to-side choledochoduodenostomy and. 2 Connelltype sritch, 334. 335 Contusions, duodenal. 45-1,455 Cooley clamps di stal splenorenalshunt and, 270 trisegmenleclOmyand,194 Coronary vein, di stal splenarenalshunt and. 272 Coude catheter(s) benignbiliary stricture and. -14.-15 Caroli 's di sease and,134 proximalcholangiocarcinoma and,64.65. 82,83,88, 89 sclerosing cholangitis and. 100, 101 Cyst(s).See alsoPancreatic pseudocyst choledochal Caroli's disease and,128 resect ionof, 116-127 hepatic aspiration of,206, 207 simple.206-209 hydatid. 206 management of,210-223 Cystadenocarcinomas, 208,386 Cystadenomas, 386 Cystic artery identificationof, 4-6 ligation of, 6,7 righthepatic lobectomy and, 182.I' Cystic duct looping of,4.5 righthepaticlobectomy and.182.1 unresectable periampullary carcinoma involving.424,425 Cysti c duct stump.ligationof, 8. 9 Cystic neoplasms,distalpancreatectomyfor. 428 Cystoduodenostomy, 384-385 Cystogastrostomy, 370, 380-383 Cystogram. 372 Cystojejunostomy, 370-379 D Dacronprosthesis,interpositionmesoca\'al shunt and.258-265 DeBakey clamp directmesoca\'alshunt and. 292. 293 distalsplenorenalshuntand.270 Debridement.pancreatic abscess drainage and.-1-16--14 Deepstellate injury. oi Ii"er. 2-10.241 De\-ascularization. oflefthepaoclobe.l:--t nghthepatic lobectomy and.1 D::a:or,. Bake;.14.15 O':i;;.,:x :rac.,ne;l3:lC;:em a.'ld. -16 . :':'2 "- =0=:_.....oIE' Ib hi -z--., DisuI.1'!IIIric ""rd'..... DisW p;mt Mesenteric vein.SeeInferior mesentf7lCSuperior mesenteric\'ein Mesentery, Puestow procedure and. Dl331 Mesoatrial shunt indicat ions for , 298 technique for , 298-311 Mesocavalshunt direct indications for, 288 technique for288-297 interpositi on indications for,252-254 technique for,254-265 Mesocolon, transverse,suturedto gastrojejunostomy, 466,46i Metastases, colorectal.toliver, 2,200 Mikuliczpads,packing with massiveliver trauma and, 246,247 pancreatic abscess drainage and. 452, .\53 +49 Sri C2.!'cino:::la: !pi,-,{r.t llX41WII()T .)?, o O?eraToc 8.Su also Cbolar:gxgra;>ie.-commor.ai1d.10 Operan ... c rraurr.4.Je:-ngnbile ductstrictures Qyer and.-o\"er stitch. 338. 339 p Packing hemostasisand,massivelivertraumaand 246,247' pancreatic abscess drainage and, 452,453 Pain,abdominal pancreas divisum and,366 pancreaticojejunostomyfor end-to-end,342 longitudinal,326 Pancreas drainage of,trauma and, 454- 461,462,467 exposure of,326-328 insulinoma and, 436-439 Pancreas divisum, accessory ductpapillotomy for,366-369 Pancreatectomy, distal forchronic pancreatitis, 350- 359 ninety-fivepercent, 362- 365 fortumor, 428-435 Pancreatic abscess,drainage of,442- 453 Pancreatic duct dilatation, 326- 329 Pancreaticoduodenectomy, 362 indicationsfor, 386 technique for,386-413 Pancreaticojejunostomy end-to-end indications for,342 technique for,342- 349 end-to-side,406- 409 longitudinal indications for,326 technique for,326- 341 Pancreatic pseudocyst,drainageof into duodenum, 384- 385 into Roux-en-Y jejunalloop,370-379 into stomach, 380- 383 Pancreatitis,sphincteropiastyfor . See Sphincteroplasty Pancreatotomy, 328 Papillary neoplasms,386 Papillotomy, accessory duct,forpancreas divisum, 366-369 Pediatric pat ients,direct mesocavalshuntfor 288' Perforations, pancreatic, 454, 455 Periampullary carcinoma pancreaticoduodenectomyfor,366 unresectable,palliati';tfor,

Perironealca'.-1::;.::'YCc:iC :::2 Pui:;cysticli';::: :" ::r ::.:t:-?:J5:::'::::::: ;:-1!;..';"_y Pcor-..ac:avaishunt end-t&->ide. Z;;;_ T.6-281 Inter;x>sllioo'"w gnlft.4. 286-2S:-indications ior. 2-;-4. 276 side-ro-side.282-2"-Portahepatis anatomy of.152 clamping of.inPringlemaneu\"er. 2-1-4 drainage of.cholecystectomy and..9 Portalhypertension, shunts and.Suhuno:il Portal pressure,measurement01.T:7 Portalvein, 152 hepaticlobectomy and left , 170,171 right , 182, 183 pancreaticoduodenectomy and,388. 389 portacavalshunt and end-to-side,280,281 282,283 t ri segment ectomy and, 192, 193 Portasystemic decompression, 266.See also Shunt(s) Pott's scissors, septotomy with, 22. 23 Pringle maneuver, 244, 245 hepatic veininjury and, 248 Prosthesis interposition"H" graft and, 274, 2ll6-2ir. knitted,interpositionmesocaval shunt and. 258-265 mesoatrial shunt and, 302- 305 Proximalcholangiocarcinoma palliation of,transhepaticsteming and hepaticojejunostomy in, 84-93 resectionof,transhepatic stenting and hepaticojejunostomy in bilateral,58- 71 hepatic lobectomy and,72-Pseudocyst,pancreatic. SeePancreatic pseudocyst Puestowprocedure indications for , 326 technique for,326- 341 Pump, Infusaid, 2 forhepatic arteryinfusion. 200-205 Pyloricexclusion,pancreatic drainage and. tar combinedduodenal and pancreatic trauma, 462- 467 Pylorus-preserving Whippleprocedure indications for , 386 technique for , 386-413 R Radiotherapy, postoperat iRproximal cholangiocarci nomaand.82.9'2 RandallStone forceps.12_13 Renalfunction. l,e\ 'eenshunt and.312 Renal ,-ein_leit. distalsplenorenal >hun! and. 2,0 Retroperironeum. distalS?ienorena15b1I!l1 and. 26S.209 Ringca:hetef15' biliary -12_-L1 Cdisea.,< ar.c.=:.-s:;C.:

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;:t!'(,x:::.:ai a1".d.S-E-cil. Roux-enY52.53 Caroli', dis""", and.136- 1&3 choledochalCystand. const ruction of.-t.8.49 S end to-side jejunojejunostomY and. 50,51 hepaticojejunosromyand. benignbiliary stricture and, 54- 57 distalstricturing secondary to sclerosing cholangitis and, 114 proximal cholangiocarcinorna and, 66- 71, 82-83,90-93 sclerosing cholangitisand,104 pancreaticoj ejunostomy and endtoend,346 longitudinal,330-335 pancreatic pseudocyst drai nageinto, 370-379,380 Saline,hypertonic, asscolecidalagent, 212 Satinsky clamp interposit ion"H" graft and, 286, 287 interpositionmesocaval shunt and, 258, 259 Sclerosi ng cholangitis, 94- 107 di stalstrictu ring secondary to, hepaticojejunostomy for,108-115 Sclerotherapy, 266,274 Scolecidalagents, 212 Scoops,forbiliary tree exploration,12, 13 Sepsis,acute pancreatitis and, 442 Septotomy, sphincteroplasty and, 22,23 Shunt(s) LeVeen indicationsfOT,312 technique for,312-323 mesoatrial indications for,298 technique for,298-311 mesocaval direct, 288-297 interposition,252-265 placement of, hepatic veininjury and,248 portacaval endtosi de,275,276- 281 "H," 286- 287 indications for, 274, 276 sidetoside, 282- 285 splenorenal, distal, 266-273 Sidetoside choledochoduodenostomy, 28- 37 Side to-side pancreaticojejunostomy, longitudinal.336- 341 Side-ta-sideponacayaishunt. 2-; 4.5ilastic cuff.mesoatrialJro5thesis c:::. :=':' :2 5!ias::t: :!a:1ShepaticS:t:::::-.' :-2:-.:g::Jili2ry s:r1c:'''::-':;:-.::. di3ec.x a:::. ;.p .... acmoma and. 64--:1 hepatic IOOFnrmy and. 82-83 ;>alliatioo rioN-i'9 Small bo...e!. di\isioo ai. Puesrm< procedure and. 332, 333 Sphincteroplasty incisionlength for.22 indications for, 18 technique for, 18- 27 Sphincterotomy,18,22,23 Splanchnicectomy, chemical, 422, 423 Spleen,mobilizationof distal pancreatectomy and, 352,353 end to-endpancreaticoj ejunostomy and. 342, 343 Splenic artery distalpancreatectomy and, 432,433 end-toendpancreaticojejunostomy and, 344,345 Splenic vein distal pancreatectomy and, 356, 357,432, 433 distal splenorenal shunt and, 268- 273 end-to-endpancreaticojejunostomy and, 344,345 Splenorenal shunt, distal indications for,266 technique for,266-273 Stell ate injury of liver, 238-249 of pancreas, 454, 455,460 Stenting, transhepatic, ofbiliary tree.See Transhepatic stenting ofbiliary tree Sternocleidomastoid muscle, LeVeenshunt and,312,313 Sternotomy,median hepaticveininjury and, 248 trisegmentectomy and,190 Stomach, pancreatic pseudocyst drainage into, 380-383 "Sump syndrome," 36 Superior mesenteric artery, pancreaticoduodenectomy and, 394. 395 Superior mesenteric vein mesoatrialshunt and, 300,301 mesocaval shunt and direct, 290,291, 294-297 interposition,254-257 pancreaticoduodenectomy and, 388, 389 Suture(s) cholecystojejunostomy and, 418- 421 cystoduodenostomy and, 384, 385 cystojejunostomy and,376- 379 distalpancreatectomy and, 358- 361. 434, 435 end-to-end pancreaticojejunostomy and. 348.349 gastrojejunostomv and. -I&I.-l65 hepaticojejunostomy and. 426.42:-matt ress Caroli's disease and.138 chromic catgut.1.,16.IC. l6-t 1';;; ce?lEition me..'-0C3\alclam? and. 25e. T mesoatrialshunt and, 304, 305 nonanatomicalliver resection and.158,159 pancreaticoduodenectomy and, 400-405 pyloric exclusion and, 462-464,466 Thoracotomy hydatidcyst and,218 mesoatrial shunt and,302, 303 Thrombosis,inBudd-Chiari syndrome, 298 Transhepatic stenting ofbi liarytree, 2 benignbiliary st ricture and,44-47 Caroli's disease and,128-141 proximal choiangiocarcinomaand palliation of, 84-89 resection of, 64-71 , 82-83 sclerosing cholangitisand, 102,103 Transverse mesocolon, suturedto gastrojejunostomy, 466,467 Trauma accessorypapilla cannulationand, 366 chronic pancreatitis dueto,distal pancreatectomy for,350 combinedduodenalandpancreatic duodenal diverticularization and pancreatic drainage for, 454-461 pyloric exclusionandpancreatic drainage for,462-467 liver,massive, 236-249 operative,benignbi le duct strict ures and, 38 Tri segmentectomy indications for , 190 technique for, 190-199 T-tube,insertionof,aftercommonducl exploration, 16, 17 Tumors. SeeCarcinoma; specific /oca/ilmor type u Ultrasonic dissector,160 Umbilicaltape,hepaticveininjury and,248 Umbilicalvein,distalsplenorenal shunt and, 272 Uncinateprocess, dissectionof, pancreaticoduodenectomyand, 394. 395 v Vagotomy, 464 Varices esophageal direct mesocaval shunt for.288 portacaval shunt for , 274 gastroesophageal, distalspl enorenalshunt for , 266 Vasabrevia,di vision of, 352,353 Veins. Seespecl/icveins Venacava,inferior.SeeInferior venacava Venousshunt,mesenteric-systemic,252, 274. Seealsa Shunt(s);specIfic type w Wedgeresection, of liver, 156,158- 159 for carcinoma of gallbladder,144- 147 Whippleprocedure,362, 406, 407, 410-413 pylorus-preserving indications for,386 technique for, 386-413