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PART I Pancreas and Biliary Tract

INTRAOPERATIVE CONSIDERATIONS General Considerations

With an overall trend toward less invasive procedures and attempts to shorten hospitalization and has- ten recovery, an emerging consideration in pancreaticobiliary surgery is the surgical approach. The minimally invasive approach has been studied most extensively with distal pancreatectomy. Various series have shown this to be a safe and effective procedure, being associated with similar rates of morbidity and mortality, as well as being oncologically sound regarding factors such as surgical mar- gins and lymph node retrieval, as compared with the open operation. In addition, laparoscopic and robotic distal pancreatectomy has been associated with shorter hospitalization time in most series. Laparoscopic and robotic PD, on the other hand, has not been widely embraced. While there are no prospective, randomized trials to compare this procedure with open PD, initial series report similar rates of morbidity, mortality, and similar oncologic parameters, compared with open PD. Patient Positioning Nearly all pancreaticobiliary operations are undertaken with the patient in the supine position. It is important to have the patient properly positioned on the operating table to give sufficient room for the placement of a self-retaining retractor, while giving the surgeon and the assistant the space to move freely. Tucked arms should be well padded, especially at the elbow and wrist, and it must be certain that any intravenous line or monitoring equipment on the tucked arm(s) continue to function. If both arms are to be left untucked, they should be at a nearly 90-degree angle—but no more—from the operating table to allow for the maximum space for the retractor post and the surgeon on that side while protecting the shoulder joint from undue strain. Monitoring/Intravenous Access Given the complex nature of a majority of these operations, proper monitoring is imperative to main- tain patient safety and ensure a favorable outcome. All patients should have an intra-arterial cathe- ter for continuous blood pressure monitoring, as well as arterial blood gas measurements. Central venous access can be beneficial in certain situations where peripheral access is inadequate or if knowledge of the central venous pressure will alter the direction of the procedure. Generally speak- ing, two large-bore peripheral intravenous lines are adequate for patient resuscitation and avoid the delays and complications associated with central line placement. Incision A variety of incisions can be employed to approach the pancreaticobiliary system. An upper mid- line incision gives good access to the entire pancreas as well as the extrahepatic biliary tree. Proper exposure can also be gained using a right subcostal incision, extending across the midline to the left subcostal area if necessary. Staging Laparoscopy In recent years, with steadily improving imaging technology, a trend has begun away from staging laparoscopy. This has been especially true for CT, a modality that has seen tremendous improve- ments since multidetector scanners replaced helical machines at the beginning of the previous decade. The cost–benefit ratio of using diagnostic laparoscopy, which when combined with lapa- roscopic ultrasound can cost as much as $3000.00 per case, has become less favorable. In cases of nonpancreatic pancreaticobiliary tumors (e.g., tumors of the distal common bile duct and ampulla), the benefit of diagnostic laparoscopy may well be so minimal as to render its use obsolete. In cases of pancreatic ductal adenocarcinoma, however, its use may affect management in 12% to 16% of cases, depending on the series. Selective use, therefore, is appropriate, especially in cases of tumors in the tail and body of the pancreas, larger and borderline resectable tumors, in cases with suspicious but indeterminate liver lesions, and cases with significantly elevated CA 19–9 levels, as these may be harbingers of undetected metastatic disease. Pancreatic Anastomosis Techniques The reconstruction phase following PD is well described in Chapter 2 and elsewhere but suffice it to say here that there are myriad descriptions of successful and low-risk techniques to restore

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