Surgical Exposure of the Pancreas

Exposure of the pancreas in patients with islet cell neoplasms is preferably obtained through an upper midline or a bilateral subcostal incision. Intraoperative evaluation of patients with pancreatic islet cell neoplasms requires a meticulous examination of the entire pancreas for tumor masses that are frequently small (less than 2 cm) and multiple. The duodenum and peripancreatic lymph nodes are also carefully examined because they may be sites of extrapancreatic islet cell tumors. The liver is examined for evidence of metastatic disease. In patients with gastrinoma, 90% of all tumors and virtually all occult tumors have been found in the gastrinoma triangle.22 The gastrinoma triangle is defined as the anatomic region bound by the junction of the cystic duct and common bile duct superiorly, the second and third portions of the duodenum inferiorly, and the junction of the neck and body of the pancreas medially (Fig. 75-4).23 Insulinomas and nonfunctional islet cell tumors are evenly distributed throughout the head, body, and tail of the pancreas, whereas glucagono-mas are primarily situated in the tail of the pancreas.24

The pancreas is exposed by retracting the stomach upward and the transverse colon downward and dividing the gastrocolic omentum (Fig. 75-5). The body and tail of the pancreas are mobilized by incising the peritoneum along its inferior border (Fig. 75-6), allowing access to the avascular plane posteriorly for bidigital palpation (Fig. 75-7), which is important for detection and assessment of tumor size and determination of proximity to the main pancreatic duct.

Complete evaluation of the head of the pancreas requires incision of the lateral attachments of the duodenum (Fig. 75-8). To facilitate duodenal mobilization, the hepatic flexure of the colon is mobilized, and then the lateral s

FIGURE 75-6. Incision of the peritoneum along the inferior edge of the pancreas using a right-angle clamp and the electrocautery. (From McHenry CR. Pancreatic islet cell tumors. In: Baker RJ, Fischer JE [eds], Mastery of Surgery, 4th ed. Philadelphia, Lippincott, Williams & Wilkins, 2001, p 557.)

FIGURE 75-6. Incision of the peritoneum along the inferior edge of the pancreas using a right-angle clamp and the electrocautery. (From McHenry CR. Pancreatic islet cell tumors. In: Baker RJ, Fischer JE [eds], Mastery of Surgery, 4th ed. Philadelphia, Lippincott, Williams & Wilkins, 2001, p 557.)

FIGURE 75-7. Bidigital palpation of the pancreas after the peritoneum along the inferior edge of the pancreas has been incised from the left of the superior mesenteric vein to the spleen. The spleen has been mobilized. (From McHenry CR. Pancreatic islet cell tumors. In: Baker RJ, Fischer JE [eds], Mastery of Surgery, 4th ed. Philadelphia, Lippincott, Williams & Wilkins, 2001, p 557.)

FIGURE 75-7. Bidigital palpation of the pancreas after the peritoneum along the inferior edge of the pancreas has been incised from the left of the superior mesenteric vein to the spleen. The spleen has been mobilized. (From McHenry CR. Pancreatic islet cell tumors. In: Baker RJ, Fischer JE [eds], Mastery of Surgery, 4th ed. Philadelphia, Lippincott, Williams & Wilkins, 2001, p 557.)

peritoneal attachments of the second portion of the duodenum are incised. Mobilization is continued proximally and superiorly, dividing the avascular portion of the hepatoduodenal ligament, which allows visualization and palpation of the common bile duct. The duodenum is further mobilized distally and inferiorly so that the inferior vena cava and the aorta can be visualized. This allows the surgeon to perform

FIGURE 75-8. A Kocher maneuver is performed by dividing the lateral peritoneal attachments of the duodenum with a Metzenbaum scissors and reflecting the duodenum medially. (From McHenry CR. Pancreatic islet cell tumors. In: Baker RJ, Fischer JE [eds], Mastery of Surgery, 4th ed. Philadelphia, Lippincott, Williams & Wilkins, 2001, p 556.)

FIGURE 75-8. A Kocher maneuver is performed by dividing the lateral peritoneal attachments of the duodenum with a Metzenbaum scissors and reflecting the duodenum medially. (From McHenry CR. Pancreatic islet cell tumors. In: Baker RJ, Fischer JE [eds], Mastery of Surgery, 4th ed. Philadelphia, Lippincott, Williams & Wilkins, 2001, p 556.)

FIGURE 75-9. Palpation of the head and uncinate process of the pancreas after an extended Kocher maneuver has been completed. (From McHenry CR. Pancreatic islet cell tumors. In: Baker RJ, Fischer JE [eds], Mastery of Surgery, 4th ed. Philadelphia, Lippincott, Williams & Wilkins, 2001, p 556.)

bidigital palpation of the head and uncinate process of the pancreas (Fig. 75-9).

Intraoperative assessment of the size, location, and proximity of islet cell tumors to the main pancreatic duct is important for deciding the best operative management. Enucleation remains the procedure of choice for small benign islet cell tumors (less than 2 cm) not in proximity to the main pancreatic duct.24 Enucleation is also recommended for malignant islet cell tumors of the head or uncinate process of the pancreas when feasible. Intraoperative ultrasonography, the single best study for localizing tumors of the endocrine pancreas, may help facilitate enucleation by defining the relationship of the islet cell tumor to the pancreatic duct. Distal pancreatectomy and pancreaticoduodenectomy are appropriate for treatment of larger islet cell neoplasms, neoplasms in close proximity to the main pancreatic duct, and tumors deep in the pancreatic parenchyma where tumor enucleation is not possible.24 With successful preoperative localization of a solitary, benign insulinoma, enucleation may be accomplished laparo-scopically with the use of laparoscopic ultrasonography.25

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