Videos/Film

PRESERVATION G. Tiberio, S.M. Giulini, L. CanEiottl, N. Portolani Department of SurgeryBRESCIAItaly The film illustrates the pancreatoduodenectomy operation carried out on a 60 year-old patient, affected by an ampullary adenocarcinoma. The technique adopted involves the removal of the duodenumpancreatic section with pyloric preservation according to the technique proposed by Traverso and Longmire with the aim of simplifying the surgical procedure and of improving the post-operatlve nutritional state of the patient. Gastric preservation doesn’t preclude the possibility of a radical lymphadenectomy, the perigastric and splenic nodes being only on exception site of metastasis in such pathology. The first step is the mobilization of the hepatic flexure of the colon and of the second duodenal portion; the isolation of the distal choledoch duct and of the upper mesenteric vein in its retropancreatic section allows the completion of the mobilization of the pancreatic head and of the third and fourth duodenal portions. The technical shrewdness that the operation foresees is seen in the film: the accurate saving of the innervation and of the vascularization of the proximal duodenal section, realised in the specific case with the respect of the gastoduodenal artery and of both of the gastric vascular arches, the supramesocolic transposition of a loop of Jejunum dorsal to the mesenteric vessels in the bed of the resected duodenum, the accurate surgical technique turned towards preventing the formation of haematic and lymphatic gatherings which can induce a transitory postoperative gastric paresis. The pancreatic and biliary anastomoses are subsequently carried out by means of a termino-lateral technique in a two layer fashion in re-absorbable synthetic material; the end-to-side JeJunostomy, carried out with continuous stitches results as technically easy and, even though it is a short distance from the pylorus, does not compromise, its function. The accurate perlanastomotic drainage completes the operation, resulting free of complications.