Transduodenal resection of the papilla of vater Tumors arising in the region of the papilla of Vater may have their origin from the distal bile duct, the duodenum, the ampulla of Vater itself, or the pancreas. Because the epithelium of origin is often impossible to determine and because their clinical characteristics are similar, these tumors are often described as periampullary tumors. Pathology You’re Reading a Preview…

General principles and preoperative approaches Although pancreatic cancer is the most common of periampullary tumors, cancers of the ampulla, the duodenum, and the distal bile duct have a better long-term survival after curative pancreaticoduodenectomy. Although rare, there also are cystic pancreatic tumors and endocrine tumors, for which surgical extirpation is indicated. Anatomic considerations (see chapter 1 ) It is essential that the surgeon be familiar with…

Introduction This chapter addresses the resection of primary malignancy of the intrahepatic and extrahepatic biliary tree. Gallbladder cancer is an important extrahepatic biliary cancer that is often discovered incidentally. Cholangiocarcinoma occurs at the biliary confluence, in the mid-duct, or in the distal duct presenting as a periampullary tumor (see also Chapter 11 ). Three distinct macroscopic subtypes of cholangiocarcinoma are well described: sclerosing, nodular, and papillary…

Cholecystectomy Open cholecystectomy for cholelithiasis is performed only in cases in which laparoscopic techniques do not allow a safe procedure. Cholecystectomy is also part of other operations, such as liver resection and pancreaticoduodenectomy. Basically, two techniques are used to perform cholecystectomy: (1) the retrograde technique, with initial dissection of the hilar structures of the gallbladder in Calot’s triangle, and (2) the anterograde or fundus-down technique, in…

Introduction Most hepatic cysts, regardless of type, remain asymptomatic, and hepatic function is not affected. Occasionally cysts are the focus of hemorrhage or infection, or produce hepatic dysfunction by bile duct compression or portal hypertension. This chapter emphasizes open surgical approaches to cystic disease of the liver. Diagnosis Ultrasound Simple cysts are characterized by acoustic enhancement posterior to the mass. They are solitary, thin-walled without focal…

Wedge resection Wedge resection of peripherally placed lesions within the liver is carried out easily for tumors measuring up to 2 to 3 cm in diameter. However, lesions occupying the convex surface of the liver and away from the free edge, such as lesions within segment VIII, are much more difficult to approach. Wedge resections, especially for lesions situated on the dome of the liver, are…

Introduction * * Note that resection of segments II and III (left lobectomy) in this text is described as a major resection in Chapter 5 . Segmental resection conserves functional liver parenchyma and minimizes the physiologic impact of liver resection. This is of particular benefit in a cirrhotic patient with impaired hepatocellular function. Segmentectomy may be regarded as a unisegmentectomy, when one segment is removed, or…

Left hepatectomy * Inflow control The hilar plate is lowered. The left hepatic artery is ligated and divided. Any accessory or replaced hepatic artery arising from the left gastric artery is similarly ligated. Dissection at the base of the umbilical fissure exposes the left portal vein. It should be controlled at this point and not at its origin from the main portal venous trunk. If the…