1. Prof. A. FOUAD

2. By AMGAD FOUAD Professor Of Surgery Gastroenterology Center Gastroenterology Center Mansoura University. PRINCIPLES OF PANCREATIC RESECTION

3. Prof. A. FOUAD The pancreas is an endocrine & exocrine organ and both of these functions should be kept in mind during pancreatic surgery Pancreatectomies continue to be one of the major operations performed by surgeons Fortunately the difficulties with the operation and the dismal cure rate have been improved.

4. Prof. A. FOUAD Topographic Relationships of surgical importance 1. The length of the Retroduod CBD allow for adequate subsequent sectioning 2. The hepatic flexure of the colon overlies some of the 2 nd and 3 rd portion of the duodenum. 3. The root of the transverse mesocolon is related directly to the head of pancreas. 4. The 3 rd part of the duodenum passes under the SMVs and over the Aorta

5. Prof. A. FOUAD Adequate Exposure Midline incision : easy Bloodless Bloodless Transverse incision: good access Extended Rt subcostal incision Proper access Proper access Good visulaizatrion Good visulaizatrion Good assessment Good assessment

6. Prof. A. FOUAD Assessment of operability and / or resectability The root of Tr mesocolon is divided as it cross over the Rt kidney & the 2 nd portion of the duodenum Dissection along the lower border of the pancreas is conducted If the tumour has affected the SMVs the tumor is considered non-resectable & the procedure is abandoned.

7. Prof. A. FOUAD Vascular Control The most difficult aspect of the operation is to control bleeding especially from the tributaries of the SMVs & V Hepatic artery → Gastro duodenal art SUP. PD art SUP. PD art + SUP M.A → Inf PD art It is important to remember the numerous anatomic variations that may be present

8. Prof. A. FOUAD Further assessment The lat parietal peritoneum is incised and the duod is mobilized The SMVs & IVC now can be further examined for tumour involvement Bx of questionable mass (Controversial)

9. Prof. A. FOUAD CBD Division The CBD is circumferentially dissected then encircled with a small rubber sling to retract it away from the portal vein prior to with division The next step involves division of the GDA thus exposing the PV It is then decided whether the tumour is non-resectable (PV invasion) or that the operation must be terminated for other reasons

10. Prof. A. FOUAD The next step involves passing a small soft rubber drain under the body of the pancrease just to the left of SMA This is the safest way to avoid injury of the small Vs and also coincides with the optimum site of division of the pancreas

11. Prof. A. FOUAD