Michael G. Sarr, Keith D. Lillemoe
Intraoperative chemical splanchnicectomy can be useful, especially in patients who are found at the time of exploration for resection to have unresectable pancreatic cancer.
Rather than having these patients undergo percutaneous or endoscopic chemical splanchnicectomy postoperatively, an intraoperative approach is easy, effective, and warranted.
■ The celiac plexus contains visceral afferent (pain) nerves from the stomach, pancreas, hepatobiliary tree, kidneys, and mid gut.
■ There are one to five ganglia on each side of the celiac and superior mesenteric arteries which lie anterior to the diaphragmatic crura and medial to the adrenal glands.
■ Supplies needed include a 10- or 20-ml syringe, a 20-gauge spinal needle, and 40 ml of a 50% alcohol or 5% phenol solution.
■ The lesser curvature of the stomach is retracted caudally.
■ The first two fingers of the surgeon's left hand "straddle" the aorta.
■ The index finger palpates the pulse of the splenic artery, while the second finger palpates the thrill of the common hepatic artery.
■ The surgeon's right hand controls the syringe with the neurolytic agent.
■ The spinal needle is advanced into the right para-aortic region just rostral to the hepatic artery, and is clamped by the assistant to prevent displacement.
■ The surgeon aspirates the syringe; if no blood is obtained (i.e., needle in vessel), 10ml of the neurolytic agent is injected, the needle removed, and the area compressed with a gauze pack.
■ The syringe is re-filled, and the same maneuver is carried out just below the common hepatic on the right para-aortic area and rostral and caudal to the splenic artery in the left para-aortic region.
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