STEP 4Reconstruction

Once the lesion is confirmed to be benign, local reconstruction is initiated; the method of reconstruction depends on the extent of resection and ductal anatomy.

Submucosal excisions are reconstructed using interrupted absorbable suture to approximate the mucosa of the ampulla to that of the duodenum. Care is taken not to obliterate the orifice of the pancreatic duct located at the caudal aspect of the transected ampulla. Intravenous secretin (0.25 mg/kg) is used to identify the pancreatic duct if the orifice is uncertain (A-1).

Ampullectomy is reconstructed by approximating the adjacent portion of the pancreatic and bile duct (inset) with interrupted 5-0 or 6-0 absorbable suture followed by reconstruction of the entire complex, as for submucosal excisions to duodenal mucosa (A-2).

Ampullectomy or more extensive resection of the pancreatic and bile ducts may require separate reconstruction (A-3).

■ Assessment of ductal patency is imperative and is done with a small probe.

■ The lateral duodenotomy is closed in a two-layer fashion.

■ A paraduodenal drain is placed in Morrison's pouch and brought out through the right lateral abdominal wall.

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