Tricks of the Senior Surgeon

■ The key to pain relief for chronic pancreatitis is pancreatic resection performed when the strict anatomic selection criteria described in this section are met.

■ Excess blood loss results in increased morbidity. To accomplish this, all named vessels are triply ligated with non-absorbable suture. The ultrasonic scissors are utilized for dividing small veins and particularly those around the right gastroepiploic and supraduodenal vessels. This technique is also handy when separating the mesenteric vascular attachments to the proximal jejunum removed with the specimen in the area of the ligament of Treitz.

■ The left hand of the surgeon standing on the left side of the patient can minimize blood loss during division of the attachments of the vascular lymphatics from the dorsal head of the pancreas to the area around the superior mesenteric artery. Pedicles of tissue are divided as the dissection proceeds along the superior mesenteric artery. Only one clamp is used for each pedicle on the patient side of the divided pedicle; the specimen side is not clamped and is compressed by the left hand.

■ Preserve all of the greater omentum as this "watchdog" of the abdomen decreases postoperative infection.

■ Use intraoperative fluoroscopic pancreatography to ensure that the pancreatic remnant is adequately drained. I use a cholangiocatheter with a balloon tip.

■ When a small pancreatic duct is used for the pancreaticojejunostomy, the anastomosis is best done with magnification to avoid crossing the sutures. The duct-to-mucosa anastomoses can be done in a more exact fashion by seeing the needle pass in and out of a small pancreatic duct. I find the surgical microscope at 12.5 power useful to minimize pancreaticojejunostomy leak.

■ The choledochojejunostomy should have all of the absorbable knots tied on the outside, and no absorbable suture should be exposed to bile flow.

■ I use a single closed suction drain made of silicone rubber.

■ An antecolic duodenojejunostomy has a marked decrease in delayed gastric emptying compared to the retrocolic method.

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