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Mastery of Surgery Volume2 5thEd 2007

Mastery of Surgery Volume2 5thEd 2007

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Published by: marinanash on Feb 27, 2010
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Ovid: Mastery of Surgery
Editors:Fischer, Josef E.Title:
Mastery of Surgery, 5th Edition 
Copyright ©2007 Lippincott Williams & Wilkins
> Table of Contents > Volume II > VII - The Gastrointestinal Tract > E - The Pancreas > 107 - Surgical Anatomyof the Pancreas
107
Surgical Anatomy of the Pancreas
Lee J. SkandalakisGene L. ColbornJohn E. SkandalakisMarios LoukasPanajiotis N. SkandalakisPetros Mirilas
The pancreas is neither striking in appearance nor obvious in function. Its early history ishardly more than a list of the names of those who noticed it in their dissections before passing onto more interesting organs. It was only with demonstration of the digestive enzymes byClaude Bernard in 1850 that the pancreas came to be seen as a complete organ with animportant function and, thus, an object worthy of study.In spite of the apparent accessibility of the pancreas, several anatomic relations combine to makeits surgical removal difficult. In 1898, Halsted was the first to successfully remove the head of the pancreas and a portion of the duodenum for ampullary cancer. Several surgeons in theUnited States and abroad subsequently developed two-stage operations for removal of the headof the pancreas. These efforts culminated in 1940 with Whipple's one-stage operation. Amajor factor in Whipple's success was the use of silk sutures, which tend to resist digestionby enzymes that destroy catgut sutures.
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Ovid: Mastery of Surgery
Sir Andrew Watt Kay wrote in 1978,
 “
For me, the tiger country is removal of the pancreas.The anatomy is very complex and one encounters anomalies.
” 
The embryogenesis of thepancreas and its deep retroperitoneal anatomy are responsible for the
 “
tiger country.
” 
In additionto the normal anatomy of the pancreas, before starting surgery the surgeon should knowwhether the patient's pancreas has any anomalies such as pancreas divisum or obstruction of the pancreatic duct, or variations in the duct's location or depth, or in the overall vascularstructure of the pancreas. No other organ is so closely surrounded by so many anatomic entities(e.g., the duodenum, stomach, spleen, left adrenal, transverse mesocolon and colon, leftkidney, right ureter, and jejunum). Figures 1, 2 and 3 show anterior and posterior relations.The proximity of the pancreas to so many organs means that it is prone to invasion by carcinoma.A study by Deziel found that metastases to the pancreas occur most frequently from thelung, followed by the breast, melanoma, stomach, colon or rectum, kidney, and ovary.Similarly, pancreatic cancer is likely to invade other organs. Tables 1 and 2 show twoimportant considerations in pancreatic cancer: organs directly invaded by pancreatic ductalcancer, and areas most likely to be involved by metastatic lesions from pancreatic cancer.In a study of 7,145 patients, cancer of the pancreas was located in the head in 73.2%, in thebody in 19.9%, and in the tail in 6.8%. Partial pancreatectomy and
 “
95 percent
” 
 pancreatectomy, first described by Barrett and Bowers and popularized by Frey and Child, areused instead of total pancreatectomy whenever possible because of the high mortality of total pancreatectomy.The pancreas lies transversely in the retroperitoneal space, between the duodenum on the rightand the spleen on the left. It is related anteriorly to the omental bursa above, the greater sacbelow, and the transverse mesocolon. For all practical purposes, it is a fixed organ.
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Ovid: Mastery of Surgery
Fig. 1.
Anterior relationships. (From JE Skandalakis, Gray SW, Rowe JS Jr, et al.Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17.)P.1224 
Parts of the PancreasAnatomical Parts
Head 
The head of the pancreas is flattened and has an anterior and a posterior surface (Fig. 4).The anterior surface is adjacent to the pylorus and the transverse colon. Theanterior pancreaticoduodenal arcade can be seen on the ventral surface of the head of thepancreas, coursing roughly parallel to the duodenal curvature.The posterior pancreaticoduodenal vascular arcade is a major entity on the posterior surface of the head. This surface of the pancreatic head is close to the hilum and medial border of the
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