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DuodenoCefaloPancreasectomia

male patient of 74 years in good physical condition. Type 2 diabetes.
diagnosis of cancer of the head of the pancreas infiltrating the duodenum.
The surgeon asked to perform a laparoscopy to detect any signs of peritoneal carcinomatosis.
Supine position, arms abduced, covered for temperature management placed on the lower limbs and heater liquids.
right subclavian central venous access in both peripheral venous access support.
invasive continuous blood pressure monitoring and central venous oppression.
bladder catheter attached to the nose and SNG.

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Laparoscopic Instruments - Instruments for open abdominal surgery
- a self-retaining Retractor fixing the bed
- Container for vascular surgery

1. OPenlaparoscopy with two access points for trocar 10. After
2. the progressive induction of the pneumoperitoneum, not evedenziati signs of peritoneal metastases of its gross
3. We proceed to perform median xipho-pubic laparotomy.
4. After ligation (laces 2 / 0) and the section of the round ligament, we proceed to place the self-retaining retractor paddles with four wall and a spatula to lift the liver and expose the subhepatic region.
5. The surgeon obtains the pancreatic head cancer invading the duodenum and then proceed with the posting coloepiploico bipolar electric scalpel and scissors is then performed
6. the mobilization of the duodenum with extensive Kocher maneuver, and with bipolar scissors
7. is isolated on the superior mesenteric vein and portal vein vesseloop red on red vesseloop
8. The pancreas is then underpass with a yellow vesseloop
9. are linked to the right gastroepiploic artery and vein with long strings of 2 / 0 and, similarly, is linked to the artery and vein is then dissected
10. pyloric duodenum with the use of a GIA
11. Isolation and section 80 of the 'bonds of gastroduodenal artery with 2 / 0
12. is then dissected the first loop ileostomy, with GIA 80 , which is mobilized
13. lymphadenectomy is then performed of the superior mesenteric artery, with bipolar, metal clips and scissors.
14. cholecystectomy is performed by anterograde and the section of the bile duct at the level of common hepatic duct, with scalpel
15. the pancreas is then dissected with a scalpel and made the pancreaticoduodenectomy enbloc with the bile duct and gallbladder
16. extemporaneous histological examination is performed on the margin of section biliary , pancreatic and duodenal ulcers, who were negative for malignancy pancrteatico The body is mobilized with bipolar and scissors, and starts the infusion of somatostatin
17. is then cannulated Diotto of Wirsung with 20G cannula.
18. Pancreogastroanastomosi termino-lateral
    • are two points of absorbable monofilament applied to the back of the stomach and the other two points on the front, at the same level.
    • gastrotomy is performed between the two points, on both sides of the stomach. On the back is passed pancreatic stump, which is placed through the anterior gastrotomy.
    • The pancreas is attached to the remaining points of the gastric mucosa with non-absorbable monofilament 3 / 0 to sutures around the entire perimeter
    • When you close the gastrotomy front atraumatic monofilament absorbable 4 / 0, in two-layer anastomosis on
    • pancreogastrica, are applied to the fixing points and consolidation in monofilament 3 / 0 non-absorbable, face back or stomach.
19. Anastomosis duodenodigiunale-to-end user in a single layer with atraumatic monofilament absorbable 4 / 0 and with the same wire is performed end-to-side anastomosis epaticodigiunale manual
20. two drains are placed in laminar panncreo-gastric bypass anastomosis and the subhepatic region sull'anastomosi hepatic-jejunal.