Ampullary Resection for Tumor



Ampullary Resection for Tumor







This procedure is used in highly selected cases, primarily for benign tumors such as villous adenomas that are not amenable to endoscopic resection. It is sometimes used for small neuroendocrine tumors or for T1 lesions in high-risk patients. The operation can be thought of as an extended version of a transduodenal sphincterotomy. The same surgical principles—identification and protection of the terminal orifices of the bile and pancreatic ducts, with reconstruction of the anatomy—apply.

Endoscopic placement of a transduodenal biliary stent facilitates identification of the ampulla and distal bile duct and should generally be done.

The orientation figure for Chapter 67 shows the typical anatomic arrangement, and the relevant anatomy is discussed in detail in that chapter.


Steps in Procedure



  • Explore abdomen and perform cholecystectomy, if not already done


  • Pass stent through cystic duct into duodenum (if not previously done)


  • Mobilize duodenum


  • Palpate tumor and indwelling stent


  • Longitudinal duodenotomy


  • Stay sutures to retract duodenal walls


  • Identify orifices of bile and pancreatic ducts


  • If not visible, begin mucosal incision between 12 and 3 o’clock with needle-point cautery


  • Cannulate pancreatic duct (and bile duct, if not previously done)


  • Complete circumferential resection of tumor and confirm margins


  • Incise anterior surface of ostia to spatulate


  • Suture each ostium to duodenal mucosa with multiple interrupted sutures of fine absorbable monofilament


  • Suture excess mucosa laterally


  • Close duodenotomy


  • Cover with omentum


  • Close abdomen without drains


Hallmark Anatomic Complications



  • Stricture of bile or pancreatic duct


  • Duodenal leak


List of Structures



  • Gallbladder


  • Bile duct



    • Intramural portion


  • Ampulla of Vater


  • Major duodenal papilla


  • Pancreatic duct (of Wirsung)


  • Duodenum


Exposure of Tumor (Fig. 68.1)


Technical and Anatomic Points

Gain access to the right upper quadrant through an extended right subcostal or midline incision, depending upon the habitus of the patient. Thoroughly explore the abdomen. If the gallbladder is still present, remove it. If an indwelling biliary stent was not placed, cannulate the cystic duct and pass a catheter down through the ampulla from above.

Perform a generous Kocher maneuver, and palpate the tumor and stent through the duodenal wall. Make a longitudinal duodenotomy over the mass. Place stay sutures to retract the duodenal walls.

Tags:
Jul 22, 2016 | Posted by in GENERAL SURGERY | Comments Off on Ampullary Resection for Tumor

Full access? Get Clinical Tree
Get Clinical Tree app for offline access