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Blumgart's surgery of the liver, biliary tract, and pancreas / editor-in-chief, William [et al.] ; editor emeritus, Leslie H. Blumgart. - 5th ed. Philadelphia: Elsevier. Edition/Format: eBook: Document: English: 5th edView all editions and formats. Summary: Comprehensive and complete, Blumgart's Surgery of the Liver. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition sample chapter ch99 To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use.


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Comprehensive and complete, Blumgart's Surgery of the Liver, Pancreas and Biliary Tract – edited by Dr. William R. Jarnagin and a team of. Online PDF Blumgart s Surgery of the Liver, Biliary Tract and Pancreas, 2- Volume Set, 6e, Download PDF Blumgart s Surgery of the Liver, Biliary Tract and . soundofheaven.info - Ebook download as PDF File .pdf), Text File .txt) or read book Department of Surgery Royal Liverpool University Hospital 5th Floor Duncan ed. Blumgart LH. A review of the literature and a report of a case associated with .

The right gastric and gastroduodenal arteries are was attempted clinically in under azathioprine-prednisone ligated and divided Fig. The area anterior to the body and tail is termed the lesser sac and is bordered by the body of the stomach and gastrocolic ligament anteriorly and the transverse mesocolon and the transverse colon inferiorly. Dennison A. Even in specialist centres. Un caso de extirpacion die lobulo izquierdo die hegado. Biliary ductal anomalies The biliary anatomy described above. Anatom Clin

If the left gastric, immunosuppression. The first humans to have liver replace- right gastric, and gastroduodenal arteries are ligated in that ment with prolonged survivals were reported by Starzl in ; order, the subsequent dissection of the common duct and the however, not until the availability of cyclosporine in the s portal vein is rendered relatively bloodless.

The common bile did orthotopic liver transplantation became accepted world- duct is transected near the duodenum, and the gallbladder is wide as effective therapy. The results improved again with the incised, permitting the bile to be irrigated out with saline see advent of tacrolimus in the s see Chapter The portal vein now to the success of liver replacement, including improved patient is dissected inferiorly to the confluence of the splenic and supe- selection and pretransplantation management, noninvasive rior mesenteric veins see Fig.

Cannulae for infusion was the crucial factor on which all else ultimately depended. When all procurement teams are ready, the aorta is cross- sented in this chapter, with an emphasis on principles rather clamped at the diaphragm or in the chest by the abdominal than details. Moderately rapid infusion of cold preserva- Donor operation tion solution is started into the portal circulation and aortic cannula.

At the same time, a cardioplegia solution is infused into The use of multiple organs from a single cadaveric donor the midportion of the ascending aorta. Congestion of the various became practical with the development of standard procure- organs is prevented by an incision in the suprahepatic inferior ment methods in the early s see Chapter 98A.

The infused through the splenic vein or inferior mesenteric vein and availability of this much time has allowed widespread sharing of 10 L infused through the aorta, although smaller volumes are livers while permitting an accurate assessment of the grafts by used for children.

When the liver becomes cold and blanched, histologic and metabolic criteria. The remaining dissection must be performed expedi- tiously but methodically. If the celiac axis is retained with the standard liver procurement graft, a proximal segment of its splenic arterial branch also In the standard procurement technique, a midline incision is should be conserved for potential reconstruction of an anoma- made from the suprasternal notch to the pubis to expose the lous hepatic artery see later.

The most common hepatic artery abdominal and thoracic organs of potential interest Fig. If the pancreas is to lobe to be retracted anteriorly and to the right. This retraction be discarded, the anomalous retroportal artery can be kept in exposes the upper part of the gastrohepatic ligament, which continuity with the superior mesenteric artery see Fig. If an anoma- that is shared with the origin of the celiac axis.

The vena cava below the liver is main left gastric artery see Fig. To protect the rights of the author s and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author s , editor s , reviewer s , Elsevier and typesetter Toppan Best-set.

The vena cava above the liver is transected with a surrounding rim of diaphragm that is carefully excised on the back table. The retrohepatic vena cava is dissected free, includ- ing ligation of the right adrenal vein and posterior lumbar tribu- taries. The liberated liver is immediately placed in a solution-filled preservation bag packed in ice Fig. Modified Donor procedures Rapid Procurement Use of the standard technique in stable donors has allowed the training of relatively inexperienced surgeons in the performance of a donor hepatectomy.

When the technique is mastered, faster methods can be applied electively or, if required, by urgent clin- ical circumstances. With the rapid techniques, little or no pre- liminary dissection is done except for encirclement of the supraceliac aorta and cannulation of the inferior mesenteric vein and terminal aorta Fig.

If the heart is to be removed, the cardiac surgeon proceeds as if other organs are not to be harvested but gives warning before the circulation is stopped.

At the moment heart function ceases, the abdominal aorta is cross-clamped above or just below the diaphragm, and an infu- FiGUre The amount of preserva- tion fluid with the rapid technique is approximately the same Tape around suprahepatic inferior vena cava Upper hepatic Infrahepatic artery inferior vena cava Common bile duct Splenic vein Portal vein Common hepatic Gastroduodenal artery artery Superior Aorta mesenteric veinO FiGUre Ascending aorta cannulation for cardioplegia Suprahepatic vena cava decompression Supraceliac aortic cross-clamping Portal vein cannula via splenic vein Aortic cannula FiGUre A common reason for back-table reconstruction is aorta.

When the liver becomes cold, the infusions are slowed. Liver, Pancreas, and Intestine Procurement The portal vein is cleaned inferiorly to the junction of the from the Same Donor splenic and superior mesenteric veins, and these two tributaries The pancreas and intestine can be retrieved independently or are divided.

As in the standard method, the surgeon must together with the liver. Before starting the procurement, the promptly exclude the possibility of a retroportal right hepatic operation should be discussed among the surgeons involved.

The hepatectomy is then com- ervation solution to be used, presence of aberrant hepatic arter- pleted. The kidneys, which are excised only after the liver has ies, length of portal vein, and a decision about which organ been removed from the field, are kept cold throughout by con- retains the celiac axis or superior mesenteric artery.

An important step in any cadaveric donor operation is the By performing all dissections in the bloodless field, it is possible removal and storage of long segments of the donor iliac arteries to remove multiple organs in about half an hour, including the and veins as well as other arteries and veins. These vessels can heart, liver, and both kidneys.

Procurement of the intestine adds be used as vascular grafts to reconstruct the blood supply of the only a few additional minutes. With increased experience, it is rare to see any of the abdominal visceral organs discarded for purely tech- Super-Rapid Procurement nical reasons.

In arrested or non—heart-beating donors, an even quicker pro- cedure can be used to procure satisfactory organs. Here, The recipient procedure tends to be long and physically demand- cooling requires urgent cannulation and cold fluid infusion into ing. Its different parts are so remarkably dissimilar that a single the distal aorta Fig.

Removal of the diseased liver may be one of the deferring cannulation and perfusion of the portal venous system most difficult challenges a surgeon faces. Yet, the vascular anas- until after the various organs are at least partly cooled intraarte- tomoses can be among the most delicate and sophisticated pro- rially Fig.

The various dissections are done in the same cedures one performs, especially in very small children. Effective appli- Achieving perfect hemostasis after the donor liver has been cation of this method requires an extremely high level of skill.

Finally, the delicate biliary tract reconstruction No matter which procurement method has been used, further becomes the final thread on which the whole enterprise is preparation of the liver is performed on a separate back table suspended.

The liver should be kept cold by submerging it in a basin containing ice- cold preservation solution surrounded by a bag containing abdominal incision and exposure sterile ice slush see Fig.

Back-table preparation includes The exact location of the incision may be influenced by previ- the following: A bilat- 1. Dissection and removal of extraneous tissue, such as dia- eral subcostal incision is the most commonly used, extending phragm, adrenal gland, lymph node, pancreatic, peripancre- on the right to just beyond the midaxillary line and on the left atic, and ganglionic tissue to the lateral edge of the rectus, with an upper midline exten- 2.

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Blumgart's Surgery of the Liver, Biliary Tract and Pancreas

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The name field is required. Please enter your name. The E-mail message field is required. Please enter the message. Please verify that you are not a robot. Would you also like to submit a review for this item? You already recently rated this item. Your rating has been recorded. It receives both an arterial and a portal blood supply from both the right and left portal structures and this is variable. Note that the left portal scissura is not the umbilical fissure since this fissure is not a portal scissura.

Therefore the left portal scissura lies posteriorly to the ligamentum teres inside the left lobe of the liver Fig. According to Couinaud. The gastrohepatic lesser omentum separates the left portion of the caudate from segments II and III of the left liver as it passes between them to be attached to the ligamentum venosum.

Surgical anatomy of the liver and bile ducts 9 Therefore in the clinical setting particularly when imaging the liver it is better to speak of the anterior and posterior sectors Fig. The anterior surface of the caudate lobe lies within the hepatic parenchyma against the posterior intrahepatic surface of segment IV.

The exact location of the right portal scissura is imprecise because it has no external landmarks. It is important to note that the middle hepatic vein defining the main portal scissura usually enters the left hepatic vein some 1—2 cm before the left hepatic vein joins the IVC Fig. As a result it lies directly between the portal vein lying anteriorly and the IVC posteriorly.

The caudate lobe segment I or segments I and IX is the dorsal portion of the liver lying posteriorly and surrounding the retrohepatic IVC. Typical hepatectomies hepatectomies reglees are defined by resection of a portion of liver parenchyma following one or several anatomical portal or hepatic scissurae. Atypical hepatectomies involve resection of a portion of hepatic parenchyma not limited by anatomical scissurae.

These resections are called left or right hepatectomies. Such resections are usually inappropriate as they will leave behind devascularized residual liver and will probably also not adequately excise all the pathologically involved parenchyma.

Therefore extended right. The usual typical hepatectomies can be considered in two groups. The small hepatic veins of the caudate lobe drain directly into the IVC. In certain pathologies multiple liver metastases or large tumours transgressing the main portal scissura hepatectomies can be extended Figure 1.

For some time the latter definition. Surgical Management of hepatobiliary and pancreatic disorders 10 drainage is likewise into both the right and left hepatic ducts. Left hepatectomy is the removal of segments II. This independent isolation of the caudate lobe is clinically important in BuddChiari syndrome. We prefer to use the definition of Couinaud. Using this functional approach to liver anatomy.

Resection of segments V and VIII between the main portal scissura middle hepatic vein and right portal scissura right portal vein on their pedicle of the anterior division of the right portal vein is defined as a right anterior sectorectomy.

Goldsmith and Woodburne describe this procedure as a left hepatic lobectomy. This includes complete resection of segment IV. One area of confusion in the definitions of hepatectomies comes in the simultaneous resection of segments II and III Fig. Surgical anatomy of the liver and bile ducts 11 hepatectomy will also include resection of segment IV.

Opening the left coronary ligament. Surgical approach to the caudate lobe dorsal sector This is initially achieved by dissection of the coronary ligament up to the right of the IVC. The falciform ligament is then dissected to the IVC and the lesser omentum incised close to the liver. Sectorectomies of the right liver are easier to define. The biliary tract Accurate biliary exposure and precise dissection are the two most important steps in any biliary operative procedure and are both totally dependent on a thorough anatomical understanding of these structures.

The caudate lobe is now isolated and the main portal fissure is divided to separate segments IV.

Each branch of the intrahepatic portal vein corresponds to one or two intrahepatic bile ducts which converge. Several authors have thoroughly described the anatomy of the biliary tract. After the hilar plate is lowered to expose the right and left portal pedicles. In particular. There is variation in the anatomy of all three components of the portal triad structures. Intrahepatic bile duct anatomy The right liver and left liver are respectively drained by the right and the left hepatic ducts.

The caudate veins to the IVC are now exposed and can be divided between ligatures as they run up the back of the caudate lobe. Surgical Management of hepatobiliary and pancreatic disorders 12 allows ligation of the inferior phrenic vein. The duct draining segment III is found a little behind the left horn of the umbilical recess. The ligamentum teres passes through this umbilical fissure to join the left portal vein within the recessus of Rex Figs 1.

As the duct draining segment Figure 1. The left hepatic duct drains segments II. III and IV which constitute the left liver. Surgical anatomy of the liver and bile ducts 13 outside the liver to form the right and left hepatic ducts. At this point the left branch of the portal vein turns forward and caudally in the recessus of Rex 23 Fig.

The left hepatic duct then. As such it is usually easily accessible at surgery to allow a biliary-enteric segment III hepaticojejunostomy anastomosis for biliary drainage if such access is not possible at the porta hepatis. Note the horizontal course of the posterior sectoral duct and the vertical course of the anterior sectoral duct.

Surgical Management of hepatobiliary and pancreatic disorders 14 Figure 1. Note the position of segment III duct above the corresponding vein and its relationship to the recessus of Rex. III begins its posterior course it lies superficially in the umbilical fissure.

The right and left hepatic ducts converge at the right of the hilum of the liver. In nearly half of individuals. In this transverse portion. Many authors now advocate en bloc resection of the caudate lobe during resection of hilar cholangiocarcinoma. Extrahepatic biliary anatomy The detail of this section will be confined to the upper part of the extrahepatic biliary tree. This hilar plate has no vascular interposition and. Surgical anatomy of the liver and bile ducts 15 passes beneath the left liver at the posterior base of segment IV.

The caudate lobe segment I has its own separate biliary drainage. This segment comprises two anatomically and functionally distinct portions.

The posterior duct joins the anterior sectoral duct formed by the confluence of the ducts from segments V and VIII as it descends vertically. In over threequarters of individuals. The junction of the two main right biliary ducts usually occurs immediately above the right branch of the portal vein. After the left duct crosses the anterior edge of that vein it joins the right hepatic duct to form the common duct at the hepatic ductal confluence.

The right posterior sectoral duct runs almost horizontally 26 and comprises the confluence of the ducts from segments VI and VII Fig. These two ducts join to enter the duodenum through the sphincter of Oddi at the papilla of Vater. The cystic artery which usually arises from the right hepatic artery crosses the common hepatic duct as frequently anteriorly as it does posteriorly Figs 1.

Exposure of the extrahepatic left hepatic duct is achieved by incising the hilar plate at the base of segment IV medially as far as the umbilical fissure.

Surgical Management of hepatobiliary and pancreatic disorders 16 Figure 1. The main bile duct normally has a diameter of 6 mm and passes downwards anterior to the portal vein in the right free border of the lesser omentum.

This point of entry is widely variable. The main bile duct is divided into its upper part. The retropancreatic portion of the bile duct approaches the duodenum obliquely. The bile duct is closely related to the hepatic artery as it runs upwards on its left side before dividing into its left and right branches.

Surgical anatomy of the liver and bile ducts 17 Figure 1. The gallbladder varies in size and consists of a neck. Note also the course of the cystic artery. Note the hepatic duct confluence anterior to the right hepatic artery and origin of the right portal vein. Its length varies widely but its lumen is usually between 1 and 3 mm. The mucosa of the cystic duct is arranged in spiral folds valves of Heister.

The gallbladder lies within the cystic fossa on the underside of the liver in the main liver scissura at the junction between the right and left livers. The relationship of the gallbladder to the liver ranges from hanging by a loose peritoneal reflection to being deeply embedded within the liver substance.

It is separated from the hepatic parenchyma by the cystic plate. B The lymphatic drainage of the gallbladder towards the coeliac axis. This variance may be because Couinaud 23 specifically identified a triple confluence of right posterior sectoral duct. This duct does not drain any specific area of the liver and never communicates with the gallbladder. The venous drainage of the gallbladder is directly through the gallbladder fossa to the portal vein in segment V Fig.

Surgical anatomy of the liver and bile ducts 19 Gallbladder and cystic duct The gallbladder receives its blood supply by the cystic artery.

In addition. The most common variant arises directly from the right hepatic artery and then divides into an anterior and posterior branch. Anomalies of the accessory biliary apparatus Gross described a number of anomalies of the accessory biliary apparatus in Biliary ductal anomalies The biliary anatomy described above. B septum of gallbladder.

C diverticulum of gallbladder. Surgical Management of hepatobiliary and pancreatic disorders 22 Figure 1. The union of the cystic duct with the common hepatic duct may be angular. D variations in cystic duct anatomy. A bilobed gallbladder. Surgical anatomy of the liver and bile ducts 23 The arterial blood supply of the liver and bile ducts The hepatic artery The hepatic artery usually arises as one of the three named branches of the coeliac trunk along with the left gastric and splenic arteries Fig.

The first named branch of the hepatic artery is the gastroduodenal artery and either of these arteries may then give rise to the right gastric and retroduodenal arteries Fig. The hepatic artery then divides into right giving rise to the cystic artery and left hepatic arteries. The hilar section receive arterioles directly from their related hepatic arteries and these form a rich plexus with arterioles from the supraduodenal section. In a small number of people other variations of these arrangements will occur Fig.

The blood supply of the extrahepatic biliary apparatus The extrahepatic biliary system receives a rich arterial blood supply. In this situation the bile duct may come to lie behind the portal vein. Surgical anatomy of the liver and bile ducts 25 blood supply of the supraduodenal section is predominantly axial. Contraindications to this approach include patients with a very deep hilum which is displaced upwards and rotated laterally. Although intraoperative ultrasound has made easier the location of dilated intrahepatic biliary radicals.

The retropancreatic section of the bile duct receives its blood supply from the retroduodenal artery. This manoeuvre will expose considerably more of the left hepatic duct than the right. Of the arteries supplying the supraduodenal section. The veins draining the bile duct mirror the arteries and also drain the gallbladder. This venous drainage does not enter the portal vein directly but seems to have its own portal venous pathway to the liver parenchyma.

Biliary-enteric anastomosis necessitates precise bile duct exposure to facilitate the construction of a mucosa to mucosa apposition. Sometimes it may be necessary to perform a superficial liver split to gain access to this duct. The umbilical fissure is then opened and with downward traction of the ligamentum teres an anterior branch of the segment III duct is exposed on its left side.

The bile ducts of the left liver are located above the left branch of the portal vein. In the usual situation of chronic biliary obstruction with dilatation of the. This is achieved by mobilizing the round ligament and pulling it downwards. This procedure usually requires the preliminary division of the bridge of liver tissue which runs between the inferior parts of segments III and IV.

Surgical Management of hepatobiliary and pancreatic disorders 26 Figure 1. Dissection of the round ligament on its left side allows exposure of either the pedicle or anterior branch of the duct from segment III.

This junction may sometimes be deeply embedded within the parenchyma of the fissure. Hjortsjo CH. Di un adenoma del fegato. Injuries of the liver in three hundred consecutive cases. The anatomical basis of partial hepatectomy. Arch Surg Anatomia hepatis. Int Abstr Surg Gunshot wound of the stomach and liver treated by laparotomy and suture of the visceral wounds.

Blumgart's surgery of the liver, biliary tract, and pancreas

A report on the bilaterality of the liver. Surgical anatomy of the liver and bile ducts 27 intrahepatic bile ducts.

Edition blumgart pdf 5th

McDermott WV Jr. DeBakey ME. Counsellor VX. Langenbuch C. Blackwell Scientific Publications. Ton That Tung. Cited in Hobsley M. The segment V duct should lie relatively superficially on the left aspect of the portal vein to that segment. Acta Anat Luis A.

5th edition pdf blumgart

Centralblatt fur chirg Ann Surg Surgical anatomy pertaining to liver resection. Mikesky WE. On a new arrangement of the right and left lobes of the liver. McIndoe AH. J R Coll Surg Edin Surg Gynaecol Obstet Healey JE Jr. La vascularisation veineuse du foie et ses applications aux resections hepatiques. Surgery of the liver. Proc R Soc Med Engl Schwartz SI. Dalton HC. Cantlie J. The ideal approach on the right side is to the segment V duct. The topography of the intrahepatic duct systems.

Rex Access to the right liver system is less readily achieved than to the left as the anatomy is more imprecise. Woodburne RT. No 15 Schroy PC. J Anat Physiol Lond The history of liver surgery. Anatomy of the biliary ducts within the human liver. Abstract from Ganzy. Glisson F. Goldsmith NA. Historical Background. Howard JM. Ein Fall von Resektion eines linksseitigen Schnurlappens der Leber.

Lau WY. Report of a case of resection of the liver for the removal of a neoplasm with a table of seventy six cases of resection of the liver for hepatic tumor. Maryland Med J Surgical Management of hepatobiliary and pancreatic disorders 28 Berl Klin Wosch Nik Akhtar B. Surg Gynecol Obstet Davin JL. Castaing D. Couinaud C. Champetier J.

Letoublon C. Robert HG. Cattell RB. Wendel W. Rocko JM. Am J Surg Partial hepatectomy. Yver R. Gross RE. Del Grande G. Presse Med Mancuso M. Wangensteen OH. Baghieri F. Successful removal of liver metastasis from carcinoma of the rectum. The removal of a solid tumor from the liver by laparotomy. The anatomy of the choledochaoduodenal junction in man. Swan KG. Etudes anatomiques et chirurgicales.

Lucke F. Delmont J. Wood D. Keen WW. C Couinaud. Lortat-Jacob JL. Anatomy of the dorsal sector of the liver. Caprio G. Bismuth H. Eponyms in biliary tract surgery. Surgical anatomy of the liver revisited.

Lazorthes F. Gastroenterol Clin Biol Entfernung der linken Krebsiten Leber Lappens. Arch Klin Chir Berlin Bilobed gallbladder. Lehey Clin Bull Hobby JAE. Sez Chir Contributo alla conoscenza della struttura segmentaria del fegato in rapportto al problema della resezione epatica. Les traumatismes operatoires de la voie biliaire principale. Duplication de la vesicule biliaire. Aberrant biliary ducts vasa aberrantia: Maghsoudi H.

Congenital anomalies of the gallbladder. Kawarada Y. New considerations on liver anatomy. Di Gioia JM. The surgical resection of gastric cancer with special reference to: A review of a hundred and fortyeight cases with report of a double gallbladder. Houssin D. Tiffany L. Bull Soc Cir Urag Montevideo Rachad-Mohassel MA. World J Surg Mizumoto R. Un caso de extirpacion die lobulo izquierdo die hegado.

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Blumgart.pdf

Surgical treatment of hilar carcinoma of the bile duct. Vol 1. Byden EA. Nataline E. Suzuki H. Hepatectomie droite regle. Les resections majeures et mineures du foie. Raven RW. Beitrage zur Chirurgie der Leber. Anatom Clin Cantrallbl Chir Vigneau B. Hepp J. Newcombe JF.

Northover JMA. Ann R Coll Surg Engl Kune GA. The accessory gallbladder. The biliary tract and the anatomy of biliary exposure. Gastroenterology Blumgart LH. A review of the literature and a report of a case associated with hepatic duct carcinoma. Henley FA. Smadja C. The influence of structure and function in the surgery of the biliary tract.

Applied surgical anatomy of the biliary tree. Rogers HI. Corlette NB. Boyden EA. Terblanche J. Am J Anat Kelley CJ. Voyles CR. J Am Med Assoc A technique for construction of high biliary enteric anastomoses. Literature review and discussion of mechanisms. A new look at the arterial blood supply of the bile duct in man and its surgical implications. Surgery of the liver and biliary tract. Left sided gallbladder. Surgical anatomy of the liver and bile ducts 29 Surg Gynecol Obstet p.

Cystic duct duplication. Vol 5. Congenital absence of the gallbladder with choledocholithiasis. Churchill Livingstone. Kalser MH. An embryological and comparative study of aberrant biliary vesicles occurring in man and the domestic mammals.

Perelman H. Crews RD. Long term results of Roux-en-Y hepaticojejunostomy. Franco D. Biliary tract. Hepaticojejunostomy in benign and malignant bile duct stricture: The main pancreatic duct is lined by columnar cells interspersed with goblet cells.

The glandular or acinar cells of the pancreas form the major part of the lining of the acini and are the most abundant cells within the exocrine lobule Fig. This structure corresponds to their function of fluid and ion transport including the secretion of bicarbonate.

These cells are interspersed with epithelial cells which are cuboidal or flat and are termed centroacinar cells.

Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edit…

The epithelial cells lining the centroacinar and interlobular ducts are flat and have interdigitating lateral basement membranes. The Figure 2. The epithelial cell lined ductules drain the acini and coalesce to form intralobular and interlobular ducts. The dorsal and ventral ducts carry the eponyms Santorini and Wirsung. Ductal anatomy A brief review of the embryology of the pancreas is required for an understanding of normal ductal anatomy and its variants. This structure is thought to reflect an interaction between the endocrine and exocrine systems.

The portal drainage of the islets is arranged such that the acinar cells have greater contact with this draining blood than does any other cell in the body. In these cases the Figure 2. The ventral bud rotates posteriorly and to the left to become the uncinate process. Acinar cells in the peri-insular regions are larger and have more insulin receptors. The pancreas begins as dorsal and ventral buds arising from the duodenum.

These proportions vary within the regions of the pancreas. The islets of Langerhans are essentially clumps of hormone secreting cells. Surgical management of hepatobiliary and pancreatic disorders 32 Figure 2.

When this is combined with failure of fusion of the two ducts. C The main duct is suppressed and loses its connection to the accessory duct pancreas divisum: The two join to form a common channel within the wall of the duodenum in the majority of normal subjects 4 see Fig.

The other variations of ductal anatomy include either the suppression or the absence of the accessory or dorsal duct. This is because the ventral pancreatic duct originates as a branch of the bile duct embryologically 4 Fig. The incidence of pancreas divisum is higher in patients undergoing endoscopic retrograde cholangiopancreatography ERCP for idiopathic pancreatitis. The exact incidence of these variants is unknown. The common channel is termed the ampulla of Vater.

The diameter is greatest in the pancreatic head at 3 to 4 mm and Figure 2. Surgical anatomy of the pancreas 33 and tends to have a greater diameter. The bulge seen at the papilla is due to these fibres. It most commonly lies within the pancreatic tissue.

It is.