Posts Tagged ‘Pancreas’

Where is the Pancreas?

Wednesday, October 8th, 2008

By Marty Makary M.D., M.P.H.

Located directly behind the stomach, the pancreas lies deep in the center of the abdomen. Its position corresponds to an area 3-6 inches above the “belly button”, straight back on the back wall of the abdominal cavity. In fact, the bones of the spine are just a few inches behind the pancreas. And the major vessels of the abdomen (the portal vein, mesenteric vessels, aorta, and vena cava) all course through or next to the pancreas, making it a treacherous area for a surgeon inexperienced in pancreas surgery.

diagram showing physical location of pancreas

The pancreas is an integral part of the digestive system. The flow of the digestive system is often altered during the surgical treatment of pancreatic cancer. Therefore it is helpful to understand the normal flow of food before reading about surgical treatment. Food is carried from the mouth to the stomach by the esophagus. This tube descends from the mouth and through an opening in the diaphragm. (The diaphragm is a dome shaped muscle that separates the lungs and heart from the abdomen and assists in breathing.)

Immediately after passing through the diaphragm’s opening, the esophagus empties into the stomach where acids that break down the food are produced. From the stomach, the food flows directly into the first part of the small intestine, called the duodenum. It is here in the duodenum that bile and pancreatic fluids enter the digestive system.

At the time of surgery, exposing the pancreas requires retracting the liver, stomach, omentum, small bowel, and colon. The liver, stomach, and omentum are retracted up towards the head and the small bowel and transverse colon is retracted down towards the feet. The kidneys do not need to be retracted because the pancreas sits between the 2 kidneys. The center of the back wall of the abdominal cavity, or the retroperitoneum, is pancreas bed, a space the pancreas shares with the first part of the small intestine (a.k.a. the duodenum). In fact, the head of the pancreas is intimately in contact with most of the duodenum.

The Whipple operation for tumors of the pancreas head removes both the pancreas head and duodenum as a unit due to their close proximity and shared blood supply. In addition, the Whipple operation removes part of the bile duct (which carries bile from the liver to the duodenum) because the bile duct courses through pancreas head. Thus after the pancreas tumor is removed in a Whipple operation, the intestine, bile duct, and remnant pancreas are meticulously reconstructed, making the operation long and tedious.

Conversely, tumors of the pancreas body or tail may not require removal of a segment of intestine and these tumors can sometimes be removed laparoscopically, even sparing the spleen in select cases. These minimally-invasive options are determined by the location of the tumor, the tumor size, the proximity to the portal vein, and the surgeon’s experience with laparoscopy.

The deep and central location of the pancreas in the abdomen, coupled with its “wet sponge” texture, make it a unique organ for surgeons to conquer. Adding to the complexity of pancreas surgery, the pancreas lacks a capsule, or covering, and is thus prone to bleed or leak juices with even a small degree of rough handling. For these reasons, we recommend that pancreas surgery be performed by a specialist who is familiar with standard tissue handling techniques for the pancreas.

When performed open, pancreas surgery often involves an incision directly over the organ. This incision begins at the lower aspect of the central sternal bone (the xyphoid), and extends to a point a few inches below the “belly button”. Laparoscopic pancreas surgery usually involves 3-4 one-inch incisions for instrumentation and a camera.

Every week, newly diagnosed patients call to ask if a their CAT scan findings indicate that surgery open, or laparoscopic, is feasible. For most patients, a quick assessment of the CAT scan findings can yield a rough estimate of surgical candidacy, and allow for planning for the next steps in assessment leading to the appropriate care in a rapid and timely fashion.

Marty Makary M.D., M.P.H.
Pancreas and Advanced Laparoscopic Surgery
Johns Hopkins Hospital