A quick and easy technique for patching small holes in the portal vein.

During pancreaticoduodenectomy (Whipple’s or Kausch-Whipple procedure depending on where you are from), tumours are often found to be adherent or invading the wall of the portal vein. This can render resection impossible or require a major portal vein resection as a tube or cylinder with replacement with a vein graft but, more often than not, the point of attachment is relatively small. In these latter cases the tumour is usually adherent to the right wall of the portal vein or anteriorly. Resection of a cuff of vein is possible but direct closure of the portal vein runs the risk of narrowing its lumen with inherent risk of portal vein thrombosis (as shown in cartoon below). Transverse closure can be equally difficult because of shortening of the portal vein.

A vein patch can be used from any suitable vein to prevent narrowing of the portal vein. One area that I sometimes use exploits the anatomy of the infrahepatic vena cava. During Kocherisation of the pancreatic head the vena cava is exposed. If you perform a full exposure you will see that the vena cava is wider at the point of insertion of the renal veins than it is either below or above their insertion.  This always struck me as being an opportune site to take a vein graft as it is possible to remove a diamond of vein from this area as the diamond can be sewn up with minimal narrowing of the IVC.I use a large Satinsky side-biting clamp and apply it to the front of the vena cava at the level of renal vein insertion.  This can be done in such a way that preserves some flow through the vena cava and also the renal veins.You can then excise a piece of vena cava in a diamond shape to almost the full length of the inner side of the clamp. Try to anticipate what the triangle will look like when it is opened out into a diamond shape and don’t take any more than you need. 

The vena cava can then be closed longitudinally with a running prolene (nylon) suture with no or minimal narrowing of the IVC. 

The patch can then be sewn into place in the portal vein window that was removed when you resected the tumour.

NB Two key points, 1. the patch almost always shrinks particularly if you put it in cold heparininised saline as I usually do. It will stretch out again when it warms up and as you sew it in. 2. Remember which is the intimal and which is the serosal surface of the patch and don’t sew it into the portal vein the wrong way around!

Other alternatives for autologous vein patches are manifold but include jugular, superficial femoral, left renal or gonadal.

Finally, I can’t remember whether someone showed me this trick or whether I worked it out for myself. If you know that it should be attributed to someone please let me know as all surgeons like names.

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