The omentum is detached from the transverse colon and the lesser sac inspected after the right gastroepiploic vessels are divided. A Kocher maneuver is carried out to mobilize the duodenum and head of the pancreas (figure 4).
The duodenum and head of the pancreas can be mobilized as for the Whipple procedure (Chapter 88). When it has been decided to remove the body and tail of the pancreas as well as the head, the peritoneum along the inferior border of the pancreas is incised in preparation for mobilization by blunt finger dissection (figure 5). The splenic artery is ligated near its point of origin. After the peritoneum over the portal vein has been incised, it is possible to insert the finger between the pancreas and the portal vein (figure 6). There should be no communicating veins anteriorly. The pancreas can be divided with electrocautery in this area, and the two segments of the pancreas resected separately if preferred.
Although antrectomy with gastrojejunostomy is the usual technique for reconstruction, some preserve the entire stomach and pylorus plus several centimeters of duodenal bulb for end-to-side anastomosis to the jejunal limb according to the method of Longmire. In the usual reconstruction, however, better exposure is obtained for the subsequent steps of the procedure if the stomach is divided at a level that ensures complete removal of the antrum (figure 7). Truncal vagotomy (Chapter 23) also is performed to decrease the incidence of late postoperative gastrojejunal stomal ulceration, unless lifetime treatment with proton pump inhibitors or other acid suppressing medication is determined to be preferable.
The spleen is freed up and all gastrosplenic vessels are divided and ligated. The spleen and left half of the pancreas are reflected to the right, providing good exposure for maximal ligation and division of the splenic artery and vein at their origins (figure 8). Any arterial branches to the superior mesenteric artery are carefully isolated and ligated (figure 9). The most difficult part of the procedure may be the isolation and ligation of the several short veins entering between the portal vein and the pancreas (figure 10). The ligated right gastric artery and the pancreaticoduodenal artery are shown in figure 10.
The gallbladder is removed in a routine manner and the common duct is divided (figure 11). The next step is to excise the rest of the duodenum down to and slightly beyond the ligament of Treitz (Chapter 88, figures 27 and 28).
A long arm of the jejunum is prepared by dividing several vascular arcades (figure 12). The mobilized jejunum is brought through an opening made in the mesentery of the transverse colon (figure 12). This opening is made at either side of the middle colic vessels, depending upon how easily the jejunal loop can be brought up to the region of the common duct. The jejunum is closed with a running 00 absorbable suture or a stapler, and this layer is inverted with a layer of 00 silk mattress or interrupted sutures. Following a gastrojejunal anastomosis, the jejunal loop is anastomosed without tension to the common duct (figure 2). Alternatively, some prefer to anastomose the biliary duct to the jejunum, followed by an anastomosis with the gastric pouch (figure 3). It is not necessary to make the stoma the full width of the stomach. A stoma of 3 to 5 cm can be made at the greater curvature end (figure 13). The jejunum should be anchored to the entire gastric outlet, regardless of how much has been closed off by sutures. The jejunum between the stomach and the common duct should be quite loose and free of tension (figure 14). All openings in the mesocolon about the arm of the jejunum should be closed with interrupted sutures to avoid angulation of the arm of jejunum or the possibility of an internal hernia. Closed-system suction catheters are commonly used.