Skip to Main Content

++
++
++
++
++
++

The right gastric vessels along the superior margin of the first part of the duodenum are isolated by blunt dissection and doubly ligated some distance from the duodenal wall (Figure 6). Palpation for potentially involved lymph nodes in the portal area is performed. If dissection is to be done, the surgeon must carefully identify and preserve the common hepatic and gastroduodenal arteries as well as the portal vein and common duct. The thinned-out gastrohepatic ligament is divided as near the liver as possible up to the thickened portion, which contains a branch of the inferior phrenic artery.

++

The duodenum is then divided with noncrushing straight forceps on the duodenal side and a crushing clamp, such as a Kocher, on the gastric side (Figure 7). The duodenum is divided with a scalpel. A sufficient amount of the posterior wall of the duodenum should be freed from the adjacent pancreas, especially inferiorly, where a few vessels may enter the wall of the duodenum (Figure 8). Even if it is extensively mobile, the duodenal stump should not be anastomosed to the esophagus because of subsequent esophagitis from the regurgitation of duodenal juices. The duodenum is closed in the usual manner.

++

The region of the esophagus and fund us is next exposed and mobilized medially. The avascular suspensory ligament supporting the left lobe of the liver is first divided. The surgeon grasps the left lobe with the right hand and defines the limits of the avascular suspensory ligament from underneath by upward pressure with the index finger (Figure 9). This procedure is facilitated if the ligament is divided with long curved scissors held in the left hand. Occasionally, a suture will be required to control oozing from the very tip of the mobilized left lobe of the liver. The left lobe should be carefully palpated for evidence of metastatic nodules deep within the substance of the liver. The mobilized left lobe of the liver is folded upward and covered with a moist pack, over which a large S retractor is placed. At this time the need for upward extension of the incision, or removal of additional sternum, is considered. The uppermost portion of the gastrohepatic ligament, which includes a branch of the inferior phrenic vessel, is isolated by blunt dissection. Two right-angle clamps are applied to the thickened tissues as near the liver as possible. The tissues ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessSurgery Full Site: One-Year Subscription

Connect to the full suite of AccessSurgery content and resources including more than 160 instructional videos, 16,000+ high-quality images, interactive board review, 20+ textbooks, and more.

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessSurgery

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.