Plate 122
###### Figure 17

In addition to the previous procedures described, drainage of the body and tail of the pancreas may be accomplished by implanting the left end of the pancreas into the open end of the arm of jejunum that has been brought up for a Roux-en-Y type of anastomosis.

When the pancreas is severely inflamed, small, and contracted, it may be advisable to mobilize as much of the tail and body as possible and to remove the spleen in anticipation of implantation into the jejunum. Once the presence or absence of a dilated duct is confirmed by needle aspiration and palpation (Figure 14), the peritoneum is incised superior and inferior to the body and tail of the pancreas, care being taken not to injure the inferior mesenteric vein (Figure 14). After the peritoneum has been incised, the surgeon inserts his index finger behind the pancreas and can very easily, by a backward and forward motion, free the posterior wall of the body and tail of the pancreas from adjacent tissues. The finger is inserted completely around the pancreas, including the splenic artery and vein, which run along the superior surface of the pancreas (Figure 15). A rubber drain is passed through this opening in order to provide gentle traction on the pancreas for the dissection of the tail and exposure during the freeing of the remainder of the pancreas and the splenectomy (Figure 16). The gastrosplenic ligament is divided, and the blood supply along the greater curvature of the stomach is transfixed to the gastric wall with interrupted 00 sutures. Alternatively, an ultrasonic dissector can be used to coagulate and divide the short gastric vessels. Any attachments between the superior pole of the spleen and the diaphragm are divided, and the spleen is mobilized well into the wound. The pedicle of the attachments between the inferior surface of the spleen and the colon is likewise divided, as is the posterior splenorenal ligament (see Plate 141). The blood supply to the spleen is divided and ligated. The vessels then are doubly ligated with 00 nonabsorbable ligatures (Figure 17). In the younger age-groups, it is desirable to make every effort to save the spleen because of the risk of subsequent sepsis. The mobilization of a chronically inflamed tail and body of the pancreas requires ligation of numerous small blood vessels entering the major splenic blood supply.

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