Plate 124
###### Figure 28

The jejunum is held up out of the wound. By transillumination the surgeon can study the vascular arcades and select more accurately the blood vessels to be divided for mobilizing the arm of the jejunum to be brought up to the pancreas (Plate 34). The jejunum is divided at a point 10 to 15 cm beyond the ligament of Treitz. A small opening is made in the mesocolon to the left of the middle colic vessels, just over the ligament of Treitz. The jejunum is pulled through this opening and measured along the full length of the pancreas (Figure 24). The length of the pancreas from just beyond the end of the opened duct to the end of its tail is marked, point X, on the jejunum, by Babcock forceps placed on its antimesenteric border (Figure 24). The tail of the pancreas will be drawn into the bowel lumen and approximated to point X. Here the surgeon must be certain that there is adequate jejunal length and that the mesenteric vascular pedicle will reach easily without angulation. Traction sutures (A and B) of 00 silk are placed on the superior and inferior borders of the capsule of the pancreas (Figure 25) to aid in pulling the tail to point X. The Potts forceps are removed from the open end of the jejunum and replaced by Babcock forceps at the antimesenteric border. The jejunum is gently stretched between the two Babcock forceps as the needles, with attached traction sutures A and B, are introduced into the lumen of the bowel. During insertion the needles are held parallel to the long axis of the holder with points backward to ensure that the bowel wall is not punctured (Figure 26A). At point X, the needle is sharply retracted to puncture the wall and carry the suture externally (Figure 26B). Gentle traction is maintained upon these sutures to aid in pulling the pancreas up into the jejunum. When the pancreas is completely encased inside the bowel, sutures A and B are tied together, bringing the tail to point X (Figure 27). The opened end of the jejunum is then circumferentially tracked down to the capsule with interrupted nonabsorbable 00 sutures. The posterior row is placed first, beginning at the ...

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