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Since the gallbladder is often quite large and distended, it should be removed to provide additional room and prevent late complication from gallstone formation (Figure 29). Many surgeons prefer to remove the gallbladder prior to dissection of the porta hepatis and identification of the common bile duct. Attention is now directed toward further mobilization of the upper jejunum in the region of the ligament of Treitz (Figure 30). Usually, the peritoneum has been opened from above the colon, just about where the dotted line is shown. The upper jejunum is grasped with Babcock forceps and the bowel held up in order to enhance the visualization of the arcades providing the rich blood supply to the jejunum. Incisions are made through the avascular portion of these arcades, so that two or three of the basic arcades can be divided and double ligated to enhance the mobilization of the upper jejunum (Figure 31). The final result is shown in Figure 31; whereas Figure 12, Plate 140 provides additional guidance as to the area of mesenteric division below the proximal jejunal vascular arcade. The arcade to be divided must be identified very carefully, and no vessels should be ligated in the mesentery near the mesenteric border of the bowel, since the blood supply to that segment may be compromised. When a segment of the mesentery of the upper jejunum has been divided, the jejunum is brought up through the opening in the mesocolon underneath the superior (Figure 31). A point to divide the bowel is selected where the mesenteric blood supply is obviously good (Figure 31). About 1 cm of the mesenteric border is freed of blood supply and the jejunum divided with a cutting linear stapler (GIA). The specimen is removed and the jejunal arm is brought up through the opening in the mesocolon must be long enough to reach well up into the gallbladder fossa without undue tension or compromise of the blood supply. If there appears to be considerable tension, the bowel should be returned back below the colon and additional mesentery divided.

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