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Transfixing silk traction sutures are applied to the superior and inferior borders of the duodenum adjacent to its retained blood supply. These traction sutures are helpful when the narrow crushing large vascular clamp is applied to the duodenum, as well as in the subsequent closure of the duodenal stump (Figure 14). After the blood supply about the pylorus has been divided and tied, the stomach is held upward in order to free any adhesions between the first portion of the duodenum and the pancreas (Figure 14). At this time the transverse colon can be returned to the abdomen and retracted out of the operating field. The field is then walled off by several warm, moist sponges.

A thin-bladed, noncrushing clamp of the vascular type (Potts) is then applied across the duodenum at the prepared level (Figure 15). A Kocher clamp is applied to the gastric side. There should be at least 1 cm of cleansed serosal surface at either border of the duodenum, between the noncrushing clamp and the traction sutures. This amount of prepared duodenal wall is necessary to ensure a safe subsequent closure of the duodenal stump. If the adjacent ligature does not permit 1 cm of cleared serosa between it and the margin of the clamp, small served clamps should be applied to the interfering vascular attachments, and such attachments should be divided and ligated. The duodenum is divided with a knife. The clamp applied to the gastric side is covered with a piece of gauze, and the stomach is retracted to one side. The duodenal stump is then retracted laterally in order to determine whether a sufficient amount of the serosa of the posterior wall has been cleared away to permit a safe closure of the duodenal stump. At least 1 cm distal to the clamp, the duodenum should be freed from the pancreas in order that subsequent sutures in the serosa may be placed under full vision. Individual clamping and subsequent ligation of the small vascular attachments must be carried out without damaging the gastroduodenal artery (Figure 16). The placement of deep sutures to control bleeding ...

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