Plate 32

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 between the clamps are divided and the contents of the clamps ligated with transfixing sutures of 00 silk (Figure 10). The incision in the peritoneum over the esophagus and between the fundus of the stomach and base of the diaphragm is outlined in Figure 10.

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