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A rather liberal incision is made in the pancreatic duct and carried over toward the right side but not up against the posterior wall of the duodenum, lest the pancreaticoduodenal vessels be divided and massive hemorrhage occur. A dilated pancreatic duct is usually encountered, and intermittent lakes or segmental dilatations may be found (Figure 4). As the pancreatic duct is divided, the fibrotic margins are grasped by Allis forceps, and all bleeding points are controlled (Figure 4). An effort can be made to establish the patency between the remaining segment of the pancreatic duct in the head of the pancreas and the lumen of the duodenum through the papilla of Vater. Frequently one or more calculi may need to be dislodged with a gallbladder type of scoop or small, fenestrated type of forceps commonly used to remove ureteral calculi (Figure 4). Considerable time may be consumed in clearing the major pancreatic duct of calculi. A French woven catheter can be directed into the pancreatic duct to determine the patency of the papilla of Vater (Figure 5). Patency can be proved by distention of the duodenum after an injection of saline. In case of doubt, it may be advisable to inject contrast medium followed by a roentgenogram to visualize the remaining short segment of the pancreatic duct.
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Ordinarily, the pancreatic duct is opened for 6 to 8 cm, and a decision then must be made as to the type of anastomosis that will be carried out: the Roux-en-Y arm as in a jejunal “fishmouth” lateral anastomosis, full-width side-to-side anastomosis, or implantation of the mobilized pancreas into the lumen of the jejunal segment. The jejunum is prepared for the Roux-en-Y anastomosis by dividing it 10 to 15 cm below the ligament of Treitz (Plate 34). The vessels in the mesentery of the upper jejunum are visualized, and several vascular arcades are divided some distance from the mesenteric border. This permits mobilization of a sufficient length of jejunum to allow it to reach up into the region of the pancreas. An opening is made in the mesocolon to the left of the middle colic vessels in an avascular portion near the base of the mesentery. The arm of the jejunum is then tested for length and is turned with the open end to the right as well as to the left to determine which position of the mobilized jejunum produces the least interference with the blood supply. Many procedures can be followed ...