Diagnostic laparoscopy is indicated in some patients to identify metastatic disease that may have been missed by preoperative imaging. Pancreaticoduodenectomy for pancreatic or periampullary adenocarcinoma should not be performed if there are liver or peritoneal metastasis. A type of incision should be selected that will ensure the extensive and free visualization of the upper abdomen, especially on the right side. While an upper midline (Figure 1, A) incision that may extend below the umbilicus is useful, many prefer an oblique or curved incision that parallels the costal margins (Figure 1, B). When the xiphoid is long and the xiphocostal angle narrow, further exposure may be obtained by excision of the xiphoid process. On the other hand, very good exposures can usually be obtained by the oblique or curved incision, first carried out over the right upper quadrant and then extended across the midline and as far to the left as the surgeon believes necessary to ensure a liberal exposure. All bleeding points must be carefully clamped and tied to keep blood loss at a minimum, especially in jaundiced patients. Regardless of the type of incision used, the round ligament is divided (Figure 2). The contents of the curved clamps must be securely ligated to avoid bleeding from a vessel in the round ligament. Further mobility of the liver can be obtained if the falciform ligament is divided well up over the dome of the liver (Figure 2). Occasionally, there are small blood vessels present in it that should be ligated. After the falciform ligament has been divided, a self-retaining retractor can be inserted and the margins of the wound freed of all clamps after the ligation of their contents.