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Mobilization of the superior part of the duodenum is continued in an effort to isolate as long a segment of the common duct as possible. This can be accomplished by gently spreading a right-angle clamp about the dilated common duct and meticulously controlling all bleeding (Figure 13).
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An effort should be made to free this portion of the common duct completely and it is encircle with a vessel loop. The surgeon can then palpate behind the duodenum with the index finger in an effort to develop a cleavage plane between the duodenum and portal vein, and at the same time to determine more accurately whether there is fixation by the tumor to this vein. Once the surgeon is sure that resection is safe without injury to the portal vein, he or she proceeds to ligate the blood supply necessary for antrectomy. The right gastroepiploic vessels should be ligated and tied (Figure 14). Following this, the antrum can be encircled with tape, gentle medial and downward traction is applied to the stomach, and the right gastric vessels are identified (Figure 15). An alternate procedure that saves the antrum and pylorus may be chosen at this point. The duodenum is transected a few centimeters beyond the pylorus and later anastomosed, as shown in Figure 17A.
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It is helpful to insert a straight clamp above the duodenum and spread the clamp parallel to the small right gastric vessels in order to better define the vascular pedicle to be doubly ligated (Figure 15). The stomach is divided (Figure 16). If there is a question about resectability, the division of the stomach should be deferred until the plan is established between the rest of the pancreas and the portal vein. Since peptic ulceration is one of the late complications following radical amputation of the head of the pancreas and duodenum, it is essential to control the acid-producing ability of the remaining stomach. This can be accomplished by use of proton pump inhibitors or other medications to suppress acid production after surgery or by truncal vagotomy and hemigastrectomy, which ensures complete removal of the antrum. This is accomplished if the resection includes all of the stomach distal to the third vein on the lesser curvature and the area on the greater curvature where the ...