Plate 132

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).

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.

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 gastroepiploic vessels are nearest the gastric wall. Some prefer to add vagotomy to the hemigastrectomy. Others prefer to conserve the entire stomach, including the pylorus and a short segment of the duodenum without vagotomy. The usual reconstruction after a pylorus-sparing Whipple procedure is shown in Figure 17A. Many surgeons prefer the pylorus-sparing procedure for patients with benign disease (usually chronic pancreatitis of the head of the pancreas only), believing that it provides a better long-term nutritional outcome. However, it often results in a prolonged hospital stay because of delayed gastric emptying. An area the width of the index finger should be cleared on either curvature to prepare for the anastomosis after the blood supply has been doubly ligated (Figure 17). Staples are applied adjacent to the traction sutures, which are left in place to define the areas prepared for anastomosis (Figure 17). The removal of the antrum greatly assists in the subsequent exposure of the more difficult portion of the resection. Most surgeons now use a linear stapling instrument or a cutting linear stapler with deeper gastric staples. A truncal vagotomy is sometimes performed (Plates 17 and 18).

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