Plate 133

If there is oozing between the staples, it is controlled by interrupted sutures of 0000 silk. The upper half of the approximated gastric outlet is inverted by a layer of interrupted 00 silk mattress sutures (Figure 18). A sufficient length of the gastric outlet near the greater curvature is retained to provide a stoma approximately two to three fingers wide. This portion of the gastric wall should not be excised until the final steps of the anastomosis, although it may be necessary to apply several sutures along the line of the clips to control oozing.

A very critical point now involves the identification of the common hepatic artery and the gastroduodenal artery, which runs downward over the pancreas behind the duodenum (Figure 19A). The common hepatic artery may be located by palpation just above the pancreas. The peritoneum over it is carefully incised and this major artery clearly visualized in order to avoid its injury. By blunt dissection, the surrounding tissue is separated until the origin of the gastroduodenal artery is visualized. This vessel must be identified clearly and doubly ligated (Figure 19B). The lumen of the common hepatic artery must not be encroached upon. The tissues about the right gastric artery also must be freed gently and separated upward, as shown by the dotted line (Figure 19B). Following the ligation of these two vessels, blunt dissection with a long right-angle clamp may be undertaken to further free the region of the common duct and portal vein (Figure 20). Since these patients are often rather emaciated, there is relatively little tissue to be separated away from the portal vein. Great care should be taken gently to develop a cleavage plane over the portal vein, which will permit the surgeon to introduce carefully a blunt-nosed clamp, such as a right-angle clamp, behind the pancreas and to open and close the clamp as the tissues are separated from the underlying portal vein. It may be safer and easier for the surgeon to introduce the index finger directly behind the pancreas and over the portal vein. Considerable time should be spent in manipulating the pancreas off the portal vein. This can be done since no vessels enter from the anterior surface of the portal vein. The tissues about the inferior surface of the pancreas may need to be incised so that the finger can be introduced completely underneath the pancreas and come out inferiorly near the region of the middle colic vein (Figure 21).

Better exposure is gained if the body and tail of the pancreas have been mobilized to serve as traction for the delicate dissection around the portal vein. Otherwise, the subsequent technical details of the procedure can be enhanced if the pancreas is divided at this point. A blunt-nosed right-angle clamp is passed between the anterior surface of the portal vein and the neck of the pancreas. The pancreas is divided with electrocautery (Figure 22). There is usually one sizable bleeding point above the pancreatic duct (Figure 23) and at least two other vessels below the pancreatic duct. These are controlled with suture ligatures of fine silk or electrocautery, making certain not to occlude the pancreatic duct. Although there is debate about the value of obtaining a negative microscopic margin at neck some surgeons continue to obtain a tissue sample for frozen section. In this case a knife is used to take a 2-mm cross section of the divided pancreas for frozen section to ensure negative margins. If the margin is positive, additional pancreas should be removed. The duodenum and head of the pancreas to be excised are grasped primarily with the surgeon's left hand as she proceeds gently to identify the friable vessels entering the head of the pancreas from the right side of the portal vein.

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