We recommend diagnostic laparoscopy to evaluate for clinically occult metastatic disease. This may be performed via open technique Hasson port placed in-line with the planned incision. The peritoneal cavity is then systematically inspected for ascites, peritoneal or liver nodules, or other evidence of metastatic disease. If any suspicious lesions are identified, an additional 5-mm port is placed to facilitate laparoscopic biopsy. Any suspicious lesions are sent for frozen section examination before proceeding.

Once absence of metastatic disease is confirmed, a laparotomy incision is made. We prefer a midline vertical incision from the xiphoid process to just above or just below the umbilicus, depending on the length of the patient’s torso. A horizontal Chevron-type incision is also feasible. The two have been shown to be equivalent in terms of postoperative pain and postoperative hernia formation. The midline incision preserves the integrity of the rectus muscles and has been shown to result in decreased wound infections [6]. The pre-peritoneal fatty tissue is excised to facilitate exposure and the falciform ligament is divided between clamps and ties or with an energy-sealing device. The liver and the celiac trunk are palpated for liver masses or abnormal celiac lymph nodes, respectively. A fixed retractor is then assembled. We prefer the Thompson retractor (Thompson Surgical Instruments, Traverse City, MI).

The stomach is grasped and elevated by the assistant, whereas the transverse colon is grasped and placed inferiorly by the surgeon. The lesser sac is entered by dividing the greater omentum between the gastroepiploic vessels and the transverse colon. Entry into the lesser sac is confirmed by visualization of the posterior wall of the stomach. This opening should be extended along the greater curvature of the stomach, following the gastroepiploic vessels, but should be stopped prior to reaching the short gastric vessels. The opening is then similarly extended toward the distal stomach and the origin of the gastroepiploic vessels. It is important for the assistant to continue holding the stomach straight up in the air to expose this area. The avascular attachments between the posterior wall of the stomach and the pancreas are divided with electrocautery. The right gastroepiploic vein is identified and is carefully followed down to the superior mesenteric vein (SMV). The right gastroepiploic vein often shares a common trunk with the right colic vein, known as the gastrocolic trunk or Henle’s trunk (Fig. 10.2). The trunk may include the middle colic vein as a trifurcation. Careful dissection should be performed along the left side of the venous trunk until the SMV is reached. The right gastroepiploic vein can be ligated and divided at this point to prevent tearing or this step can be performed later once final determination of resectability has been made.

Once the SMV is identified, it is critical to determine that there is an adequate length of vein uninvolved by tumor to proceed safely with resection. This typically requires a minimum of 2–3 cm of infra-pancreatic SMV to allow for placement of a vascular clamp to permit vascular reconstruction. It is acceptable to begin a tunnel between the anterior surface of the SMV and the neck of the pancreas, however significant dissection at this stage is strongly discouraged as vascular control of inflow and outflow has not been obtained and exposure is severely limited at this stage of the operation. Furthermore, in most cases, high quality preoperative imaging should clearly define the status of the plane behind the pancreatic neck. If an attempt to dissect this plane is made at this stage, any resistance during dissection should lead to this maneuver being immediately aborted. If small-volume bleeding is encountered, it is best controlled by applying pressure for some time, as there is no exposure to control it directly. If there is high-volume bleeding that will not stop with pressure, vascular control of the portal vein above and SMV below must be obtained while holding direct pressure. If necessary, the neck of the pancreas should be divided to expose the underlying source of bleeding. Next, we typically prefer to identify the superior mesenteric artery (SMA) just posteromedial to the SMV. This will help define the right lateral border of the SMA and later facilitate the uncinate dissection.

The transverse colon is grasped and elevated. Any attachments to the gallbladder are divided. The hepatic flexure attachments are divided with an energy sealant device exposing Gerota’s fascia of the right kidney and the proximal duodenum. There is a discrete, avascular tissue plane between the colon mesentery and Gerota’s fascia. This plane should be widely opened so that the colon can be packed caudally, maximizing exposure of the duodenum.

The duodenum is gently rolled to the patient’s left side by the surgeon, placing the underlying retroperitoneal attachments on tension. These attachments within an avascular plane are then divided with electrocautery, staying close to the edge of the duodenum. Care should be taken to avoid injury to the retroperitoneal structures in this region, including the right gonadal vessels, the right renal vein, and the inferior vena cava. This dissection should be continued under the head of the pancreas until the left renal vein and ligament of Treitz are reached. Tumor adherence to the inferior vena cava or aorta or abnormal lymphadenopathy in this region signifies advanced unredectable disease.

Attention is next turned to the stomach. We often perform a standard pancreaticoduodenectomy including a small portion of the antrum and pylorus with the specimen. Multiple randomized, controlled trials have confirmed no difference in outcomes with standard versus pylorus-preserving techniques. Any remaining gastrohepatic ligament attachments are cleared for about 3–4 cm proximal to the pylorus. A target area on the greater curvature side of the stomach is selected and is similarly cleared of any remaining omental attachments. The stomach is then divided with a linear stapler. After assuring hemostasis on the staple line, the proximal stomach can then be packed into the left upper quadrant.