The patient is positioned supine with arms padded and tucked at their side (preferred) or at 90 degrees. A fixed retractor is positioned to allow bilateral cephalad retraction of the costal margins.

An initial right subcostal or limited upper midline incision is made. A thorough exploration is performed focusing on all peritoneal and visceral surfaces. In the absence of metastatic disease, the subcostal incision is extended to the left. The subcostal retractors are placed and secured to the frame of the fixed retraction system chosen. To maximize the exposure, the inferior abdominal wall flap is secured with a heavy suture to the inferior abdominal wall. Initial dissection is performed to identify evidence of any local findings that would preclude resection. Mobilization of the hepatic flexure of the colon optimizes exposure for kocherization and the eventual distal duodenal dissection. A full kocherization of the duodenum is then performed, extending medially to the aorta (Fig. 7.1). This maneuver allows assessment of the pancreatic head and exclusion of retroperitoneal extension of inflammation or tumor. The left hand is placed around the pancreatic head and the tips of the fingers assess for involvement of the superior mesenteric artery (SMA). In the current era of improved CT imaging, these maneuvers will rarely identify evidence of local unresectability, however, they optimize initial exposure and allow improved control needed during dissection of the superior mesenteric and portal vein. Careful inspection of the lesser sac is performed to exclude peritoneal metastases and assess for adjacent organ involvement by inflammation or malignancy. The omentum is dissected off the transverse colon in the avascular plane and the lesser sac is widely exposed (Fig. 7.2). With the anterior surface of the pancreas exposed, the avascular attachments between the stomach and pancreas are divided. The middle colic vein is followed to the superior mesenteric vein (SMV) and the gastrocolic venous trunk is identified, ligated, and divided (Fig. 7.3A). This allows safe exposure of the SMV and the inferior border of the pancreas. The middle colic vein is occasionally divided on the basis of necessary exposure or suspected proximity to tumor. Retraction of the colon inferiorly without division of the gastrocolic trunk can lead to inadvertent avulsion and

bleeding. If bleeding is encountered during dissection or ligation of the gastrocolic trunk, the left hand placed posterior to the pancreatic head with the thumb anteriorly will allow direct compression of the SMV to control hemorrhage and facilitate venorrhaphy.

With the gastrocolic trunk divided, the SMV can easily be followed to the inferior border of the pancreas. A curved, blunt clamp is used to develop the plane between the SMV and the posterior aspect of the pancreatic neck (Fig. 7.3B). The clamp should advance easily. Difficulty in passing the clamp posterior to the neck of the pancreas should prompt consideration of malignant invasion or significant inflammatory involvement of the superior mesenteric or portal vein. After an initial assessment of the pancreatic neck from the inferior approach, assessment at the superior aspect is performed. The gastrohepatic ligament is incised and the right gastric artery ligated and divided (Fig. 7.4A). The common hepatic artery is dissected at the
superior border of the pancreatic neck and the consistent lymph node in this region is excised. This allows excellent exposure of the origin of the gastroduodenal artery and the insertion of the coronary vein. Ligation and division of the gastroduodenal artery is performed (Fig. 7.4B). Careful dissection at the inferior border of the common hepatic artery near the origin of the gastroduodenal artery will identify the portal vein (Fig. 7.4C). From an inferior approach, a clamp is now advanced anterior to the SMV with the tip oriented in the same direction as the exposed portal vein. Care should be taken to avoid veering to the medial aspect of the vein, as inadvertent injury to the insertion of the coronary vein or splenic vein can occur. A cloth “tape” is passed around the neck of the pancreas which facilitates exposure and retraction of the pancreas (Fig. 7.4D).