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273
PLATE
128
R T P
S P, L
INDICATIONS Laparoscopic resection of the body and tail of the pancreas
is limited to certain pancreatic neoplastic diseases including pancreatic neuroendocrine tumors such as insulinomas, pancreatic cystic neoplasms, and
pseudopapillary tumors. e approach is not recommended for chronic calci c
pancreatitis. For adenocarcinoma of the body and tail of the pancreas splenectomy should be performed. Splenic preservation is recommended and should
be attempted in the absence of a malignant neoplasm.
PREOPERATIVE PREPARATION The preparation is related to the preopera-
tive diagnosis. As splenic preservation is not always possible, it is recommended
to vaccinate the patient weeks prior to the surgery against encapsulated organisms including pneumococcus, haemophilus in uenza, and meningococcus.
ANESTHESIA General anesthesia with endotracheal intubation is required.
POSITION A cushioned beanbag should be placed on the operating table
prior to bringing the patient into the room. A er insertion of a bladder catheter, the patient should be positioned in a partial lateral position at about
degrees with the le arm crossing the chest and supported on an arm board or
pillows (
roll is used. Liberal padding is used between and around both arms. e abdomen and ank area should be exposed. e le knee is exed, with a padding
of blankets or pillows between the legs. Alternatively, the patient may be positioned in a modi ed lithotomy position, also using a cushioned beanbag and
taking care not to ex the thighs excessively so as to avoid interference with the
range of motion of the instruments.
OPERATIVE PREPARATION Hair removal is accomplished with skin clip-
pers from the level of the nipples well out over the chest wall and down
over the abdomen, including the anks. e skin is prepared in the routine
manner.
INCISION AND EXPOSURE e surgeon stands on the patient’s right side
similar to a laparoscopic le adrenalectomy (figure 1a). e camera operator stands to the right of the surgeon and the assistant on the le side of the
patient. If the modi ed lithotomy position is employed, the surgeon is positioned between the legs and the camera operator to the patient’s right and the
assistant to the patient’s le . Port placement is shown in
-degree laparoscope is placed above the umbilicus using the open technique
of Hasson as described in Plate . e abdomen is insu ated to mmHg
pressure. e laparoscope is introduced and all four quadrants of the abdomen
are examined for metastatic disease. Two -mm ports are placed: one in the
midline and one to the le side midway between the umbilicus and the xiphoid
process at the midclavicular line. e ports are place about to cm apart in
the crainiocaudad orientation to permit bimanual operation without physical
restriction. A - or -mm port is placed on the le side at the level of the
umbilicus in the anterior axillary line. An additional -mm port is placed just
below the right subcostal margin in the midclavicular line. A -mm port is
required for an endoscopic stapler with .-mm staples that may be used to
divide a thicker pancreas, whereas a stapler with .-mm staples or less will be
able to be introduced through a -mm port.
DETAILS OF PROCEDURE e stomach is grasped with an atraumatic lap-
aroscopic clamp and retracted superiorly. e lesser sac is then entered using
a harmonic scalpel to divide the omentum along the greater curvature of the
stomach (
allow exposure of the body and tail of the pancreas. e lateral extent of the
incision is carried to the level of the short gastrics. e short gastric vessels are
not divided when planning splenic preservation. Medial exposure is essential;
therefore, the opening in the omentum is carried to the right gastroepipolic
vessels. Sharp as well as blunt dissection is used to sweep the posterior gastric
wall away from the pancreas, particularly in the region of the antrum, to make
certain the middle colic vessels have not been angulated upward and attached
to the posterior gastric wall. e surgeon must ensure a clear view of the entire
pancreas and the rst part of the duodenum all the way over to the hilus of
the spleen (
divide the communicating vein between the right gastroepiploic vessels and the
middle colic vein inferior to the pylorus. is permits better mobilization in
the region of the antrum. e pancreas should be visually inspected to identify
the pathology. Intraoperative ultrasound may be helpful.
to the lateral to medial direction for an open distal pancreatectomy. An incision
is made in the peritoneum along the inferior border of the body and tail of the
pancreas (
the superior mesenteric vein and the portal vein (figure 3). e splenic vein is
figure 1a). e right arm is placed on an arm board and an axillary
figure 1b. A -mm
figure 2). e opening in the lesser sac should be generous and
figure 2). To avoid troublesome bleeding, it is usually desirable to
e operation will be carried out in a medial to lateral direction, as opposed
figure 2). Gentle dissection along the neck of the pancreas will expose
identi ed. An incision is then made along the superior edge of the pancreas to
the le of the gastroduodenal artery and inferior to the hepatic artery. A plane
between the portal vein and the neck of the pancreas is created by gentle blunt
dissection in the inferior to superior direction with a blunt nose laparoscopic
dissector (figure 4). Once the opening is complete and the blunt tipped dissector can be seen protruding from the superior edge of the pancreas, a half inch
Penrose drain shortened to cm is placed into the abdominal cavity through the
- or -mm port. It is then passed underneath the neck of the pancreas and the
ends are secured with an endoloop (
the pancreas, which is essential to dissecting the plane along the superior mesenteric vein and the neck of the pancreas, and will also facilitate mobilization of the
splenic vein away from the proximal body of the pancreas. e assistant grasps
the Penrose drain and pulls it superiorly and anteriorly. e surgeon then begins
to gently dissect the mesenteric vessels and portal vein away from the neck. e
splenic vein will come into view, and prior to division of the pancreas, small
branches of the vein are divided with the ultrasonic dissector and larger branches
are clipped. is dissection is carried out in the medial to lateral direction for to
cm. It may be necessary to place a shortened vessel loop around the splenic vein
to provide countertraction and proximal vascular control. Once to cm of the
vein has been dissected free, the neck of the pancreas is divided. is is accomplished with a reticulated endoscopic stapling device with .- or .-mm staples.
e staple line may be reinforced with a commercial material (
the proximal and the distal staple lines are inspected for bleeding, and if bleeding is found, it is controlled with electrocautery or the ultrasonic dissector. e
Penrose drain may be removed at this point, as retraction of the pancreas may be
obtained by grasping the distal staple line. Once the pancreas is divided, the body
of the pancreas is retracted superiorly (figure 7). is will permit the branches
of the splenic artery to be divided. e splenic artery will come into view superior to the splenic vein. Small braches of the splenic artery are then divided with
the ultrasonic dissector and larger branches are clipped. (
shortened vessel loop may be passed around the splenic artery in order to provide
counter traction as well as proximal vascular control. Once the branches of the
proximal splenic artery are divided, the remaining branches of the splenic vein
are ligated. e distal pancreas is pulled downward to further expose the splenic
artery (
figure 8). e branches of both the artery and the vein are very fragile
and unavoidable avulsion will occasionally occur. For small braches, bleeding
may be controlled with pressure. Larger branches should be grasped with a Maryland dissector to control the bleeding and then clipped if there is su cient length
or ligated with a - or - mono lament suture if there length is insu cient. e
peritoneum is further divided along the inferior edge of the pancreas. e posterior margin of the dissection will be the splenic vein and artery. e proximal
jejunum may be seen and should be retracted inferiorly. Defects in the mesocolon
should be closed with sutures to prevent internal hernias. e peritoneum is also
divided along the superior edge of the pancreas with the ultrasonic dissector. As
dissection proceeds, the vein will next be seen as it exits the splenic hilum. Shortly
therea er, the artery will be seen entering the spleen. e distance between the
end of the tail of the pancreas and the spleen is variable. e nal attachments
are divided with the harmonic ultrasonic dissector. e specimen is extracted
from the abdominal cavity using a specimen retrieval bag or similar device
(
figure 9). It is removed from the abdominal cavity from the umbilical port.
Once it is removed, the abdomen is reinsu ated and the lesser sac exposed to
permit inspection of the splenic artery and vein for bleeding. If vessel loops have
been used, they are removed at this point.
CLOSURE The specimen should be examined to determine that the pathol-
ogy has been removed. A frozen section at the margin should be obtained
for pancreatic cystic tumors and intraductal mucinous neoplasms. A closedsuction Silastic drain may be placed by passing the external portion of the drain
through the - or -mm port and withdrawing from one of the -mm port
sites. e - or -mm port site is closed with absorbable suture. e umbilical port site is closed with absorbable suture.
POSTOPERATIVE CARE A nasogastric tube is not necessary. Crystalloids
should be given in an adequate amount. Pain management will require intravenous narcotic analgesics for one to two days. Antibiotics are discontinued
within hours. Glucose monitoring should be performed as a transient diabetic state may occur. e hemoglobin and electrolytes should be checked on
the rst postoperative day and repeated as deemed necessary by the clinical
course. An initial postoperative diet may be started on the rst postoperative
day. e drain amylase should be measured prior to removing the closedsuction drain. e drain should not be removed if the amylase is great than two
times the upper limit of normal. Supplemental pancreatic enzymes are usually
not necessary. e patient is discharged when tolerating a diet.
figure 5). is will allow anterior traction of
figure 6). Both
figure 7). A second
■
274
275
PLATE
129
P
(W P)
INDICATIONS e head of the pancreas is usually removed for malignancy
involving the ampulla of Vater, the lower end of the common duct, the head
of the pancreas, or the duodenum. Far less frequently, the procedure is
carried out to manage intractable pain associated with a chronic calci c
pancreatitis or for massive trauma when there is irreparable “burst” damage to the head of the pancreas, the ductal structures, and the duodenum.
In the presence of malignancy, the resection is indicated in the absence of
proven metastases and if the tumor is of such a limited size that the portal
vein is not involved beyond the ability of the surgeon to accomplish a safe
vascular resection and repair. Total pancreatectomy may be considered in
some cases because of the tendency for multicentric foci of malignancy to
develop as well as seeding within the pancreatic duct. is procedure also
decreases the incidence of postoperative complications from the leakage of
pancreatic juice from the anastomosis. e patient should be made aware of
the problem of diabetes mellitus a er operation as well as the need for daily
pancreatic enzyme replacement.
PREOPERATIVE PREPARATION Patients will have had imaging including
CT, MRI, and possibly endoscopic ultrasound prior to the procedure. Some
patients may have had biliary stents placed by an endoscopic or transhepatic route. Transfusions of blood products may be required preoperatively
to restore the blood volume and decrease the tendency to hypotension and
renal shutdown that may occur a er operation. e electrolyte levels should
be returned to normal and particular care should be taken that the INR
is normal and that renal function is not impaired, as shown by creatinine
and blood urea nitrogen levels. Blood should be available. e measured
amount of blood lost should be replaced during the operative procedure,
preferably via a central venous catheter. It is advisable to have a catheter
in the bladder in order to follow the postoperative hourly output of urine.
Antibiotic therapy should be started prior to operation. is is particularly
important for patients with stents, as they are prone to wound infections.
ANESTHESIA A nasogastric tube is inserted. General anesthesia with
endotracheal intubation is recommended.
POSITION e patient is placed supine on the table with the feet slightly
lower than the head. Facilities should be available for performing a cholangiogram or pancreaticogram.
OPERATIVE PREPARATION e skin should be shaved from the level
of the nipples well out over the chest wall and down over the abdomen,
including the anks.
INCISION AND EXPOSURE Diagnostic laparoscopy is indicated in
some patients to identify metastatic disease that may have been missed by
preoperative imaging. Pancreaticoduodenectomy for pancreatic or periampullary adenocarcinoma should not be performed if there are liver or
peritoneal metastasis. A type of incision should be selected that will
ensure the extensive and free visualization of the upper abdomen, especially on the right side. While an upper midline (figure 1, a) incision
that may extend below the umbilicus is useful, many prefer an oblique or
curved incision that parallels the costal margins (figure 1, b). When the
xiphoid is long and the xiphocostal angle narrow, further exposure may be
obtained by excision of the xiphoid process. On the other hand, very good
exposures can usually be obtained by the oblique or curved incision, rst
carried out over the right upper quadrant and then extended across the
midline and as far to the le as the surgeon believes necessary to ensure a
liberal exposure. All bleeding points must be carefully clamped and tied
to keep blood loss at a minimum, especially in jaundiced patients. Regardless of the type of incision used, the round ligament is divided (figure
2). e contents of the curved clamps must be securely ligated to avoid
bleeding from a vessel in the round ligament. Further mobility of the liver
can be obtained if the falciform ligament is divided well up over the dome
of the liver (figure 2). Occasionally, there are small blood vessels present
in it that should be ligated. A er the falciform ligament has been divided,
a self-retaining retractor can be inserted and the margins of the wound
freed of all clamps a er the ligation of their contents.
DETAILS OF PROCEDURE e type, location, and extent of the patho-
logic process now must be determined by thorough exploration. Evidence
of metastatic spread to the liver, the lymph nodes around the celiac axis,
and the region above the pancreas, as well as in the hepatoduodenal ligaments, should be sought by careful exploration.
When a very large gallbladder and common duct are encountered in
the presence of an obstructive jaundice, it may be helpful to aspirate the
contents of the gallbladder to enhance the exposure and at the same time to
localize accurately the site of obstruction by injecting radiopaque contrast
material into the biliary system. A point for the needle aspiration should be
selected on the underside of the fundus, since this area may be required for
a cholecystoenterostomy if resection is found to be contraindicated. Since
the bile is o en thick and inspissated, a rather large-bore needle, such as an
- or -gauge, is useful, and as much bile as possible is aspirated. e needle is le in place, to mL of iodinated contrast medium is injected,
and the patient is made ready for a cholangiogram. A purse-string suture is
placed in the wall of the gallbladder around the needle so that the opening
in the gallbladder can be closed as the needle is withdrawn.
While the surgeon is waiting for the return of the cholangiograms
to be inspected, he or she can proceed with mobilization of the duodenum and head of the pancreas by the Kocher maneuver (figure 3). e
duodenum is grasped with one or more Babcock forceps and retracted
medially as the peritoneum along the lateral wall of the duodenum is
incised. Usually, it is not necessary to ligate vessels in this area; in the
presence of jaundice, however, it is advisable to carry out a meticulous
hemostasis. Finger or gauze dissection is used to push the posterior wall
of the pancreas from the underlying vena cava and right kidney. An avascular cleavage plane can easily be developed (figure 4). A column of
peritoneum that remains forms the lower boundary of the foramen of
Winslow (figure 5). e surgeon can place this column of peritoneum
under tension by inserting the index and middle ngers on either side
of the peritoneum and should incise it very carefully, avoiding injury to
the underlying vena cava. In the presence of recurrent ulceration in the
region of the second part of the duodenum, considerable scarring and
xation in this area may be encountered.
A er the posterior wall of the duodenum and head of the pancreas have
been inspected carefully for evidence of tumor or metastatic involvement,
further freeing of the second or third part of the duodenum is indicated
to determine whether the lesion is operable. Care should be exercised in
sweeping away the middle colic vessels that, surprisingly enough, frequently
cross to the hepatic exure of the colon high up over the second part of the
duodenum (figure 6).
CONTINUES
276
Falciform ligament
2
1
B
A
Round ligament
Gallbladder
3
Foramen of Winslow
4
Foramen
of Winslow
5
Tumor
Duodenum
Kocher incision
6
Pylorus
Tumor
Foramen
of Winslow
Right kidney
Middle
colic vessels
Inferior
vena cava
277
PLATE
130
P
(W P)
DETAILS OF PROCEDURE e gallbladder, antrum of the
stomach, head of the pancreas, and duodenum have been separated to
call attention to the various relationships, including the blood vessels that
must be ligated in this procedure. ese structures are numbered for convenient identi cation. e gallbladder is removed since there is a tendency
for gallstone formation in case of long survival. To facilitate the anastomosis, as much of the common duct as possible should be saved below the
junction of the cystic duct except in cases of possible cholangiocarcinoma.
e common hepatic artery and its branches must be identi ed carefully.
e right gastric and the pancreaticoduodenal vessels are identi ed and
ligated in order to gain access to the region of the portal vein. Since no vessels enter at the anterior surface of the portal vein, this is the logical point
for dividing the head of the pancreas from the body and tail. A number
of pancreatic veins enter at the lateral border of the portal vein opposite
the point where the splenic vein joins the superior mesenteric to form the
portal vein. e middle colic artery and vein should be preserved.
Before the blood supply of the head of the pancreas is compromised, the
antrum of the stomach is transected, using the landmarks for hemigastrectomy (see Plate ). If a pyloric-sparing anastomosis is planned, the rst
portion of the duodenum is divided. Otherwise, the antrum is transected.
Either of these divisions provides a direct approach to the pancreas in the
region of the portal vein.
e pancreatic duct varies in size, depending on the amount of
obstruction that may have occurred as a result of a prolonged block by
calculi or tumor formation. If it is quite small, direct implantation of the
duct is impossible, and direct implantation of the tail of the pancreas
into the lumen of the jejunum can be carried out. Usually, there is one
blood vessel that needs to be ligated above the pancreatic duct in the substance of the gland and two below. In the presence of adenocarcinoma
of the pancreas, consideration should be given to the desirability of total
pancreatectomy.
Since marginal peptic ulceration may occur in a prolonged survival,
the ability of the stomach to produce acid may be controlled with truncal
vagotomy and by removing the entire antrum of the stomach. e latter can
be accomplished by hemigastrectomy, selecting as the point of division the
stomach at the level of the third vein on the lesser curvature and the point
on the greater curvature where the epiploic vessels are nearest the gastric
wall (see Plate ). Alternatively patient’s may be treated with lifelong acid
reducing medication.
One of the most di cult parts of the procedure is the freeing of the third
part of the duodenum, because of the short mesentery in this area. A portion
of the upper jejunum should be resected along with the duodenum to ensure
free mobilization of the upper jejunum, which is to be brought through the
opening in the mesentery to the right of the middle colic vessel.
CONTINUES
278
1. Tu m o r
2. Duodenum
3. Pancreaticoduodenal artery and vein: (a) Superior (b) Inferior
4. Right gastroepiploic artery and vein
5. Right gastric artery
6. Right gastric vein
7. Gastroduodenal artery
Liver
5
Caudate
lobe
21
5
6
4
3a
2
8. Common duct
9. Cystic duct
10. Cystic artery
11. Common hepatic artery
12. Portal vein
13. Coronary vein
14. Splenic vein
15. Superior mesenteric artery and vein
16. Pancreatic veins
17. Pancreatic duct
18. Pancreas
19. Splenic artery
20. Left gastric artery
21. Vagus nerves
22. Mddle colic artery and vein
23. Intestinal artery and vein
24. Jejunum
10
7
8
1
3b
9
18
17
13
11
14
7
5
8
12
16
22
15
17
20
19
18
24
23
279
PLATE
131
P
(W P)
DETAILS OF PROCEDURE When the second and third parts of
the duodenum are well mobilized, the surgeon may or may not have proved
the presence and the extent of a tumor. Additional information can be obtained
by palpating the head of the pancreas between the thumb and index nger
(figure 7). It should be remembered that pancreatic adenomas are occasionally found extending into the wall of the duodenum on the inner curvature side. e presence of a tumor involving the lower end of the common
duct, and particularly ulceration with tumor involvement in the region of the
ampulla of Vater, may be veri ed by palpation. A major concern when a tumor
is felt or visualized is to determine whether it is a benign or malignant lesion
and whether the portal vein is involved. Unless the surgeon is skilled in potential resection and repair of the portal vein, there should be good evidence that
the tumor does not extend into or about the portal vein before deciding to
proceed with the radical extirpation of the head of the pancreas.
It is not unusual to have considerable di culty in proving the presence or absence of a malignant tumor deep in the head of the pancreas
that is producing an obstructive jaundice. A surgeon is o en reluctant to
mobilize the head of the pancreas adequately and to carry out a biopsy
to prove the presence of tumor because of potential complications, such
as hemorrhage or a pancreatic stula and because of the poor accuracy
of frozen section in di erentiating between adenocarcinoma and chronic
pancreatitis. A transduodenal needle biopsy is utilized by some to obtain
su cient material for frozen-section diagnosis. Proof of the diagnosis may
not be possible before proceeding with pancreaticoduodenectomy. e
surgeon must use his judgment to establish a reasonable diagnosis based
on the gross ndings. If the lesion is not resectable and palliation is to
be provided by such surgical procedures as cholecystoenterostomy and
gastroenterostomy, chemotherapy, and radiotherapy, then microscopic
proof of cancer diagnosis is required. It permits a more rational plan for
the patient’s care, which may extend over a long period. e surgeon must
decide whether the best approach for the biopsy of the tumor is anterior or
posterior (figure 8). A biopsy needle, such as the large Tru-cut type, can
be inserted into a deep-seated tumor and biopsies taken. If the pathologist is hesitant to provide a diagnosis from the minimal amount of tissue
available, the surgeon must consider the possibility of proceeding with a
wedge biopsy using a small knife blade (figure 9). Alternatively, he may
send additional needle biopsies for permanent histology, which is more
accurate than frozen section.
A small blade can be used to remove a wedge of tumor and the adjacent
tissue compressed together with a trans xing suture of silk on French
needles. All bleeding must be controlled. is is not believed to be particularly dangerous provided that the sutures are not placed so deeply as to
obstruct the major pancreatic duct. Next, the surgeon should proceed with
further mobilization of the pancreas by entering the lesser sac (figure 10).
e omentum is retracted upward and the incision made into the lesser sac
for more thorough evaluation of potential metastases above the pancreas
and about the region of the celiac axis. Since some tumors of the pancreas
are multiple, it is important that the entire pancreas be visualized and palpated, especially if a diagnosis of gastrinoma has been considered. It is
usually advisable to open the lesser sac completely by freeing the omentum
from the underlying transverse colon all the way over to and including
the region of the splenic exure of the colon (figure 11). It should be
kept in mind that the blood vessels to the colon may be angulated upward
and attached for several centimeters to the undersurface of the mesocolon.
e incision, therefore, should be made several centimeters away from the
visualized bowel wall, as shown in figure 11. It may be necessary to free
the spleen, especially during the exploration of the pancreas for islet cell
adenomas. Next, the surgeon explores the structures above the rst part
of the duodenum (figure 12). e contents of the enlarged gallbladder
can be aspirated if exposure is limited. e peritoneum is incised over the
superior border of the duodenum, which is an initial step in isolating the
common duct from the adjacent vascular structures.
CONTINUES
280
8
7
Tumor s
Duodenum
Biopsy needle
Portal vein
Tumor
9
Biopsy of tumor
10
Stomach
Pancreas
11
Transverse colon
Approach to
lesser sac
Transverse colon
Greater omentum
12
Spleen
Dilated
common
duct
Pylorus
281
PLATE
132
P
(W P)
DETAILS OF PROCEDURE Mobilization of the superior part
of the duodenum is continued in an e ort to isolate as long a segment of
the common duct as possible. is can be accomplished by gently spreading a right-angle clamp about the dilated common duct and meticulously
controlling all bleeding (figure 13).
An e ort should be made to free this portion of the common duct completely and it is encircle with a vessel loop. e surgeon can then palpate
behind the duodenum with the index nger in an e ort to develop a cleavage plane between the duodenum and portal vein, and at the same time to
determine more accurately whether there is xation 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. e
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 identi ed
(figure 15). An alternate procedure that saves the antrum and pylorus may
be chosen at this point. e 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 de ne
the vascular pedicle to be doubly ligated (figure 15). e 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. is can be accomplished by use of proton pump inhibitors
or other medications to suppress acid production a er surgery or by truncal vagotomy and hemigastrectomy, which ensures complete removal of the
antrum. is 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. e usual reconstruction a er 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 o en results in a prolonged
hospital stay because of delayed gastric emptying. An area the width of the
index nger should be cleared on either curvature to prepare for the anastomosis a er the blood supply has been doubly ligated (figure 17). Staples
are applied adjacent to the traction sutures, which are le in place to de ne
the areas prepared for anastomosis (figure 17). e removal of the antrum
greatly assists in the subsequent exposure of the more di cult 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 and ).
CONTINUES
282
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