The incidence of PMS-VT may be influenced by the lack of clear recommendation regarding anticoagulation following “high-risk” surgery procedures (i.e., major venous reconstruction, extended hepatic resection, pancreaticoduode­nectomy). In particular, some surgeons delay or completely withhold routine venous thrombo­embolism prophylaxis following major hepatec­tomy, because it is believed that these patients are at risk for postoperative liver insufficiency, leading to the concern they are already antico­agulated. This belief is often supported by the resulting laboratory derangements in measur­able liver function, including elevations in the prothombin time/international normalized ratio (PT/INR) and partial thromboplastin time (PTT), as well as occasional thrombocytopenia. Be­cause of that, many surgeons carefully observe patients with portal vein thrombosis following hepatectomy and initiate anticoagulation therapy only when the thrombus extended to the superior mesenteric vein or reduced portal venous flow. In contrast with this practice, Ejaz et that despite

stump, vascular anastomoses, or other peripan­creatic vessels [22]. A pedicled falciform liga­ment is easily and rapidly obtained during a mid­line abdominal incision. After incising the linea alba, the preperitoneal fat is dissected laterally (to the left) when incising the peritoneum. The fal­ciform ligament is mobilized by dividing it near the umbilicus and incising its anterior peritoneal reflections along the posterior rectus sheath. An additional length is obtained by continuing the anterior incision cephalad to the anterior surface of the liver. The pedicled falciform ligament is completed by taking down the attachments of the liver until just the obliterated umbilical vein remains attached. Note that the pedicled falci­form ligament (Fig. 26.1) normally reaches the space between the pancreaticojejunostomy and the major vessels exposed during resection. After completion of the pancreatectomy, the pedicled falciform ligament is spread widely anterior to the common/proper hepatic artery with special attention to coverage of the GDA stump. A ro­bust flap usually also covers the superior mesen­teric vein (SMV), portal vein (PV), and splenic vein confluence effectively separating the vessels from the afferent jejunal limb (Fig. 26.2). When a distal pancreatectomy is performed, the pedicled falciform ligament can be fixed with 4-0 prolene sutures to the remnant pancreas thereby rein­forcing the pancreatic closure. This procedure enables the complete separation of these vessels

exposed in this way before dividing the common hepatic duct. Care during this critical step in the performance of PD can minimize trauma to the hepatic artery and allow for a secure closure of the GDA stump [22].