Editing Pancreaticoduodenectomy (section)

== Technique ==

* Bilateral subcostal is best, but midline can also be used
* Exploration for metastatic disease - abort if found
* '''Trial dissection:'''
** Enter lesser sac by taking omentum off transverse colon
** Kocher manoeuvre to level of left lateral aortic border, which confirms that the tumour is resectable
** Identify infra-pancreatic SMV by following middle colic vein down. Make a tunnel behind pancreas, anterior to portal vein, to confirm it can be freed from PV.
** Divide lesser omentum
** Now make a tunnel in front of PV from above, joined to inferior tunnel behind neck of pancreas

* '''Conservative pancreaticoduodenectomy'''
** Right gastric artery and GDA ligated and divided, after confirming collateral circulation through CHA
** First part of duodenum separated from pancreas - mobilise the pylorus and proximal 6cm of duodenum
** Divide CBD
** Divide proximal duodenum (3cm distal to pylorus)
** Mobilise ligament of Treitz to allow jejunum to come up into the supracolic compartment
** Divide distal duodenum
** Divide pancreatic neck under vision 
*** Stapler
*** Protect PV posteriorly
** Separate head and uncinate process of pancreas from PV and SMV (moving from left to right, peeling the disconnected pancreatic head off the vessels)
* '''Reconstruction''' (16.14A above)
** Pancreatic neck to jejunum (double layer duct to mucosa)
** Bile duct to jejunum (single layer end to side)
** Duodenal stump to jejunum (two layer end to side, 25cm distal to biliary anastomosis)
* Drains adjacent to joins
* Feeding jejunostomy in patients with pre-operative malnutrition