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Approach : right subcostal laparotomy.

The vasculature of the pancreas. Related arteries important to manage during the Whipple procedure.

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Cholecystectomy and dissection of the gastroduodenal ligament : on the right, the hepatic and gastroduodenal artery; on the left, the bile duct; in the middle and more deeply, the portal vein.

Kocher maneuver : the duodenum is mobilized on the left discovering the IVC.

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Elevation of the omentum. In the transverse mesocolon a vein is exposed and followed to the superior mesenteric vein. The right gastroepiploic vein (not represented) is still not ligated.

The passage between the neck of the pancreas and the mesentericoportal axis is developed.

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Ligature of the gastroduodenal artery.

A. For the pylorus preserving pancreatectomy (PPP) a passage is developed behind the past pyloric duodenum and the duodenum is stapled.

B. In case of distal gastric resection the stomach can be stapled with the 80 GIA®.

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A. The ligament and muscle of Treitz.

B. Section of the ligament of Treitz for the mobilization of the first jejunal loop.

C. Opening of the first loop mesentery and stapling of this loop.

The first loop is passed on the right of the root of the mesentery. Ligature of the right gastroepiploic vein and all the collaterals on the right of the SMV.

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Transection of the neck of the pancreas between 4 resorbable ligatures to minimize bleeding from the pancreaticoduodenal arteries.

The venous and arterial collaterals are put under tension, clipped or ligated and sectioned.

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The retroportal fascia is cut. The uncinated process is removed.

Hemostasis is checked after removal of the specimen. The posterior capsule of the body of the pancreas is dissected in front of the splenic vein to facilitate the pancreaticoduodenal anastomosis.

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A. The mucosa of the distal Wirsung duct is sutured to the parenchyma with 3 or 4 5-0 resorbable stitches to facilitate the pancreatic juice flux.

B. A small plastic catheter (fixed to the mucosa) maintains the Wirsung lumen wide open.

C. Posterior external plane : 5-0 resorbable interrupted stitches between the jejunal serosa and the pancreatic capsule.

D. Posterior internal plane : 5-0 resorbable interrupted stitches taking the whole intestinal wall and the pancreatic parenchyma.

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