After exposing the duodenum, Kocher's maneuver is performed, and the posterior wall of the duodenum is completely exposed in case of perforation. In case of bleeding, the anterior wall is opened, and single stitches are placed on all four sides of the ulcerative lesion.
The ulceration is excised (see "Local Excision in the Stomach", STEP 2). As a rule, primary closure of the lesion may not be advisable, as mobilization of the posterior duodenal wall is limited. Hence, a duodenojejunostomy is put in place. The gastro-duodenal artery is exposed and ligated at its origin. In case of bleeding ulcers, this step might be taken first, when the bleeding source has previously been identified in gastroduodenoscopy.
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