The clamp should pass through the ampulla into the duodenum (A-3).
The pancreatic head containing the ampullary portion of the pancreatic duct invaginates into the duodenum; looking down from above on the anterior surface of the gland, the pancreaticoduodenal junction is not a guide to locating the ampulla.
The ampulla is 2-3cm more lateral and posterior due to invagination of the pancreatic head into the duodenum. This consideration is important, because failure to the open main pancreatic duct down to the duodenum will leave a significant portion of the main pancreatic duct of Wirsung in the head of pancreas undrained along with its tributary ducts; the thicker the head of pancreas, the longer the undrained portion of pancreatic duct. This situation occurs when the anterior surface of the pancreatoduodenal junction is used as a guide to the position of the ampulla; unexcised small retention cysts associated with tributary ducts located deep within the fibrotic head of pancreas may be a source of persistent pain (A-4).
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