An upper midline incision from the xiphoid to just below the umbilicus gives optimal exposure.
A mechanical retractor elevates and retracts the costal margins (Fowler retractor, Pilling Surgical, Horsham, PA) and an articulating Martin Arm retractor (Elmed, Inc., Addison, IL) retracts the liver off the hepatoduodenal ligament.
Division of the round ligament with excision of the abdominal portion optimizes exposure.
Wide dissection frees the cephalad superior surface of the duodenal bulb and pylorus from the hepatoduodenal ligament and the dorsal inferior surface from the head of the pancreas, right gastroepiploic artery, and the nest of veins entering the right gastroepiploic vein on the surface of the SMV. The neurovascular supply to the pylorus rostral and caudal to the duodenal bulb is carefully protected and preserved.
The following blood vessels are divided at their origins away from the pylorus: right gastric artery (if present, usually not one major vessel), superior duodenal vessels of Wilkie, and the gastroepiploic artery and vein at the inferior border of the pancreas.
Dissection of the duodenal bulb is continued for 3-5cm to the junction of the first portion of the duodenum to the area where the duodenum and pancreas merge, to form an "angle"; distal to the angle, tiny shared blood vessels are encountered between the pancreas and duodenum.
The duodenum is divided with a stapling device at this angle; the stomach and stapled first part of the duodenum are now mobile and retracted toward the left upper quadrant.
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