Extend the dissection from the body toward the head of the pancreas. This facilitates bimanual examination and palpation of the anterior surface of the gland.
Place a broad curved retractor beneath the posterior wall of the stomach and retract superiorly.
Palpate and determine the location of the main pancreatic duct.
The pancreas should be easily appreciated because of its hard, fibrotic texture.
The dilated main pancreatic duct feels a bit like a large vein on the arm with a ballotable texture and a definite "trough."
The superior and inferior borders of this softer area feel like a canyon or a cliff and this represents the fibrotic pancreas on both sides.
Once the palpation is conclusive, a 22-gauge needle is passed through the anterior surface of the pancreas and into the pancreatic duct; on removing the needle, you should see clear fluid return, confirming that the main pancreatic duct has been accessed. The purpose of this maneuver is to avoid incising into the splenic vein or another structure mistaken for the main pancreatic duct.
Once pancreatic juice is determined, then electrocautery is utilized to incise the anterior surface of the body of the pancreas into the pancreatic duct parallel and adjacent to the needle, which is left in the pancreatic duct as a guide.
A right angle clamp will facilitate using the electric cautery to open widely the duct out to the tail of the pancreas laterally and toward the head of the pancreas. As you reach the genu of the main pancreatic duct it is important to extend the incision through the genu and toward the ampulla. This maneuver requires not only turning the incision inferiorly but also considerably increasing the depth of incision through the parenchyma of the pancreas in the head of the gland because the duct goes more posteriorly. This area also has a rich blood supply, and some amount of hemorrhage may be encountered during this incision. Success rates are thought to depend on in great part on an adequate drainage into the head of the pancreas in this manner. There appears to be less significance to the extent of drainage into the tail of the pancreas except in patients who have more localized disease in the tail of the pancreas.
Once adequate space is established, a Seurat clamp may be utilized. All stones encountered should be removed from the duct; any secondary ductular stones should also be removed.
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