STEP 3Preparation of neoduodenum A1 A2

Using a harmonic scalpel, the mesenteric vascular attachments to the proximal jejunum are divided; the jejunum is divided with a stapler 6-8cm distal to the ligament of Treitz.

The avascular portion of the transverse mesocolon is opened just to the left of the middle colic vein.

The defect in the ligament of Treitz is closed to avoid internal hernia.

An intraoperative fluoroscopic pancreatogram of the pancreatic remnant is obtained if this area of the duct was not visualized by preoperative ERCP. A partial longitudinal incision with lateral pancreaticojejunostomy may be indicated to the body and tail of the gland if chain-of-lake strictures are seen on pancreatography.

Treitz Ligament
A-1

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