The head of the pancreas is rotated ventroinferiorly. This can be achieved by bluntly freeing the head of the pancreas from the portal vein. Small branches entering the portal vein directly must be ligated and divided. The head of the pancreas is released from the retroportal region with little technical difficulty as long as individual dissection of the vessels entering into the portal vein proceeds meticulously. Also, the pancreatic parenchyma is transected along the left lateral wall of the intrapancreatic portion of the distal common bile duct toward the papilla.
Subtotal resection of the pancreatic head is completed by including the tissue of the uncinate process. It is not necessary to preserve the gastroduodenal artery for adequate blood supply to the duodenum because the supraduodenal vessels, as well as duodenal vessels arising from the superior mesenteric artery, maintain sufficient perfusion of the duodenal wall. In most patients it is not difficult to dissect the pancreatic tissue along the wall of the intrapancreatic portion of the common bile duct towards the papilla and further down including the uncinate process. Removal of fibrotic tissue along the common bile duct results in decompression of the duct in most patients. In patients with inflammation in the wall of the common bile duct, the duct is opened by an incision in the lateral wall for an internal biliary bypass. After subtotal resection of the pancreatic head, a 5- to 8-mm shell-like remnant of the pancreatic head between the common bile duct and the duodenal wall remains.
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