Using the umbilical tape to pull the portal vein out of its bed, the portal vein is cleared to the point where it disappears behind the pancreas. The tough fibrofatty tissue that binds the portal vein to the pancreas must be divided. Several tributaries that enter the medial aspect of the portal vein and one tributary that enters the posterolateral aspect are divided. It is usually not necessary to divide the splenic vein. Wide mobilization of the portal vein is essential for performance of a side-to-side portacaval anastomosis. Failure to mobilize the portal vein behind the pancreas is a second major reason for difficulty in accomplishing the side-to-side shunt. In some patients, it is necessary to divide a bit of the head of the pancreas between right-angled clamps to obtain adequate mobilization of the portal vein. Bleeding from the edges of the divided pancreas is controlled with suture ligatures. Division of a small amount of the pancreas is a very helpful maneuver and we have never observed postoperative complications, such as pancreatitis, from its performance. Before incising the pancreas, the surgeon should insert his or her index finger into the tunnel between the portal vein and the pancreas to determine by palpation if there is a replaced common hepatic or right hepatic artery arising from the superior mesenteric artery and crossing the portal vein. Since the portal venous blood flow to the liver is diverted through the portacaval shunt, ligation of the hepatic arterial blood supply may be lethal.
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