The most important and difficult part of the operation involves complete mobilization of the SMPV confluence and separation of the specimen from the right lateral border of the SMA.
Place traction sutures on the superior and inferior borders of the neck of the pancreas. This is important along the inferior border of the pancreas, where a small artery will be found in most patients.
Transect the pancreas with electrocautery down to the anterior surface of the SMPV confluence.
If there is evidence of tumor adherence to the PV or SMV, the pancreas can be divided at a more distal location (along the left or medial border of the SMPV confluence) in preparation for segmental venous resection.
Reflect the specimen to the patient's right and separate it from the PV and SMV by ligation and division of the small venous tributaries to the uncinate process and pancreatic head. Note: The relationship of the tumor to the lateral and posterior walls of the SMPV confluence can be directly inspected only after gastric and pancreatic transection. This relationship cannot be accurately assessed intraoperatively by simply developing a plane of dissection between the anterior surface of the SMPV confluence and the posterior aspect of the neck of the pancreas (which is why this age-old maneuver is no longer performed earlier in the operation).
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