STEP 7Removal of uncinate process

Complete removal of the uncinate process from the SMV and its first jejunal branch (which courses posterior to the SMA) is required for mobilization of the SMPV confluence and identification of the SMA. The first jejunal branch of the SMV, which originates from the right posterolateral aspect of the SMV (at the level of the uncinate process), travels posterior to the SMA, and enters the medial (proximal) aspect of the jejunal mesentery, giving off one or two branches directly to the uncinate process that need to be divided. If tumor involvement of the SMV here prevents dissection of the uncinate process from the SMV, the first jejunal branch can be divided (in which case we expose the SMA medial to the SMV). Injury to the SMV at the level of the first jejunal branch, or a tangential laceration in the first jejunal branch (as it courses posterior to the SMA), is hard to control and represents the most frequent cause of iatrogenic SMA injury as one attempts to suture a venous injury prior to exposure of the SMA.

Jejunal Branch Smv

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