Tricks of the Senior Surgeon

■ Assess resectability preoperatively; the relationship between the tumor and the SMV/SMA is difficult and usually impossible to assess accurately before gastric and pancreatic transection.

■ Do not attempt blunt dissection of the GDA origin as an intimal dissection may result in occlusion of the hepatic artery. When the tumor extends close to the origin of the GDA, obtain proximal and distal control of the hepatic artery and sharply divide the GDA at its origin; the resulting arteriotomy can be closed with 6-0 polypropylene with or without a vascular pledget.

■ Always fully mobilize the SMPV confluence and expose the SMA. The SMA will not be injured if it is in direct vision.

■ Bring the jejunum retrocolic and not retroperitoneal (in the bed of the resected duodenum) for pancreatic and biliary reconstruction. The incision in the transverse mesocolon should be to the patient's left of the middle colic artery.

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