Some of the mobilisation described here will already have occurred if the liver has been removed. The hepatic flexure is taken down and the peritoneum is incised down along the right colon so that the colon and small intestine may be reflected to the right.
Next the duodenum is Kocherised so that the IVC and aorta are visible as far as the left renal vein. Care must be taken not to damage the superior mesenteric vein as it enters the lower pancreas from the small bowel mesentry.
The greater omentum is divided outside the gastro-epiploic arcade so that the omentum and colon may be pushed inferiorly and the stomach elevated to enter the lesser sack. Care must be taken to avoid bleeding from the short gastric vessels between the stomach and the spleen.
The spleen is next mobilsed from its attachments to the diaphragm, colon, kidney and stomach, this complets the mobilisation of the stomach. Care should be taken to see if there is an abberant left hepatic artery from the left gastric system, which may be liable to damage during this mobilisation.
The spleen may then be used to aid mobilisation of the pancreas. The tail and body of the pancreas are mobilised using tranction on the spleen.
Slings are placed around the first part of the duodenum and the junction of the third and fourth parts of the duodenum. About 10 cm of duodenum will be retreived with the pancreas.
The common bile duct is ligated close to the duodenum. The splenic artery is divided as close as possible to the coeliac axis (marking it with a 6/0 prolene suture aids subsequent identification). The splenic artery will be used to supply blood to the body and tail of the pancreas. The portal vein is divided half way between the liver and the pancreas. Any vessles connecting the transverse mesocolon to the meseteric vessles at the lower border of the pancreas are divided. The superior mesenteric vein is ligated and divided at the lower border of the pancreas. The superior mesenteric artery is ligated at the lower border of the pancreas, care must be taken not to damage the inferior pancreatico duodenal artery as this is required to supply the head of the pancreas. Similarly the superior pancreatico duodenal artery (a continuation of the gastro duodenal artery) must be safely ligated at the upper border of the pancreas. Finally the superior mesenteric artery should be dissected back to the aorta and a Carel patch taken from the aorta around the origon of the superior mesenteric artery.
A graft of iliac artery including the common iliac artery with the external and internal branches should be taken as this is used at the bench to bring blood into the splenic and proximal superior mesenteric arteries.