Cephalic pancreatoduodenectomy with Blumgart anastomosis and biliopancreatic separation (Merheim technique) - general and visceral surgery

Surgical access is gained via a standard transverse incision. Follow this with inspection and palpation of the entire abdomen to rule out distant metastases and signs of local unresectability.

After inserting a wound edge protector mount the cable winch retractor system.

Note:

In patients with a sharply angled costal arch perform a midline laparotomy.

Enter the omental bursa by detaching the omentum from the right colic flexure to the left third of the transverse colon. Now that the pancreas can be examined in detail from the left too, look for any infiltration of the stomach or postpyloric duodenum. Take down any adhesions between the pancreas and posterior gastric wall.

Note:

The duodenum should be preserved over a distance of 2–3 cm. If this is not possible, perform partial gastric resection.

First, detach the right colic flexure from the anterior aspect of the duodenum and pancreatic head. Then mobilize the duodenum with the Kocher maneuver. Transpose the mobilized colon section to the left, and after incising along the outer margin of the duodenum release the duodenum together with the head of the pancreas from its retroperitoneal attachments. Continue mobilizing the head of the pancreas across the aortic plane up to the ligament of Treitz until the pancreatic head can be completely enclosed and palpated from posterior.

Next, palpate the mobilized pancreatic head to rule out retroperitoneal infiltration and also palpate the lymphatic pathways and large vessels.