Pylorus-preserving pancreaticoduodenectomy (pp Whipple) with T-drain (PPPD)

Open the abdomen through a bucket-handle incision about 3-4 fingers below the costal arches with transection of skin, subcutaneous tissue, anterior fascial lamina, rectus muscle and posterior fascial lamina/peritoneum. Divide the round ligament of the liver between clamps and secure the stumps with suture ligatures (Vicryl® 2-0). Free the falciform ligament with monopolar electrocautery far over the anterior aspect of the liver. After draping the margins of the incision with damp lap towels install the retractor system comprising a frame and a cable winch system such as the Ulrich retractor. This is followed by systematic exploration of the abdominal cavity: Liver (metastases?), stomach (tumor? position of gastric tube), small intestine (adhesions? peritoneal carcinomatosis?), large bowel (tumor?), greater omentum (adhesions? carcinomatosis of peritoneal cavity?)